The prevalent use of pharmaceuticals as enhancers of performance or appearance in the athletic arena is well-known. However, the legal and moral issues surrounding their use prevent users from access to credible and reliable medical information on health issues associated with their use. Medical practitioners cannot legally or ethically prescribe them for use by athletes and the doctors themselves are often inadequately informed about the physiology of the drugs. This is especially true when you consider the various dosing schemes and polypharmacology that is often employed by athletes, especially bodybuilders. Even the published scientific information available to them is not free from bias. Although newly published studies are reporting more objective conclusions regarding increases in muscle mass and strength, the health risks associated with the supraphysiological doses and durations used by many athletes remain unknown.
Regardless, these drawbacks have not deterred many male athletes and bodybuilders from experimenting with illicit drugs to enhance their performance or appearances. Before anabolic-androgenic steroids (AAS) were legally classified as Schedule III controlled substances in 1990, the occasional athlete could obtain AAS for ‘injuries’ by a few practicing MDs, but they were never freely dosed like antibiotics. In these cases, the physicians could monitor the users’ physical status. However, even then most AAS were illicitly obtained outside of medical approval and supervision. Obviously, the reclassification of AAS drove their use by athletes even more underground than before.
Not only do AAS increase muscle mass, they reduce the muscle breakdown that often results from overtraining and extreme dieting by enhancing recovery, and they are useful for recovering from injuries. Both men and women in sports have proved their efficacy by decades of use. However, the legal ramifications of their use have relegated that users experiment without medical supervision and monitoring.
Self-prescribed dosages and stacking regimens based on anecdotal testimony and amateur science are easily accessible by males in the athletic world. This prevails especially in bodybuilding where the use of AAS is more commonplace than in other sports-related activities. Couched chatter in the locker room, internet/usenet forums, affordable steroid handbooks, magazine articles; there are sources of information on steroid use everywhere. However, that information is typically male-dominated: use of drugs for men and accumulated by men.
The Amazonian female bodybuilders of several years ago attained their muscularity with the use of AAS to augment their training and diets. The heyday of the female extreme muscularity has now faded to smaller muscled women bodybuilders and fitness competitions. The Bev Francis and Vicki Gates physiques have been replaced with big-breasted women who perform dazzling acts of gymnastics or show how well they can diet. Despite the smaller female physiques of today, the use of drugs continues. The top competitors are the cream of the crop. In order to gain that competitive edge, they still resort to the aid of drugs, including AAS.
Information on the use of AAS for women is less reliable and credible than that for men. Women have been coached on their use by their boyfriends or other men in their immediate circles of gym partners. Chatter amongst women relating experiences can be found in some usenet groups, but the issues are still vague. Much of the disseminated information is based on the use of AS by men without consideration and knowledge of the differences in physiology: the hormonal milieu of women is very different from that of men. Nevertheless, women using or considering using AAS are not likely to approach their family practitioner for advice or medical supervision. The stigma associated with AAS use is stronger for women than men and the medical aspects associated with them are also less known.
To provide women with credible knowledge about the health issues associated with using AAS, the author interviewed four physicians and academic authorities specifically addressing female concerns. The interviewees are from North America and Europe representing a cross-section of international experience with women athletes. The names of the interviewees are withheld and replaced with a letter designated by the author. Each offers their response to a series of questions that were based on concerns voiced by women or known medical concerns.
Question:Given the sensitive nature of not only anabolic steroid (AS) use but especially use by a female, how can a woman approach a physician for monitoring her health during AS use?
Dr. A:This is very hard. You must make sure that the physician is knowledgeable and also not judging. It is very hard to find a physician that is open for this type of monitoring, unless you explain to the physician why you are doing it and that you are also willing to work and listen to him, and make the necessary changes with him.
Dr. B:Difficult to do as there is still a medical stigma associated with having anything at all to do with anyone using anabolic steroids. At present there are a few doctors that I know of that are facing discipline as a result of involvement with anabolic steroid using athletes. If you do manage to see a doctor with liberal views on the subject, these doctors would be much less likely to monitor their use in females, given the androgenic nature of these compounds.
