ANABOLIC STEROIDS: A PRIMER
By William Llewellyn
(Reprinted with permission of Muscular Development Magazine)
I think it is fairly commonly known that in spite of, or perhaps even as a direct result of, all the sentiment against steroid use in the media these days, steroid use is on the rise globally. Occasionally you see a tangible indicator of this fact, as was the case last week when I was giving a speech in the UK on steroid use. I was asked to provide some insight into anabolic steroids at the NCIDU-06 Conference (National Conference on Injecting Drug Use), and in the process had learned just why the group was so eager to gain a better understanding of these drugs. Apparently, across the UK more new patients are entering needle exchange programs that use anabolic steroids than are addicted to heroin or other narcotics, the main focus of this program in the first place. Clearly, things are changing in the UK with regard to steroid use, and I think this growth mirrors what is happening in most countries as well.
For the conference I was charged with succinctly summarizing anabolic steroids in a 25-minute presentation, not an easy task. I did my best to whittle down a tight speech that would touch on the most important aspects of steroid use – an overview of what these drugs were and how they worked, a short look at their very long history in modern medicine, and discussion of the popularly cited health risks, and a plan for “harm reduction” as it would apply to the steroid user. I realized in forming my outline that it would be perfect to develop a detailed “primer” article on steroids from, and that is what I have decided to do this month for Muscular Development. At the expense of disappointing some of my readers looking for a more technical discussion, this month we are going to take a well needed but slight detour, for a basic overview of these drugs and what would be considered “safer” steroid use today.
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OVERVIEW
All anabolic steroids come from Testosterone. Testosterone is the primary male sex hormone, and is responsible for a number of functions in the body. These functions are quite numerous, although the primary (for our purposes here) can be placed in one of three categories. The first are the anabolic actions of testosterone. These actions include the building and maintenance of skeletal muscle tissue, increasing the retention of calcium in the bones, and stimulating the production of red blood cells via renal erythropoietin. It is these actions of testosterone that are often discussed when we speak of the “constructive” properties of this hormone. Testosterone also has androgenic properties, which focus on the development and maintenance of secondary male sexual characteristics. This includes such things as stimulating body and facial hair growth, increasing libido, and supporting sperm quality and quantity. Lastly, testosterone also provides an estrogenic component. Estrogen and testosterone are structurally very similar, and the body regularly converts testosterone to estrogen. Testosterone actually serves as a principle source of estrogen in men, where it plays a number of important physiological roles.
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MEDICAL APPLICATIONS FOR ANABOLIC STEROIDS
Anabolic steroids, which are all forms of or functional derivatives of testosterone, have been used medically for a wide number of different purposes since their time of inception. Currently, the main clinical uses for these drugs are fairly small, and can be included in one of six categories.
Hypogonadism – This is a general term referring to the low production of testosterone in males, a hormone of gonadal origin. Low testosterone levels can be caused by a number of different things, including illness, injury, aging, or even a natural genetic predisposition for low androgen output. Given the expanding attention paid to declining androgen levels with aging (Andropause), hypogonadism is the principle use for anabolic/androgenic steroids in modern medicine.
Osteoporosis – This refers to a disorder in which the bones become increasingly porous and brittle, often resulting in fractures. This weakening of the bones often occurs with aging, but can also be association with certain hormonal disorders. Estrogens are often used with postmenopausal women to combat osteoporosis, as these hormones can often block the loss of calcium in the bones. Anabolic steroids, however, can offer en even stronger effect, significantly increasing the retention of calcium in a percentage of such patients.

Anemia – Red blood cell deficient anemia was once a common application for certain anabolic steroids, owing to the fact that these drugs increase the output of erythropoietin. Erythropoietin is a principle stimulator of red blood cell production, making these class of drugs fairly effective treatment options. Recently years have brought forth recombinant erythropoietin, which is far more efficient at stimulating red blood cell production and is not accompanied by the same androgenic side effect. Although anabolic steroids are still used for this purpose, and likely will indefinitely, anemia is a slowly declining focus of medical anabolic steroid use.
Tissue Healing/Injuries and Burns – The anabolic properties of these drugs sometimes lends them to be useful in aiding recovery from burns or injury. At one time in history this was a widely prescribed use for steroids, although during the 1990’s there was a great recession in this application for the drugs. Recent years and more positive studies seem to have revived interest in this use of steroids.
Breast Cancer – Androgens and estrogens have opposing roles on the growth of mammary tissue in humans. Likewise, certain hormone-responsive breast cancers can be positively affected by the application of anabolic/androgenic steroids. These drugs are usually applied only as secondary medications with postmenopausal women whose cancer is deemed inoperable.
Anti-wasting – Lean body mass is important for maintaining optimal health, and many diseases starve the body by hindering the ability to maintain normal muscle mass. Wasting is commonly associated with HIV infection, for example, and here anabolic steroids have been applied with excellent success, often revitalizing an otherwise frail patient. Recent years have seen great expansion in this use of steroids.

