How do injectable steroids impact liver function. What are the potential hepatotoxic effects of anabolic steroid use. Which factors influence the severity of liver damage from steroids. Can liver injury from steroids be reversed. How do oral and injectable steroids differ in their effects on the liver.

The Basics of Anabolic Steroids and Their Impact on the Body

Anabolic steroids are synthetic substances derived from testosterone, designed to promote muscle growth and enhance athletic performance. While they can be effective for these purposes, their use comes with significant health risks, particularly to the liver.

Anabolic steroids work by binding to androgen receptors in cells, stimulating protein synthesis and promoting the development of male secondary sexual characteristics. However, their effects extend far beyond muscle tissue, impacting various organs and systems throughout the body.

Chemical Modifications and Their Implications

The potency and duration of action of anabolic steroids are often increased through chemical substitutions on the testosterone molecule. One crucial modification is 17-α-alkylation, which allows steroids to be taken orally. However, this alteration also slows the clearance of the drug in the liver, potentially increasing hepatotoxicity.

Injectable vs. Oral Steroids: Comparing Liver Effects

Injectable and oral steroids differ in their routes of administration and, consequently, in their effects on the liver. Injectable steroids are often considered less hepatotoxic than their oral counterparts. Why is this the case?

• Injectable steroids bypass first-pass metabolism in the liver
• Oral steroids undergo 17-α-alkylation, increasing their resistance to liver breakdown
• The slower clearance of oral steroids in the liver increases potential for hepatotoxicity

However, it’s important to note that while injectable steroids may be less damaging to the liver, they are not without risks. The overall impact on liver health depends on various factors, including dosage, duration of use, and individual susceptibility.

Factors Influencing Steroid-Induced Liver Damage

The frequency and severity of liver-related side effects from anabolic steroid use can vary significantly between individuals. Several key factors contribute to this variation:

1. Drug formulation (oral vs. injectable)
2. Route of administration
3. Dosage
4. Duration of use
5. Individual sensitivity and response
6. Concurrent use of multiple steroids or other drugs

Anabolic steroid users often take supraphysiologic doses or combine multiple steroids and other substances simultaneously. This practice, known as “stacking,” can significantly increase the risk of adverse effects, including liver damage.

Hepatotoxic Effects of Anabolic Steroid Use

Anabolic steroid use can lead to various forms of liver damage. What are the primary hepatotoxic effects associated with steroid use?

• Elevated liver transaminases
• Acute cholestatic syndrome
• Chronic vascular injury
• Hepatic tumors
• Toxicant-associated fatty liver disease
• Significant changes in lipoproteins

These effects can range from mild and reversible to severe and potentially life-threatening. The development and progression of liver damage often depend on the factors mentioned earlier, such as dosage and duration of use.

Elevated Liver Enzymes: A Warning Sign

One of the earliest indicators of steroid-induced liver stress is an elevation in liver enzymes, particularly aspartate aminotransferase (AST) and alanine aminotransferase (ALT). These enzymes are typically contained within liver cells, and their presence in the bloodstream suggests liver cell damage or death.

Regular monitoring of liver function tests is crucial for individuals using anabolic steroids to detect potential liver damage early. How often should liver function be tested in steroid users? While there’s no universal consensus, many healthcare providers recommend testing every 4-6 weeks during steroid use and for several months after cessation.

Cholestatic Liver Injury: A Serious Complication

Cholestatic liver injury is a severe complication associated with anabolic steroid use, particularly with oral formulations. This condition occurs when bile flow from the liver is impaired, leading to the accumulation of bile acids and other toxins in the liver.

Symptoms of cholestatic liver injury may include:

• Jaundice (yellowing of the skin and eyes)
• Itching (pruritus)
• Dark urine
• Pale stools
• Abdominal pain

Cholestatic liver injury can be severe and potentially life-threatening if not addressed promptly. In most cases, discontinuation of the offending steroid is necessary for recovery.

Reversibility of Steroid-Induced Liver Damage

A critical question for many steroid users is whether the liver damage caused by these substances can be reversed. The answer depends on several factors, including the type and extent of damage, as well as the individual’s overall health.