Dr. C:First, a female athlete considering the use of AS should try to find a physician with a distinct background in the sport of bodybuilding or power lifting. These will be the ones who are most open minded when it comes to use of performance enhancing drugs. She should tell the physician about her intentions for using AS and should show him that she has accumulated quite a bit of knowledge about risks and side effects of these substances on the female body. Then the MD will see that she has decided to do so not because of spontaneous thoughts but based on a longer lasting decision process. She should clearly state that she doesn’t want any AS prescribed (which is illegal in most states) but just monitoring her health for safety reasons.
Even with these cautions women should be aware of the fact that most physicians won’t follow her arguments and will deny any cooperation. So she probably has to speak with several of them until she will find one who is open minded enough for health monitoring of a female athlete taking AS.
Question:Any steroid use could potentially have wide-ranging effects on various biological systems, including metabolic (e.g. insulin sensitivity), endocrine, and cardiovascular. What type of tests/assays should be recommended during and after use? How important are baseline (before use of AS) tests?
Dr A:First you should always have baseline labs, they are the must important labs, because it will let the physician know how good, bad or ok you are doing, you should monitor them depending in your dosages, changes of drugs or cycles and if you are sexually active. Tests to be run are:1-Liver Profile, CBC, Lipid screen, TSH, T4, T3, free and total testosterone, PSA [prostate-specific antigen] if a male, estrogen, LH and FSH, physical exam including pap smear if not done before. I include CRP and homocysteine, and Hgb 1 AC , and finally depending if the patient is using prohormones I will check those and, believe it or not an EKG for baseline heart and a good blood pressure reading.
Dr. B:Baseline tests are useful, as they’ll give you the normal lay of the land before you interfere with the landscape. I usually recommend a complete blood count, LH, FSH, free or bioavailable, and total testosterone, SHBG, TSH, T3, T4, liver and kidney function tests, total, HDL, LDL cholesterol, glycosylated Hb, lipoprotein(a), C-reactive protein, homocysteine
Dr. C:Baseline tests are of utmost importance to be aware of any pre-existing health problems. If there are any problems, AS use should be discussed with the female athlete again or the changes in the parameters have to be reevaluated very carefully every few weeks while on cycle.
Important tests are liver markers (gamma-GT, GOT, GPT, Cholinesterase, GlDH), parameters for kidney function (creatinine, BUN), blood cell count (erythrocytes, leucocytes, platelets, hematocrit), blood sugar after overnight fasting as well as an oral glucose tolerance test, creatine kinase (CK), blood lipids (total cholesterol, HDL, LDL, triglycerides, lipoprotein(a), hormone concentrations (estrone, estradiol, testosterone (all total, bound and free), SHBG, LH, FSH).
Question:Considering that most users of AS typically ‘stack’ compounds by using more than one AS simultaneously, one author suggests assaying for total, bound and free testosterone concentrations during any type of AS use . The reasoning for this is that regardless of the AS used the endpoint (i.e. the increase in the three chemistry measures) is still the same. Do you agree with this?
Dr. A:Yes I do because you will have a baseline of where you were before and where you should be. Also there is a balance between these values and I will know what that ratio is.
Dr. B:This guy must be on drugs. How can you get increases in testosterone with the use of anabolic steroids? They depress the HPTA and lower testosterone levels. The only time you’re going to get an increase in serum testosterones is if you use injectable/oral/topical testosterone.
Dr. C:No, I don’t. In my experience most assays can discern between testosterone and synthetic analogues, meaning that while on a cycle of synthetic AS the testosterone concentrations will decrease markedly because of the negative feedback, while the concentration of the synthetic analogue will be high (if specifically measured). When using testosterone as the only steroid (will be the exception with women) measuring the testosterone concentrations would be sufficient. Evaluating the SHBG is sometimes useful as well, as AS decrease the binding protein markedly (esp. stanozolol). A lowered SHBG is a quite good marker if someone is taking AS (SHBG is below the reference range even after a few days of even low doses of AS).
Question:In light of #3, would use of the non-aromatizing AS change your response to the question? If so, what other markers would be informative?
Dr. A:No, you must also protect yourself as a physician.
