Our expert says:
I am pasting an article from one of our top experts (Prof Mike Lambert), regarding the health effects of steroid use, .
Whilst it might seem easier to just "go with the crowd" - consider the long term implications and try to think of your entire life in perspective rather than winning a rugby game right now.
Health implications of anabolic androgenic steroid use
M.I. Lambert, PhD and A. St Clair Gibson, MBChB, PhD
(Lambert, M.I. and St Clair Gibson, A. Health implications of anabolic steroids use. In: MIMS Disease Review 1999)
Anabolic androgenic steroids (AAS) are synthetic analogues of the natural hormone testosterone. AAS can be injected intramuscularly or ingested orally and were synthesised initially for hormone replacement therapy and for treatment of a variety of medical disorders. They are now widely used by sports participants for non-medical purposes with the primary goal of improving the user's muscle size and strength 1, 2, 3. AAS were banned for use by sports participants by the International Olympic Committee in 1976 and were classified as schedule V drugs in South Africa in 1991. Illegal possession or use of AAS carries a fine of up R40 000 or up to 10 years imprisonment (South African Parliament Act 101, 1965). Despite this, use of AAS across a range of South African sports participants persist 4. Studies show that the prevalence of use of AAS in South African school boys (16 to 18 years) is 2.8% 5 and 38% in competitive South African bodybuilders6. These data are similar to the prevalence of use reported in North America 7. The type of AAS used varies depending on the geographical region and the availability of the drugs (Table 1). The drugs are usually taken in cycles lasting from 6 to 12 weeks with a two to four week washout period between cycles.
Therapeutic use of AAS
The principle medical use of AAS is as a hormone replacement in primary and secondary hypogonadism. However, AAA have also been prescribed for various clinical conditions such as anemia associated with renal disease, hereditary angioedema, endometriosis and fibrocystic breast disease 8. AAS have also been used with varying degrees of success as adjunct therapy for conditions of protein deficiency in both human and veterinary medicine, and for patients recovering from cachexia induced by surgery, severe infections or burns9.
Ergogenic effects of AAS
The goals and objectives of individuals using AAS vary. Bodybuilders use AAS with the aim of increasing muscle mass while decreasing fat mass. Weight lifters and power lifters use AAS with the goal of increasing their muscle strength, while endurance athletes use AAS to reduce the catabolic effect of high training volumes. The extent to which AAS allow the users to achieve these goals is controversial. There is an overwhelming belief among the users of AAS that they do indeed have profound ergogenic effects 6. This is, however, contrasted by the paucity of scientific data supporting their ergogenic action. The American College of Sports Medicine (ACSM) issued a position statement in 1977 that there was no conclusive scientific evidence that extremely large doses of AAS aids or hinders performance 10. However, the studies used in developing this position statement were later criticised because many studies used untrained subjects, lacked dietary controls, used low intensity training or non-specific forms of testing muscle strength. Therefore, in 1984 the ACSM revised the position statement to conclude that gains in muscle strength achieved through high intensity exercise and proper diet can be increased by use of anabolic steroids in some individuals 11. Subsequently, other review articles have concluded from carefully selected studies that anabolic steroids have the most pronounced affect in those athletes who have trained to the point that they are in a chronic catabolic state1.
Therefore, it may be concluded from the anecdotal and scientific evidence that AAS increase muscle mass and strength providing the athlete is (i) highly trained, (ii) training hard while using the drugs, and (iii) eating a high energy, high protein diet.
Adverse effects of AAS
There are varied reports in the literature describing the adverse effects of supraphysiological doses of AAS. This may be attributed to the fact that clinical testing of supraphysiological doses of AAS is banned and field case studies report findings of different drugs, dosages, and exposure time to the drug. These varied responses, coupled to the fact that certain adverse effects may only manifest after several years, make it difficult to assess the overall negative impact AAS have on the health of the users. The following topics are those adverse affects which are supported by controlled clinical trials or case studies.
Males who self-administer AAS usually become infertile while using AAS as a result of reduced spermatogenesis and altered sperm morphology 12. However, there are no documented cases of this being a permanent side effect 13. Both increases and decreases in libido have also been reported. Gynaecomastia may also develop in men using AAS as a result of the conversion of excess androgens to oestrogens. Isolated cases of priapism have also been reported.