In many cases, liver function will stabilize or improve after cessation of steroid use. However, some forms of liver damage may be long-lasting or even permanent. For instance, hepatic tumors induced by anabolic steroids may persist even after discontinuation of the drug.

Timeline for Liver Recovery

The timeline for liver recovery after steroid use can vary significantly between individuals. In general, mild elevations in liver enzymes may normalize within a few weeks to months after stopping steroid use. More severe forms of liver damage, such as cholestatic injury, may take several months to resolve fully.

Factors that can influence recovery time include:

• The duration and intensity of steroid use
• The specific steroids used
• Individual liver health and overall health status
• Adherence to a liver-supportive lifestyle (e.g., avoiding alcohol, maintaining a healthy diet)

It’s important to note that some individuals may experience prolonged liver dysfunction even after stopping steroid use, emphasizing the need for ongoing medical supervision and liver function monitoring.

The Hidden Danger: Contaminated Supplements

While much of the focus on steroid-induced liver damage centers on intentional anabolic steroid use, there’s another significant risk that often goes overlooked: contaminated over-the-counter supplements. Some dietary supplements, particularly those marketed for bodybuilding or athletic performance enhancement, may be contaminated with anabolic steroids.

This contamination can lead to unintended steroid exposure and subsequent liver damage in unsuspecting consumers. How prevalent is this issue? While exact figures are difficult to determine, several studies have found anabolic steroid contamination in a significant proportion of tested supplements, sometimes at levels comparable to therapeutic doses.

Protecting Yourself from Contaminated Supplements

To minimize the risk of unintended steroid exposure from supplements, consider the following precautions:

• Choose supplements from reputable manufacturers
• Look for third-party testing certifications
• Be wary of supplements promising dramatic muscle gains or performance enhancement
• Consult with a healthcare provider before starting any new supplement regimen

Remember, even “natural” or “herbal” supplements can potentially contain undeclared steroid ingredients, so vigilance is key.

Medical Monitoring and Management of Steroid-Induced Liver Damage

Given the potential for serious liver complications from anabolic steroid use, proper medical monitoring and management are crucial. What should this monitoring entail?

1. Regular liver function tests (LFTs)
2. Periodic imaging studies (e.g., ultrasound, CT, or MRI) to check for structural liver changes
3. Monitoring of lipid profiles
4. Assessment of other potential steroid-related complications

If liver damage is detected, management typically involves immediate cessation of steroid use and supportive care. In some cases, medications to support liver function or manage complications may be necessary.

The Role of Liver Support Supplements

Some steroid users turn to liver support supplements in an attempt to mitigate potential liver damage. While certain supplements, such as milk thistle (silymarin), have shown promise in some studies, their effectiveness in preventing or treating steroid-induced liver damage remains controversial.

It’s important to note that no supplement can completely prevent liver damage from steroid use, and they should not be relied upon as a substitute for responsible use practices or medical supervision.

Legal and Ethical Considerations of Anabolic Steroid Use

The use of anabolic steroids for non-medical purposes is illegal in many countries, including the United States. Beyond the legal implications, there are also significant ethical considerations, particularly in sports and athletics.

The use of performance-enhancing drugs like anabolic steroids is generally considered cheating in competitive sports, leading to disqualifications, loss of titles, and long-term bans for athletes found to be using these substances.

The Broader Impact of Steroid Use

The effects of anabolic steroid use extend beyond the individual user. Consider the following broader impacts:

• Public health concerns due to potential long-term health consequences
• Strain on healthcare systems from treating steroid-related complications
• Erosion of fair competition in sports
• Psychological and social effects on users and their families

These far-reaching consequences underscore the importance of education, prevention, and responsible decision-making regarding anabolic steroid use.

Alternatives to Anabolic Steroids for Performance Enhancement

Given the significant risks associated with anabolic steroid use, many individuals seek safer alternatives for enhancing athletic performance and building muscle. What are some evidence-based strategies for achieving these goals without resorting to steroids?