Dr. C:The use of a non-aromatizing AS will lower the natural testosterone production as well, but not that markedly, because estradiol is a quite strong suppressor of LH/FSH release in the hypophysis, at least in men. Measuring the estradiol concentration will give a good picture of the aromatase activity in the body in men. Therefore, while on a cycle of non-aromatizing steroids, estradiol will be low (below normal because of lowered natural release). While on a cycle of aromatizing AS, estradiol will often be above the norm, depending on the aromatase activity in the body. In women estradiol also stems from the ovaries. If estradiol is increased in a female athlete one can also assume a high aromatization activity in the body, because the natural estradiol production in the ovaries is lowered while on AS.
Question:Prohormone use is typically considered benign in the weightlifting circles and their efficacy in men is debatable. Prohormone supplementation may result in greater increases in testosterone (or nortestosterone) in women because their baseline level of androgens is much lower than that of males’ and they exhibit preferential conversion of androstenedione to testosterone. What cautions would you specifically recommend for women who use prohormone supplementation?
Dr. A:Must have a baseline. Also some side effects are equal to the steroids, and believe it or not, keep a check on their moods. Also make sure you can’t get pregnant. They are not benign they are active compounds that we still don’t know enough about them.
Dr. B:The same as using anabolic steroids. Be careful of the virilizing effects. If you don’t want your voice to deepen, more facial hair, less hair on top, and a bigger clitoris, then be very careful in using either the prohormones or AS.
Dr. C:I would advise a female athlete to start with a nor-testosterone prohormone, using low dosages in the first 2-3 weeks and watching herself carefully for signs of virilization (lowering of the voice, acne, increased body hair growth etc.). Keeping cycles short (4-6 weeks) with sufficient breaks should help to avoid such side effects. But every physician has to keep in mind that the onset of virilization symptoms can differ tremendously between women, depending on genetic factors and others.
Question:Reproduction function is a health concern for both men and women who use AAS. The most prevalent side effect of AS use by women is changes in menstrual cycles. Many women bodybuilders experience menstrual irregularities or amenorrhea (absence of menstrual cycle for six months or more). Are there differential effects based on the type of AS used, or is it primarily a dose and duration issue?
Dr. A:Actually both; what type how much and even route has a different effect
Dr. B:Dose and duration overshadow anything else.
Dr. C:In my experience the main factor is the individual responsiveness that determines the severity of symptoms. Besides that the androgenic index of a particular AS is very important to anticipate the magnitude of side effects. With testosterone esters or trenbolone side effects will occur the earliest and the most severe. But even with more anabolic steroids with a less androgenic index side effects will occur with a higher dose and longer duration of use. From empirical evidence the lowering of the voice is one of the earliest signs female athletes will encounter.
Question:What type of monitoring would be best for menstruation status?
Dr. A:A baseline here is important, and also you should know when you get those measurements so you are not measuring two different levels at different times.
Dr. B:Monitoring for menstrual status is useless while using anabolic steroids since any testing is meaningless. Attaining pre-steroid status should be the main concern regardless of the dosages used and duration of use.
Dr. C:Besides the reports of the female athletes, hormone concentrations of estradiol, progesterone, LH and FSH are important markers for menstruation status.
Question:Given the high propensity and prevalence of menstrual dysfunction occurring with AS use, what approaches can be used to normalize menstruation after cycles of AAS use? Which approach has the highest success?
Dr. A:It depends on the above and what your goals are after and how long. Sometimes you might not be able to fix somebody, and to normalize them you are forced to use hormones again, including HCG, estrogen, DHEA, test and progesterone and sometimes thyroid and herbs.
Dr. C:In my experience with female athletes there is no real pharmaceutical solution. In many cases just ceasing AS use and waiting for normalization of menstrual function is the most practical way.
Question:Loss of bone mineral density is highly associated with amenorrhea. Can any precautions be taken against loss of BMD?
Dr. A:No fucking way you are losing BMD during steroids, they are the best to increase BMD.
Dr. B:BMD is associated with levels of both estrogen and androgens – in both men and women.
Dr. C:I would advise the female athlete to pay attention to the acid balance of the body (use of buffering agents, e.g. potassium citrate) and to keep the intake of green veggies with a high calcium content high. On the other hand AS have high calcium retaining properties and females involved in strength sports have stronger bones, therefore I don’t see a real concern about bone mineral density with females using AS.
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