Steroid Use and Women’s Health – An interview with selected medical practitioners (Part 2)

Question:How does AS cycle length correlate with symptom development of endocrine dysfunction (see above)? How does the duration of use compare with cycles commonly used by male athletes?

Dr. A:The duration is usually less and the amount less depending on the sport. The longer [the duration] the worse the side effects if you are going to have any, and also how much.

Dr. B:The more you take and the longer you take it , the more symptoms you’ll have and the tougher it will be getting your system back to normal.

Dr. C:The cycle length is a very important factor for development of endocrine dysfunction. I would advise females to keep cycle length below 6 weeks for avoiding such side effects. In my opinion women should use AS for shorter periods than men with longer breaks, as my experience shows that hormonal imbalances are more severe with females.

Question:Virilization is partly dependent upon the androgenic properties of the AS used. However, the undesirable side effects also depend on dose and duration as well. It is suggested that some virilization is reversible and others irreversible. How can virilization such as hair growth and voice changes be minimized?

Dr. A:With lower dosages and shorter cycles, or using different type of AAS with lower androgenecity like anavar primo and winstrol. Remember though that side effects are dependant on genetic predisposition

Dr. B:First of all I find that there isn’t much difference in the various anabolic steroid preparations if what you’re looking at is the anabolic response you’re getting. You need to take more of the less androgenic compounds to get the same anabolic effects as the more androgenic compounds. And when you take more of the less androgenic compounds you also get significant and comparable androgenic effects.

Dr. C:The most important point is to keep dosages low, cycle length short and breaks between cycles at least as long as the duration of the intake. The genetic susceptibility is probably the main factor for developing virilization symptoms. After onset of lowering of the voice or increased body hair growth AS use should be stopped immediately. In these cases the side effects are reversible nearly every time.

Question:Liver function and toxicity are a concern for any person using AS. The oral C-17 alkylated AS are more associated with liver toxicity than the injectable non-alkylated AS. What liver function (LF) markers should be monitored?

Dr. A:All, GGT, AST, Alt, alkaline phosphate, cholesterol, and even sometimes pancreatic enzymes .You can also monitor IGF-1 if you want to.

Dr. B:I usually recommend a liver function screen including several of the enzymes.

Dr. C:Important liver markers are GOT, GPT, GlDH, Cholinesterase, gamma-GT. Besides that a sonography of the abdomen twice a year helps to discover morphological changes (e.g. peliosis hepatis) of the liver early enough.

Question:Some LF markers are elevated in response to exercise. How does the clinician differentiate elevations in LF markers due to exercise and AS use?

Dr. A:That is why the baseline is so important; exercise, diet meds, sleeping and stress affect liver enzymes.

Dr. C:The muscle enzyme creatine kinase in the blood is important for differentiation between liver pathologies and elevated transaminases because of heavy training. A high creatine kinase coupled with moderately elevated GOT and GPT usually is just a sign of muscle cell damage and not of liver problems.

Question:Use of AS can lead to unfavorable changes in serum lipid profiles. Changes documented include increased LDL and decreased HDL; however, there is no consensus regarding detrimental changes in trigylceride and cholesterol levels. What lipid markers should be monitored?

Dr. A:All of the above and sometimes homocysteine and CRP. Cholesterol levels are affected though, depending how long and how much, usually come down. The total, that is. LDL does not truly increase but the ratio. Some people require little lipoprotein a.

Dr. B:The main ones are the LDL and HDL. If they’re out of whack then measures should be taken to bring them in line. Total cholesterol and triglycerides levels are more affected by genetic predispositon and diet.

Dr. C:The triglyceride values are often increased with AS use as well, probably because of the decreased insulin sensitivity. A high intake of fish oil (10-15 g / day with 3-5 g of EPA + DHA) can counteract that effect in most cases. Usually the total cholesterol shows no change because the lowering of the HDL cholesterol fraction is of about the same magnitude as the increase of the LDL cholesterol fraction. Lipoprotein (a) (one of the detrimental blood lipids) often decreases while using AS and should be monitored as well.

Besides these lipid parameters, homocysteine and c-reactive protein should be monitored as well because of the importance of these markers for beginning arteriosclerosis.

Question:Apparently, there is some debate on the effect of AS on cardiac hypertrophy. Some case studies have reported hypertrophy and cardiomyopathy. However, studies also demonstrate that resistance training itself can induce cardiac hypertrophy independent of AS use. As well as in men, cardiac remodeling has been documented in female weight lifters. At what point should the clinician be concerned with cardiac remodeling? What type of test can be performed to track morphological changes?