1. Optimized nutrition: A well-balanced diet rich in protein, complex carbohydrates, and healthy fats
2. Progressive resistance training: Structured weightlifting programs designed to gradually increase strength and muscle mass
3. Adequate rest and recovery: Allowing sufficient time between workouts for muscle repair and growth
4. Natural supplements: Certain supplements like creatine and protein powders have been shown to support muscle growth and performance when used in conjunction with proper training
5. Hormone optimization: Working with a healthcare provider to address any underlying hormonal imbalances through lifestyle changes or appropriate medical interventions

While these strategies may not produce results as rapidly as anabolic steroids, they offer a safer, more sustainable approach to improving physical performance and body composition.

The Importance of Realistic Expectations

One of the challenges in promoting alternatives to anabolic steroids is managing expectations. The dramatic muscle gains and performance enhancements seen with steroid use are often not achievable through natural means alone.

Educating individuals about realistic, healthy body composition goals and the time frame required to achieve them naturally is crucial. This education can help prevent the temptation to turn to potentially dangerous substances like anabolic steroids.

Anabolic Steroid Effect on the Liver

Review

. 2018 Mar;17(3):97-102.

doi: 10.1249/JSR.0000000000000467.

Mark W Niedfeldt 
¹

Affiliations

Affiliation

• ¹ Medical College of Wisconsin Private Practice, Mequon, WI.

• PMID:

  29521706

• DOI:

  10.1249/JSR.0000000000000467

Review

Mark W Niedfeldt.

Curr Sports Med Rep.

2018 Mar.

. 2018 Mar;17(3):97-102.

doi: 10.1249/JSR.0000000000000467.

Author

Mark W Niedfeldt 
¹

Affiliation

• ¹ Medical College of Wisconsin Private Practice, Mequon, WI.

• PMID:

  29521706

• DOI:

  10.1249/JSR.0000000000000467

Abstract

Anabolic steroids are synthetic derivatives of testosterone shown to increase muscle size and strength. Chemical substitutions on the testosterone molecule cause increased potency and duration of action. The 17-α-alkylation modification allows steroids to be taken orally, but the slower clearance in the liver makes them more hepatotoxic. The frequency and severity of side effects depends on several factors including the formulation of the drug, route of administration, dosage, duration of use, and individual sensitivity and response. Anabolic steroid users tend to take supraphysiologic doses or multiple steroids and other drugs simultaneously which increases risk of adverse effects. Hepatotoxicity can be seen as elevated liver transaminases, acute cholestatic syndrome, chronic vascular injury, hepatic tumors, and toxicant-associated fatty liver disease, as well as significant changes in lipoproteins. Many of these changes will stabilize or reverse with cessation of steroid use, but some can be life-threatening. Over-the-counter supplements can be contaminated with anabolic steroids, causing hepatotoxicity in unsuspecting consumers.

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7 ways anabolic steroids affect your health

Androgenic-anabolic steroids (AAS) have been used to enhance athletic performance since the 1940s, but some of the health risks of steroid abuse have only recently come to light. Anabolic steroids have widespread effects on the body and its internal systems, so it’s not surprising that aside from their potential effect on muscle growth, they can harm other cells and organs. That’s why regular health screening and blood testing is so important. Find out more with our Sports Hormone Check.

How do anabolic steroids work?

Anabolic steroids are synthetic derivatives of the hormone testosterone which amongst other things is responsible for muscle development – “the anabolic effect”, and the development of male sexual characteristics – “the androgenic effect”.

Anabolic steroids work in several different ways in the body:

1. When we lift heavy weights we create tiny micro-tears in muscle fibres. Testosterone stimulates the creation of new and bigger muscle fibres in reaction to this. Anabolic steroids tend to cause an exaggerated version of this reaction due to the high doses people use.
2. Anabolic steroids stimulate production of growth hormone (GH) which in turn stimulates the production of IGF-1. IGF-1 has growth-promoting effects on almost every cell in the body especially skeletal muscle, cartilage and bone.
3. Intense exercise releases cortisol known as the stress hormone, which breaks down muscle tissue. Anabolic steroids inhibit this breakdown resulting in an overall anabolic effect.
4. There is evidence that anabolic steroids may increase oxygen uptake and increase cardiac output.
5. Anabolic steroids may also improve athletic performance by increasing aggressive behaviour.