HISTORY: 1930’s-40’s – “The Early Days”

The 1930’s and 40’s were the early era of anabolic steroids. Testosterone was first synthesized in a laboratory in 1931, allowing clinical experimentation with this hormone. By 1934, the first steroid for hypogonadism was introduced, Proviron from Schering Germany. By 1936 we saw the first injectable testosterone esters, as well as oral testosterone (methyltestosterone), which carried the chemical modification that would ultimately lead to most commercial oral steroids (c-17 alkylation). Scientists soon began altering the testosterone molecule itself to strengthen or weaken the androgenic, anabolic, and estrogenic properties of the hormone. By the 1940’s, various forms of testosterone and other early anabolic/androgenic steroids were being used in clinical medicine throughout the Western word. We have used these drugs for over 70 years, and actually have much more history with them than most prescription medicines currently being sold.

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HISTORY: 1950’s – “Research Decade”

The 1950’s were the most active period of time for steroid research. During this decade hundreds of effective analogs of testosterone were created, many of which would be developed into medicines. It was here that scientists also made the most progress dissociating the anabolic and androgenic effects of testosterone. Estrogenicity has been eliminated in many new structures, but complete dissociation of anabolic and androgenic effects has not been accomplished. Scientists have come to understand during this time that they probably never would be able to achieve the goal of a purely anabolic substance, as both anabolic and androgenic effects are mediated by the same receptor in the human body. Thus, all steroids have a balance of both androgenic and anabolic actions.

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HISTORY: 1960’s-70’s – Steroid Use Widespread

The use of anabolic/androgenic steroids to enhance muscle size and sports performance spread like wildfire in competitive circles during the 1960’s and 1970’s. During most of this time period, anabolic steroids were largely unknown outside of the locker rooms, and little was done to prevent their use. The International Olympic Committee doesn’t officially ban the use of these drugs until 1975, and first attempts testing in 1976. Steroid use is still effectively open given the lack of inclusion of testosterone in the list of banned medications until the early 1980’s. For all intents and purposes, steroid use was functionally allowed (due to lack of ability to test for the drugs) throughout this era. During the 1960’s and 70’s many new commercial steroids were released as well, based on research conducted in the 50’s and early 60’s, further complicating efforts to test for their use.

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HISTORY: 1980’s-90’s – Anti-Steroid Era

By the 1980’s, there is a growing sentiment to remove drug use from competitive sports. There are countless media articles calling for more accurate testing, stronger bans and penalties, and most commonly, exclaiming the excessive danger surrounding the use of these drugs. In 1984, Dr. Bob Goldman’s “Death in the Locker Room” was published. This book takes a very harsh view on the use of steroids among athletes. It includes a chapter called “How Steroids Destroy The Body”, which alarms a great many readers, and is used for decades to reference the dangers of steroid use. In 1988, Canadian sprinter Ben Johnson beats favorite Carl Lewis (U.S.) in the 100 meters. Johnson sets a world record, and later tests positive for stanozolol. Johnson is stripped of his gold medal, a defining moment in the anti-steroid movement. It solidifies a false view of the “isolated steroid cheat” in the eye of the public. Many experts simply cite poor planning on the part of Johnson’s preparation team.

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HISTORY: 1987-1990 Congressional Hearings:

During the period between 1987 and 1990, Congress holds a series of investigations and hearings in the “steroid issue”. Various government agencies and private medical experts are called to testify about the potential classification of anabolic/androgenic steroids into the schedule of federally controlled substances, alongside narcotics and medications of strong abuse potential. The U.S. Drug Enforcement Agency, The Department of Health and Human Services, and The American Medical Association all seem to acknowledge that steroids are being widely used outside of proper medical circumstances, although they oppose the scheduling of anabolic steroids, generally feeling that they do not fit the classification necessary as drugs of high abuse potential. Several medical experts also agree with the position that the drugs should not be classified as controlled substances. In spite of this, minority opinion gains the favor of Congress, and the drugs are schedules as controlled substances in February 1991. For an eye-opening view of the very important turning point in history, I urge readers to pick up Legal Muscle by steroid attorney Rick Collins.