Dr. A:You must have a baseline EKG, and if you have symptoms, then I will be concerned and I will order an echo or what I think is necessary depending on the symptoms.

Dr. B:Although several reports over the years have suggested that anabolic steroids have detrimental cardiac effects, I’m not convinced since studies in humans don’t account for the many variables that can affect cardiac muscle, including the type of steroid used, stacking of steroids, genetic predisposition, etc. In fact it’s quite possible that the cardiac remodeling that occurs secondary to steroid use may be protective since MI in males up to the age of 75 is associated with a more favorable outcome.

Dr. C:There should be a careful monitoring of heart morphology by sonography. Wall thicknesses (septum and posterior wall) as well as inner diameter of the left ventricle are important parameters. The ratio of the sum of septum as well as posterior wall thickness and inner diameter of the left ventricle (called hypertrophy index) is important for disclosing concentric heart enlargement. Besides that diastolic function as a marker of stiffness of the heart should be monitored.

Question:A meta-analysis of studies suggests that the type of resistance training program can influence the type of cardiac remodeling, demonstrated by changes in left ventricle (LV) geometry . Although nearly 40% of all resistance-trained athletes had normal LV geometry, eccentric hypertrophy was more associated with bodybuilders, whereas concentric hypertrophy was found more often in Olympic lifters. Powerlifting was associated with normal geometry. However, regardless of the type of resistance training, AS use tended to cause marked concentric hypertrophy. Is there any way to differentiate between cardiac hypertrophy induced by resistance training and by AS use?

Dr. A:No, only you have been working out for a while and you have baseline echos. In addition, that is why you must have a baseline before AAS.

Dr. C:In my experience the hypertrophy index of the heart (see above) in male athletes seldom reaches values above 42 % when examining strength athletes training without AS. AS use is often coupled with values between 42 % and 50 %.

Question:Are there any special implications of the above that pertain to women?

Dr. A:No, they are the same as men.

Dr. C:I don’t have enough data about female athletes, but I suspect that the hypertrophy index is a useful diagnostic tool here as well. Values above 40 % with females would make me suspecting AS use.

Question:The belief that AS use increases risk or even causes cardiovascular heart disease prevails through the lay and medical communities. This is based on evidence suggesting that AS stimulates platelet aggregation, increased coagulation enzyme activity and coronary artery vasospasm. Another association reported by AS users is elevation in blood pressure. Are these symptoms and changes a concern for female as well as male users of AS?

Dr. A:Yes, it is, but because the dosages are smaller you see less side effects. But if you have any cardiac history in the family, then you must be very careful especially if a member like the father mother or siblings died at early age.

Dr. C:There is no reason to suspect that females shouldn’t be concerned with these changes.

Question:Does polypharmacy, in other words, the use of other drugs along with AS, exacerbate the effects of AS on the heart?

Dr. A:Most definitely; the more drugs the more side effects.

Dr. C:The concomitant use of growth hormone, clenbuterol and high-dose thyroid hormones will probably exacerbate the side effects on the heart in male and female users of AS.

Question:How can persistent effects on the heart be ascertained after discontinuation of AS use?

Dr. A:Baseline EKGs, homocysteine, CRP, and stress test if necessary.

Dr. C:The probably best method for evaluating persistent effects on the heart is ultra sonography coupled with duplex sonography. With these methods wall-thickness and diastolic function should be measured. These are the most often detrimental changed parameters even after longer discontinuation of AAS use.

Question:AS use has been linked with some types of cancer in men. Tumors or carcinomas have been reported in the livers and prostates of men who were long-term AS users. A few cases of hepatic tumors were also reported in females prescribed androgens for therapeutic purposes. In vitro studies associate androgen levels with increased proliferation and decreased cell death. Epidemiological studies show a correlation between high androgen levels and increased risk of epithelial ovarian cancer disease . Do you feel that increased cancer risk is a concern for female AS users?

Dr. A:No, unless using IGF-1, GH or insulin combination, or if you have a cancer history that is dependent on hormonal properties like breast cancer.

Dr. C:In my opinion there is not enough data for women up to now to draw definite conclusions and there won’t be in the next years because of the lack of long-term studies. But the possibility for an increased cancer risk certainly exists in female users.

Question:As with the use of any injection, there is a concern about diseases associated with injectable AS agents. Hepatitis C, B and HIV have been associated with people who inject AS (hepatitis more prevalent) . Would you recommend testing for these diseases?

Dr. A:Unless you are a fucking moron, I don’t see why. The only one I will worry about is infection at the site.