Unintended physical consequences

A common misconception is that because anabolic steroids are a man-made derivative of a hormone occurring naturally in the body they should be safe to supplement with. The human body controls the blood and tissue levels of testosterone within a small range as too high or low a concentration can be harmful. However the typical doses taken as supplements by athletes are significantly higher than the amount that naturally circulates in our system. Use of anabolic steroids can therefore lead to multiple harmful physical side effects with shrunken testicles and male breast growth probably the most well known. An excess of androgens resulting from steroid use can also lead to male-pattern baldness, severe treatment resistant acne as well as altered libido.

Chronic steroid use causes the body to stop its own internal production of testosterone in an effort to maintain a constant level. This can lead to shrunken testicles that can no longer produce testosterone themselves. In addition, testosterone is converted to oestrogens which are important for modulating libido, erectile function and sperm generation. However an excess of testosterone can raise oestrogen to abnormal levels resulting in gynecomastia or the enlargement of male breasts. These effects can be permanent.

What lies beneath

In addition to the more noticeable effects associated with steroid use, there are other potential consequences that may not be so obvious but can pose a serious health risk. While blood testing can help pick up some of the abnormalities associated with excessive anabolic steroid use it is important to be aware that many of the harmful effects may not cause abnormalities in the blood until it is too late. It is also important to be aware that many of the treatments for the conditions described below are less likely to work with continued steroid use.

Here we describe 7 ways that anabolic steroids can damage your health without you even realising it:

1. Cardiovascular disease

There have been many studies on the impacts of anabolic steroids on the cardiovascular system in athletes and bodybuilders. Steroids have been shown to increase levels of LDL (bad cholesterol) and decrease levels of HDL (good cholesterol) – this increases the risk of atherosclerosis (hardening of the arteries) and heart disease such as angina, heart attacks and sudden cardiac death. Similarly steroid use is also associated with elevated C-reactive protein (CRP) levels – CRP is an marker of inflammation within the body and there is evidence that constant high levels may predispose people to cardiovascular disease. Find out more with our Sports Hormone Check.

Chronic steroid use can affect heart muscle causing a condition known as left ventricular hypertrophy which is an enlargement and thickening of the walls of the heart’s main pumping chamber. The enlarged heart muscle loses elasticity and eventually may fail to pump with as much force as needed. This is known as heart failure and is a common cause of disability and death in the elderly.

High blood pressure has been reported in some cases of anabolic steroid use which further increases the risk of cardiovascular disease.

2. Liver toxicity

Most metabolism of anabolic steroids occurs in the liver which is therefore prone to damage. Whilst athletes with pre-existing liver conditions are most at risk the damage can occur in anyone. The two markers of liver stress most commonly elevated in users of anabolic steroids are the enzymes ALT and AST. These enzymes are necessary for amino acid metabolism in the liver and will leak into the bloodstream as the liver becomes inflamed or damaged. ALP and GGT are also important markers of liver health during steroid use, and elevated levels can indicate liver toxicity. It is important to be aware that significant liver damage can be occurring even with normal liver function tests and that often the blood levels of these liver markers only start rising when the damage is severe enough. Find out more with our Sports Hormone Check.

3. Kidney injury

One of the kidneys many crucial functions is acting as a filter for the blood, removing excess waste products in the body. Bodybuilders frequently use dietary supplements including protein, creatine and vitamins to build strength and muscle bulk. High-protein intake is a concern as it increases the demand on the kidneys to filter off the excess products of protein metabolism. Often this is not a huge problem on its own, but when high-protein intake is combined with anabolic steroid use, this compounds the load on the kidneys and can lead to scarring and possibly kidney failure. Find out more with our Sports Hormone Check.

4. Infertility

Chronic anabolic steroid use causes a decrease in luteinising hormone (LH), and follicle-stimulating hormone (FSH) which are needed for sperm generation. This can cause a decrease in sperm count and mobility. Decreases in LH and FSH can be seen within 24 hours of beginning anabolic steroid use, and infertility may result within months. Usually infertility is reversible typically within 1 year of stopping steroid use, but it can take longer particularly in long-term users.

Men may also experience priapism, impotence, difficulty or pain with urination, and a possible increased risk for prostate cancer, which is why a regular prostate check is important. Find out more with our Sports Hormone Check.