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HISTORY: Today - Dichotomy

Today we are in a very unique period historically. There is little question that the anti-steroid sentiment is stronger than ever. It seems that almost daily there are new news stories discussing the dangers or the latest incidence of cheating. At the same time, steroid use for performance or body enhancement is much more popular than it has ever been. Many will argue that this is a result of the widespread and almost constant media attention given to these drugs. We can also see that today, the medical use of anabolic steroids is expanding a great deal. This was after a period of recession during the 1990’s, as many companies began distancing their operations from the steroid manufacturing. We currently see exponential growth in the treatment of Andropause with anabolic/androgenic steroids, and many new preparations are being introduced for this purpose, a clear sign of expected continued market growth. And what I believe is a small sign of the times, Dr. Bob Goldman, who authored Death in the Locker Room, is now an advisor to the American Academy of Anti-Aging Medicine, which supports the controlled use of anabolic steroids for anti-aging purposes.

HEALTH RISKS:

Cardiovascular – Anabolic steroids can have several effects that may increase the risk of cardiovascular disease or event. The most commonly discussed is the effects the drugs have on serum cholesterol, most notably a decrease in HDL (good) cholesterol. This is sometimes associated with an increase in LDL (bad) cholesterol. It is important to point out that oral anabolic/androgenic steroids tend to have a much more profound negative impact here than injectable (non 17-alkylated) steroids. Many athletes avoid oral steroids in an effort to reduce some of the negative impact steroid therapy can have on cholesterol values. Anabolic steroid using athletes also notice more LVH (Left Ventricular Hypertrophy) than non-steroid-using athletes, which is another risk for heart disease. Blood pressure can also increase with steroid use, but clinically dangerous increases in blood pressure are not common. This side effect can be more pronounced in “estrogenic” anabolic/androgenic steroids.

Brain Cancer – The death of professional football player Lyle Alzado in 1993 popularized a new side effect of steroids, brain cancer. Alzado attributed his cancer to years of steroid use, and before he died had urged people not to make the same mistakes as him and avoid the drugs. This was a very sad and tragic event, but it is also important to point out that there is no proven medical association between steroid use and brain cancer. Alzado’s physician has also stated that there is no known association between his steroid use and brain cancer.

Prostate Cancer - Androgens can increase the volume of the prostate. This is well documented and understood. These drugs need to be used with caution in people suffering from an enlarged prostate or previous prostate cancer. Medical evidence is not conclusive that androgens can promote prostate cancer, however. Currently, a great deal of attention is being given to androgen therapy in older men, and as of yet no conclusive link between supplementing androgens in aging men and prostate cancer is established. That is not to say it will not, however, but at this point prostate cancer is not accepted as a side effect of periodic steroid use in an otherwise healthy male.

Liver Cancer/Failure - This potential side effect of steroid abuse is highly overstated, however, it is also valid at some level. This is caused by the chemical structure of many oral steroids. A hormone like testosterone is too efficiently destroyed by the liver to be given orally, thus must be modified to resist metabolism before it can be used in the form of a pill or capsule. The process of steroid c-17 alkylation was developed, which eliminated the principle metabolic pathway of steroid breakdown in the liver. This has allowed the development of effective oral steroids such as Dianabol, Winstrol, and Anadrol, but also created steroids that place some strain on the liver. With severe abuse liver failure can result, but medically documented cases of this occurring in otherwise healthy athletes numbers less than 10, and usually follows a very high level of abuse. Non-alkylated injectable steroids such as nandrolone, testosterone, Primobolan, and Equipoise offer no toxicity, even in high doses.

Infertility – This is commonly stated and valid, though also a temporary side effect. What occurs is very similar to estrogen-based birth control in women. When you administer a sex steroid from an outside source, the natural hormone cycle is interrupted, blocking normal fertility. The World Health Organization has even evaluated testosterone as a potential male birth control option, deeming it to be effective, safe, and reversible. At one point in time “Testosterone Rebound Therapy” was common, which involved a 6-8 week cycle of testosterone followed by a potential window of fertility (greater sperm production) after the drug is withdrawn and the body is returning its natural hormone balance (which may include brief post-cycle spikes in hormone/sperm production). Medical intervention is sometimes necessary following long-term steroid abuse, but no case of permanent irreversible sterility due to steroids has even been documented.

Stunted Growth – This also is a valid side effect when anabolic/androgenic steroids are taken during adolescence. It is important to point out, however, that this is actually due to estrogens, not androgens. Estrogen is the reason women tend to have a shorter stature than men, and also the reason men tend to keep growing for a longer time during youth. Stunted growth is only an issue with estrogenic steroids. Some steroids have actually been used successfully to treat adolescents with constitutionally delayed growth, given their effects on the retention of calcium in the bones.

Mental Health – Male aggression is linked to androgen levels. This is well understood, and increased aggression is possible with steroid use. To give an example, it might be to the extent where someone would become angry after getting cut off in traffic, where they would otherwise just “let it go”. We are not talking to the extent of “roid rage”, which refers to violent behavior in an otherwise mentally stable person. Roid rage is largely discounted among those that closely study steroids. Suicide is also commonly discussed with relation to steroid use, due to a small number of high profile teen suicides that included steroid use. While the media may rush to concluding such a link, no such has ever been established in the medical literature, and suicide is not an accepted side effect of steroid use in an otherwise healthy individual.