Dr. B:You don’t have to test for them if you’re not stupid. Don’t share bottles or needles! On the other hand in the past few years there have been at least two reports of septic shock and a gluteal mass in bodybuilders using AS. Also keep in mind that any injection results in a local inflammatory response and scarring, with the degree of both depending on response to both the drug injected and the medium the drug is dissolved/suspended in.

Dr. C:In my experience needle sharing between female athletes is very seldom. I’d ask the athlete if she was sharing needles in the past and if not, I won’t test for these diseases.

Question:The lay opinion is that AS use induces mood changes and aggressive behavior. Psychiatric symptoms reported range from mania to hypomania and depression to addiction. The debate in the literature centers on objectivity in studies. It cannot be discounted that individuals with a positive psychiatric history may be more susceptible to changes in mood and aggression. Additionally, tendency of use and/or abuse of AS may be higher in individuals with pre-existing psychiatric disorders. Dr. Robert Sapolsky at Stanford University once commented on the issue of testosterone’s effects on mood and behavior: “It’s like turning up the volume of the noise on the radio.” What can the clinician be aware of or watchful for that may indicate negative psychological effects or addiction?

Dr. A:This is the must common side effect that I see in any AS user, not physical but emotional: depression, lack of sleep and more aggressiveness. Is this due to the type of person that uses AAS? I don’t think so because I see this with prohormones also.

Dr. B:I’ve been careful to downplay the psychological and addictive effects of steroids since it’s so overplayed in the media and in articles. It’s true that the use of anabolic steroids may accentuate aggressive and other tendencies, but part of this is a result of the “expectation” that steroids will do this. Also the increase in confidence coupled with changes brought about by intense exercise will also contribute to the changes that people feel in their confidence and ability to handle things.

Dr. C:This kind of effect is very difficult to determine. I think that talking to the relatives of the athlete gives the best impression. In many cases AS using women don’t recognize their mood changing themselves. Therefore, asking persons who are in a close contact with the female athlete about behavior changes is the best way to go. Unfortunately it is often very difficult to get in contact with friends or relatives of the patient.

Dr. D:There are numerous self-report measures that have been used to pick up on changes in affect, cognition, or self-reported behavior. Note, however, that to use these on a continuous basis assumes close and ongoing monitoring of psychological health in the same manner that one would want to monitor physical health during cycles in the most optimal circumstance. Several different measures that involve self-ratings of positive and negative affect and reports of cognition and behavior might show the onset of changes in psychological function. However, the correlations between these measures and behavior, for instance, the relationship among measures of hostility or aggression and actual aggressive behavior, is not that high. Studies that have shown changes in measures of psychological function, including aggression, have not found concomitant increases in observations of aggressive behavior by clinicians or others close to the proband. Nonetheless, optimal close monitoring might also involve others in the individual’s social network that can provide more objective reports of behavior changes.

Regarding addiction, given that AS are not addictive in the sense that they have strong psychoactive effects nor do they seem to create a physiological dependence, indicators of addiction are likely to be more behavioral in nature. Psychological addiction to AS is likely to manifest itself in the inability to maintain scheduled dosage and on/off cycles due to disruptions in body image and other self-evaluations during off cycles and subsequent emotional disturbances associated with these changes. The best means for monitoring this possibility will, as above, involve long term monitoring of the psychological health of the user and their ability to maintain any prescribed regimen. In this case, clinicians might also best monitor ongoing reports of body image disturbance, as well as track dosing patterns in relation to preplanned regimens. Any deviations from dosing plan, or planned off periods, changes in body perception, might signal the beginning of a psychological reliance on AS.

The author thanks the interviewees for their candid responses. Hopefully this article will partially fill the gap in providing women with credible information on the use of AS and associated health concerns. However, this does not replace personal and individualized monitoring and counseling by a practicing medical caretaker. Nevertheless, any individual, male or female, should educate themselves before deciding to experiment with AS.

Footnotes:

Aitken, C., C. Delalande, et al. (2002). “Pumping iron, risking infection? Exposure to hepatitis C, hepatitis B and HIV among anabolic-androgenic steroid injectors in Victoria, Australia.”Drug Alcohol Depend65(3): 303-8.

Edmondson, R. J., J. M. Monaghan, et al. (2002). “The human ovarian surface epithelium is an androgen responsive tissue.”Br J Cancer86(6): 879-85.

Haykowsky, M. J., R. Dressendorfer, et al. (2002). “Resistance training and cardiac hypertrophy: unravelling the training effect.”Sports Med32(13): 837-49.

Kutscher, E. C., B. C. Lund, et al. (2002). “Anabolic steroids: a review for the clinician.”Sports Med32(5): 285-96.