5. Impaired glucose tolerance

Studies have shown that anabolic steroid use affects the body’s ability to handle sugar and can lead to type 2 diabetes. This can have a devastating health impact and further increase the risk of kidney damage, heart disease, strokes and blindness amongst other things. Testing of fasting blood sugar can help pick this up early before these complications start to arise. Find out more with our Sports Hormone Check.

6. Blood disorders

Anabolic steroid use increases stimulates the production of red blood cells and also increases the levels of haemoglobin (the protein in red blood cells that carries oxygen) and haematocrit (the percentage of red blood cells in the blood). This can result in a condition known as testosterone–induced polycythaemia or “sludging”. This causes the blood to become thicker which can in some people trigger life threatening blood clots to form in the bloodstream. Find out more with our Sports Hormone Check.

7. Thyroid dysfunction

Studies have shown negative effects of anabolic steroids on thyroid function. The thyroid is responsible for a huge number of important metabolic processes, and a thyroid hormone imbalance can cause a wide range of health issues (refer to our blog on thyroid function for more information). An annual thyroid check is important to keep track of thyroid function. Find out more with our Thyroid Check.

The importance of blood work

The use of anabolic steroids can lead to a number of negative health consequences most notably with cardiovascular and liver health. By the time physical symptoms of these develop, permanent harm may already have been done. The safest medical advice that any health professional would give you is to stop using these due to their risks. However, if you chose to continue taking these supplements it is important to be vigilant for any signs you may be harming your health. As discussed in this blog some of these effects can be identified in blood work before physical symptoms become apparent. These are the blood tests we recommend which are included in our Sports Hormone Check:

• Cholesterol status – there are many factors which contribute to your cardiovascular health. Your cholesterol (both high density and low density lipoproteins) and triglyceride levels are one risk factor we can assess by blood testing.
• Inflammation – the biomarkers c-reactive protein and creatine kinase provide insight into cardiovascular disease and muscle damage.
• Liver function test – your liver processes drugs and filters toxic chemicals. Liver damage is often evident from the assessment of liver enzymes and other key markers of liver function.
• Kidney function test – your kidneys filter waste from your body. Extreme athletes are more at risk of kidney failure due to high protein intake, excessive muscle breakdown from intense exercise as well as anabolic steroid use. Measuring key waste products as well as electrolytes, minerals and glucose provides good insight into kidney function.
• Full blood count – measuring steroid-induced increases in red blood cell count, haematocrit, and haemoglobin concentrations are important in determining the risk of heart attack or stroke.
• Hormone profile – supplementing with anabolic steroids can cause changes in hormone profile over time. Key hormones to measure include the androgens testosterone and free testosterone, as well as FSH, LH and oestradiol.

It is important to understand what your own ‘normal’ levels are for your blood biomarkers, and to track changes to these over time. Monitoring changes in your health data typically provides greater insight than a single isolated result, and will allow you to track any improvements or declines in performance.

If you want to reduce your health risks, then don’t take anabolic steroids. But if you are supplementing then visit our Sports Hormone Check to understand more about how blood testing and health screening can help manage your risk.

Steroids » City Polyclinic No. 1

Liver damage.

There is evidence of adverse effects of steroids on the liver, especially when taken orally. Most of the studies have been conducted on patients suffering from diseases such as anemia, kidney failure, impotence, and pituitary dysfunction. Various forms of cancerous tumors – benign (adenoma) and malignant (hepatocellular carcinoma) also cannot be ignored.

There is also evidence that liver tumors are caused by anabolic steroids containing a 17-alpha-alkyl group. Usually, benign tumors resolve after cessation of steroids. However, there are indications that steroid use by athletes can lead to hepatic carcinoma. Often such changes go unnoticed, since hepatitis and tumors in the liver do not always cause changes in the blood, which is usually used to judge the state of this organ.

The use of anabolic steroids causes an increase in the activity of liver enzymes in the blood. They are present in hepatocytes (liver cells) in a relatively high concentration, and an increase in their plasma level indicates damage to the liver, or at least an increase in the permeability of hepatocellular membranes. However, the results of studies on the effect of steroids on the liver are very controversial. In some cases, enzyme levels were elevated, and in others they were not.