Females using AAS have a risk of developing acne, coarsening and deepening of the voice due to laryngeal hyperplasia, hirsutism, reduction in breast size, clitoral hypertrophy and disruption of the menstrual cycle. It is not known if these side effects in females are permanent. AAS may also increase or decrease their libido.
Although prostate cancer can be induced in rats after several months of AAS treatment no such cause and effect had been established in man14. A case study has shown that administration of AAS increases prostatic volume, reduces urine flow and alters voiding patterns 15.
The liver is the principal site for AAS clearance from the blood. Orally ingested AAS are transported to the liver before being distributed through the circulation to the peripheral organs. Patients who have compromised liver function or who are exposed to high doses of orally ingested AAS are at increased risk of developing of cholestatic jaundice and peliosis hepatis 16. Although there have been case reports of athletes with histories of prolonged use of AAS dying of liver tumors, the link between AAS and the tumors have not been firmly established.
The majority of research shows that serum low density protein cholesterol (LDLC) concentrations do not change significantly with AAS use. However, serum high density lipoprotein cholesterol (HDLC) concentrations decrease within weeks of AAS use and recover within a month of cessation of use. However, there is evidence to suggest that the decrease in HDLC is not associated with an increased risk of coronary heart disease 17. Further experimentation is needed to confirm this.
Hypertension resulting from AAS use was first documented in the controversial ACSM (1977) position statement and was often quoted as being a side-effect of AAS use10. However, there are very little data supporting this and the current belief is that AAS do not have a significant effect on blood pressure. Case report studies have reported episodes of myocardial infarction and left ventricular hypertrophy, but a causal relationship is still controversial 18, 19.
AAS use may lead to collagen fibril dysplasia which decreases the tensile strength of tendons 20. These detrimental effects on the mechanical properties of connective tissue can predispose the user of AAS to musculotendinous injuries 21.
Although AAS use is associated with significant disturbances in personality profiles 22 there is still debate as to whether these personality traits are a direct consequence of AAS use or rather a predisposition for use. Increased aggression is a personality trait associated with use of AAS. This increased aggression places the female partners of males users of AAS at increased risk of physical abuse 23. There are also data which support a psychological dependence on AAS manifesting as 1) preoccupation with drug use, 2) difficulty stopping despite psychological side effects and 3) drug craving 7.
A number of skin conditions have been associated with use of AAS1. These include acne, subcutaneous striae and increased incidence of skin infections. The acne most commonly occurs after the cessation of AAS use.
It is currently illegal for sports participants to use AAS. Penalties for AAS use include banning from competitive sport and criminal charges for illegal possession of AAS. There is concensus that AAS have an ergogenic effect which results in their widespread use. Therefore there is a high probability that medical practitioners will be approached by AAS users for advice on side effects of the drugs. These side effects and the medico-legal consequences of using a schedule V drug should be explained to the user. Any users who persist in using the drugs should be referred to specialists in sports medicine 24.
Table 1. Typical types and dosages of anabolic androgenic drugs used by body-builders in South Africa (adapted from Titlestad et al., 1994).
Name of AAS Reported dose range (mg/daymin max Maximumrecommended clinical dose (mg/day)(for a 80kg person)
Anapolon-50Ò (50mg/tab) (oxymetholone) 50 350 400
OrabolinÒ (2mg/tab) (ethylestronol) 2 20 4
PrimobolanÒ (5 and 25 mg/tab) (methenolone acetate) 10 125 20
ProvironÒ (25 mg/tab) (mesterolone) 25 100 75
AndroxonÒ (40mg/tab) (testosterone undecanoate) 40 200 160
Deca-durabolinÒ (25 and 50 mg/ml) (nandrolone decanoate) 25 300 17
PrimobolanÒ (100 mg/ml) (methenolone enanthate) 100 200 50
DurabolinÒ (25 mg/ml) (nandrolone phenylpropionante) 50 300 50
Depo-testosteroneÒ (100 mg/ml) (testosterone cypionate) 100 400 100
Sustanon-250Ò (250 mg/ml) (testosterone phenyl- propionate decanoate 250 750 83
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