Cosmetic (Acne, Hair Loss, Gynecomastia, Virilization, Water Retention) – I placed these under one category, as it is important to stress that these are all cosmetic, not health-threatening, potential side effects of steroid use. They may be of issue to the physical appearance of the user, and therefore of great interest to monitor during use, but will not result in death or illness. Acne, of course, is self-explanatory. Hair loss is possible, but only if the person is genetically predisposed to hair loss in the first place. If so, the androgenic component of steroids may accelerate the process. Gynecomastia refers to the development of female breast tissue, which usually amounts to an unsightly puffiness under the nipples before the athlete takes measures to mitigate this. This is only linked to estrogen, and not associated with non-estrogenic steroids. Sometimes drugs can correct mild gynecomastia, while at other times surgery may be required. Virilization refers to the appearance of masculine features on women, due to the taking of what are essentially male sex hormones. Side effects such as deepening of the voice, thickening of the skin, and growth of male body/facial hair can be permanent side effects if left to progress unchecked. Water retention is the simple increased holding of water in the tissues, often causing a puffy appearance in the face and body. This, again, is largely associated with estrogen, and estrogenic steroids.

HARM REDUCTION:

Proper Injection Procedures - A focus on correct injection procedure can help eliminate some of the complications associated with non-medical steroid use. Steroids are given via deep intramuscular injections. The most common site of application is the upper outer quadrant of the gluteus muscle, although the drugs are also commonly injected to the upper outer thigh and shoulder. Site injections (in smaller muscle groups) are discouraged, as they are technically more difficult to navigate, and more prone to complications with self-administration. Comfortable injection volumes should be stressed, generally no more than 3 ml per application. A general focus should be made on cleanliness, such as the use of alcohol pads before injection, and the proper disposal of all needles after each use. It is important to stress that needle sharing is highly unlikely in the bodybuilding community, as these are not drugs of addiction, and the process is usually undertaken with great planning.

Steroid Use, Not Abuse - Steroids can be used to build muscle and improve performance with high-relative safety, provided attention is paid to several things.

* Megadosing – The practice of taking very high doses for more rapid gains is unnecessary, especially for recreational/cosmetic use. Sufficient muscle can be built on moderate doses. In the case of a testosterone ester like testosterone cypionate, this may call for 200-400 mg per week (roughly 2-4 times natural production). There is little need to take doses of 1,000mg per week or more, as they are wasteful and greatly increase side effects and the negative impact of steroid therapy on cardiovascular risk factors.

* Proper cycling – This should be emphasized, which usually includes 6-8 weeks of use followed by equal time or greater off all anabolic/androgenic steroids.

* No Orals – The limited use of oral steroids should be emphasized, as they are more likely to have a very strong negative influence on cardiovascular disease risk. Oral steroids usually present some liver toxicity as well.

* Visit the Doctor – Users should visit a doctor regularly with each cycle. Blood work should be done several times. Fasting cholesterol and HDL/LDL ratio should be examined for heart disease risk, NOT JUST TOTAL CHOLESTEROL. Blood pressure, blood cell counts, triglycerides, homocysteine, and liver enzymes should also be evaluated.

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Avoid Counterfeit & Underground Steroids – Counterfeit and underground drugs are often of dubious quality. For example, The Hartford Courant recently ordered 13 steroid products from the Internet and had them tested for potency and contaminants. While approximately half were sterile and properly dosed, many more were contaminated. Such things as lead, tin, furfural, benzyl chloride, and diethylstilbestrol were found in some containers, clearly unwanted ingredients in human medications. Ironically, laws that prevent doctors from prescribing these drugs or limit their supply are presenting new risks to the community of users by forcing them to buy off the black market, where unsterile drugs are widely sold.

In Closing

So to sum up what I am trying to say here, I think we could focus on several key points. 1) Steroids have a long history in human medicine, and are well, not poorly, understood. 2) The short-term (acute) risks associated with these drugs are very low. 3) The long-term (when used for many years) risks are tangible, and mainly concern cardiovascular disease. 4) Laws restricting the supply of steroids were founded in ethics and politics, not a public health crisis. 5) Laws that restrict the supply of these drugs may ironically present more risk for steroid users, by denying ready access to pharmaceutical-quality medicines. 6) Steroids are not addictive drugs, and do not cause violent behavior or suicide. 7) To sum up the mentality of the steroid user, I think it is fair to say that he of she generally feels they are taking a low risk in exchange for high reward.