Moreover, this increase was insignificant and quickly disappeared when the drug was discontinued. There are suggestions that the reaction of liver enzymes to steroids is determined by the state of the organ itself before that. Therefore, people with impaired liver function are at greater risk when using steroids.

Effect of steroids on the male reproductive system

The use of steroids leads to a high physiological concentration of testosterone or its derivatives. Synthesis and release of luteinizing hormone and follicle-stimulating hormone are reduced. Prolonged use of high doses of anabolic steroids leads to hypogonadotropic hypogonadism with reduced concentrations of luteinizing and follicle-stimulating hormones, as well as testosterone in plasma.

The duration of administration, dosage and chemical structure of steroids affect the plasma concentration of gonadotropins. And its slight decrease causes a decrease in sperm production and testicular atrophy. In athletes taking steroids, the number of degenerative spermatozoa increases, which reduces the ability to fertilize. In order for these functions to recover, it may take several months after stopping the drug. A well-studied side effect of steroids is female-type breast development (gynecomastia).

This is a common side effect of steroid use and you can always tell who is using or has used steroids by looking at it without doping control. Bill Phillips claims that at least nine Mr. Olympia contestants in recent years have undergone surgery to remove fatty tissue that accumulates around the nipples. This is due to increased circulation of the female sex hormone estrogen in the body. Estrogens estradiol and estrone are formed in men by peripheral aromatization from anabolic steroids. Elevated levels of available estrogen stimulate the growth of breast tissue. Breast changes are usually irreversible. Sometimes it is even accompanied by the secretion of milk!

Some experts have linked increased estrogen levels in men who use steroids to risk factors for cardiovascular disease.

Steroids may affect sex drive. Although several experiments have shown an increase in sexual desire, cases of erectile dysfunction are becoming more frequent. Here you can see a contradiction, but it is easy to explain it. Sexual desire depends on androgens, but erection is not. Due to the increase in aggressiveness along with the increase in sex drive, the athlete taking the steroid can commit a sexual offense.

Effect of steroids on the female reproductive system

In a normal female body, a small amount of testosterone is produced and, like in men, an artificial increase in its level with the help of anabolic steroids affects the hypothalamus-pituitary-gonads system. An increase in the amount of androgens in the body suppresses the production and release of other hormones (estrogen and progesterone, among others), which leads to a slowdown in the formation of follicles, ovulation and menstrual irregularities.

Another effect of steroids is increased sexual desire and clitoral hypertrophy. Such conclusions were made on the basis of studies of patients undergoing treatment with anabolic steroids.

Some other side effects are acne, baldness, lifting of the anterior hairline, male-pattern bald patches, deepening of the voice, increased facial hair growth, and chest atrophy. Moreover, a decrease in the timbre of the voice, a decrease in breast size, clitoral hypertrophy and hair loss are irreversible changes.

Effect of steroids on blood lipoproteins and heart

Most of the research on the effects of anabolic steroids in humans has focused on the risk factor for cardiovascular disease and especially on their effects on blood pressure and plasma lipoproteins. In most studies, plasma cholesterol and triglyceride levels were not significantly different between steroid users and steroid avoiders. However, over the course of a course of steroids, total cholesterol tends to rise, while high-density lipoprotein (“good” cholesterol) falls below normal levels. The level of low-density lipoprotein (cholesterol) changes slightly, increasing slightly or remaining unchanged. An experiment was conducted when ten strength athletes taking steroids were compared with their sports colleagues who did not use steroids. The control group consisted of ten men who did not go in for sports at all. Using an electrocardiogram and ultrasonic density video equipment, the researchers found that the steroid-using athletes had significantly higher diastolic blood pressure and greater left ventricular hypertrophy than those in the other two groups. This gave reason to conclude that steroids adversely affect the heart muscle and heart function.

There is further evidence that steroids cause structural changes in the heart and reduce ischemic tolerance. An echocardiographic examination of bodybuilders taking anabolic steroids revealed slight left ventricular hypertrophy. Some scientists associate cases of cardiomyopathy, myocardial infarction, and other cerebrovascular diseases with steroid use. There is strong evidence that injectable steroids are safer than oral steroids.

Hypertension (high blood pressure)

High or at least elevated blood pressure becomes a problem for many athletes who use steroids. This, as a rule, occurs simultaneously due to both water retention in the body and rapid body weight gain. The initial symptoms of high blood pressure may be headaches, insomnia, and difficulty breathing. This condition is also fraught with gradual degeneration of blood vessels, which leads to aneurysms, heart attacks, and even progressive heart disease. It should be remembered that the output of blood pressure beyond 130/90 or more is a signal to take action to regulate your condition. First of all, it is weight loss, reduced salt intake, aerobic exercise. There is no need to convince you once again that chronic high blood pressure is the cause of many diseases of the cardiovascular system that kill the most people on the planet.

Diseases of the cardiovascular system

Anabolic steroids are a significant risk factor for heart disease. This is largely due to the fact that steroid use negatively impacts the user’s cholesterol levels and profile: total cholesterol increases, high-density lipoprotein (HDL) levels decrease, and low-density lipoprotein (LDL) levels increase. This can lead to the formation of cholesterol plaques on the walls of arteries, and later to complete blockage of blood vessels. To avoid this condition, experts advise using blood test data as a starting point for deciding whether to take steroids, especially if you have elevated cholesterol levels before starting steroid therapy.

The risk with anabolic steroid use is variable and depends on the types of steroids, doses, duration and patterns of use, dietary composition, genetic susceptibility to cardiovascular disease, volume and types of exercise, and the presence or absence of other risk factors.

Heart enlargement

Cardiac hypertrophy can occasionally develop with long-term massive steroid use. This condition can be very dangerous. Symptoms of this side effect may be shortness of breath, increased heart rate, high blood pressure. In this case, you should stop using steroids, reduce body weight and work on a low-intensity aerobic exercise program.

Psychological effects of steroid use

Steroids affect human behavior. An increase in the amount of testosterone leads to a more “masculine” type of behavior, an increase in aggressiveness and an increase in sexual desire. This is beneficial in training, but can be dangerous outside of the gym or track. There are cases of aggressive, sometimes even criminal, behavior of people taking steroids. Other side effects are euphoria, excitability, sleep disturbance, morbid restlessness, paranoia, and hallucinations.

An increase in aggressiveness is very common among steroid users. Some athletes feel that this helps them to endure training loads more easily, perform better in competitions. However, more often aggressiveness becomes a negative phenomenon. Many steroid users find themselves hostile towards family, friends, co-workers; their behavior becomes defiant and unbearable. Ordinary situations that, without leaving a number of life situations, develop in training halls or outside them, can cause an aggressive reaction in such a person, which becomes even more pronounced when using alcohol. Highly androgenic steroids lead to this type of behavior. In addition, the athlete must anticipate such developments and prepare to forcefully suppress unwanted outbursts of rage.

Two Harvard Medical School psychiatrists, Dr. Harrison Pope and David L. Katz, have discovered severe mental disturbances in anabolic steroid users: depressive episodes, visual and auditory hallucinations. Individuals among the users of steroids found themselves in uncontrollable outbursts of irritability, manic episodes. In the West, some psychiatrists and psychologists are already widely using the term “steroid rage” due to the fact that the manifestations of this side effect are becoming more frequent and fixed.

When using steroids, the effect of emotional instability is classically manifested. Dr. Kitzman believes that steroid users develop a certain type of psychological dependence on them.

In a study of adolescents, psychologists found that those who were on steroids were three times more likely to engage in antisocial enterprises. They sleep with just anyone – of course, without condoms. And as a result: a bunch of “interesting” diseases.

A psychopathically thoughtless attitude towards their own and other people’s life manifests itself at every step: if they get behind the wheel of a motorcycle, then without a helmet and in a drunken state, they carry various self-made weapons with them and get involved in fights – more often without any reason.

Drug addiction among young “muscles” is generally a special issue. Drugs and steroids go hand in hand like twin brothers. One dangerous habit is bound to lead to another. Anyone who dabbled in “weed” without hesitation begins to inject themselves with steroids. Conversely, steroid users often become heavy drug addicts. In the US, more and more steroid users find themselves behind bars due to their violent behavior, attacks on people and even murders. There are reports that lawyers in some US states are bringing in steroid experts to make sure that their clients’ behavior is due to steroid use. Megalomania, paranoia are also very common signs of this side effect of steroids, and you probably could see for yourself.

Sodium retention

This is the most common side effect. It causes edema (tissue swelling due to excess water retention). For most athletes, this is expressed in a slight increase in body volume and smoothing of the relief. This swollen appearance is the most noticeable sign that even without doping control it is possible to determine that the athlete is sitting on a cycle. This is especially noticeable on the cheeks and under the eyes. In addition to this cosmetic inconvenience, sodium and water retention, as a result, can lead to acute attacks of high pressure. Sometimes such water retention is a sign of an underlying heart or kidney disease. Especially strong water retention can be caused by various testosterone preparations.

Acne (acne)

This is also a very common side effect of steroid use. Anabolic steroids can cause acne or aggravate an existing acne problem. Human skin has the ability to destroy androgenic hormones, which are found in it in very small quantities. When exogenous steroids are used, the concentration tends to rise beyond what the skin can handle, and this allows bacteria to multiply. When this is combined with increased greasiness of the skin, which is inevitable with steroid use, the situation becomes even more unfortunate.

There may be a genetic predisposition to acne. The degree of acne skin damage depends on the androgenicity of the steroids taken. Severe acne on the back, chest, shoulders, neck and face is a signal that some athletes are sitting on the cycle.

Oncological diseases (Cancer)

The use of anabolic steroids is very rarely associated with cancer. The consequence of taking steroids are tumors in the liver, suspected of cancer. It must be said that in most cases these deviations were recorded in persons who used alpha-alkylated oral drugs for a long time. It is known that the liver and kidneys are subjected to a powerful load when using steroids. “Peliosis hepatitistis”, that is, blood-filled cysts in the liver, is becoming an equally rare occurrence. This condition is reversible, i.e. they disappear with discontinuation of steroid use, but it is nevertheless associated with the development of liver cancer. It has also been established that prolonged steroid therapy, especially at high dosage, leads to progressive cholestasis, jaundice and other negative changes.

Steroid smile

Someone who takes steroids for a long time is easy to recognize . .. by the teeth. More than 70% of bodybuilders who inject themselves with steroids suffer from a special disease – spasms of the jaw muscles. In the morning, they wake up with tightly clenched jaws, and the compression is so strong that it changes the position of the teeth and damages the enamel. At night, the relatives of such bodybuilders are disturbed by the “creaking” of teeth, which is also a consequence of jaw spasm. However, this is not the only consequence of taking steroids associated with teeth. Doctors call at least 5 more pathological symptoms: Wear of the ligaments of the jaw attachment due to spasmodic contraction of the jaw muscles.

Weakening of the salivary glands, leading to a deficiency of saliva (dry mouth). After tooth extraction, suppuration occurs more often. Removal is associated with complications due to thickening and hardening of the jawbone. Reduced resistance to dental and oral infections.

Anesthesia during dental treatment often gives a picture of shock due to the reaction of painkillers to the altered blood composition. In conclusion, mention should be made of the serious consequences of taking anabolic steroids in combination with other pharmacological drugs. On the one hand, this is done in an attempt to neutralize their side effects. Growth hormone, thyroid hormones, antiestrogens, antidepressants are used. On the other hand, people try to maintain the anabolic effect of steroids by taking other anabolic hormones such as growth hormone, insulin, clenbutirol, or another form of anabolic steroids. All this is done without proper medical supervision and can lead to serious illness.

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Consequences of non-medical use of anabolic steroids

Post-mortem observation . A professional athlete, 42 years old, who has been engaged in bodybuilding since the age of 24 and independently used anabolic androgenic steroids (AAS) and protein preparations throughout this entire period of time in order to build muscle mass, felt unwell when lifting the barbell during training, was hospitalized in the nearest hospital . Ultrasound and CT examination revealed an enlarged liver with a large multicystic formation, presumably regarded as a manifestation of echinococcosis (Fig. 1). There were hyperbilirubinemia of 74.6 mmol/l, an increase in ALT activity up to 1340 units, AST up to 1005 units. For further examination and treatment, after 2 days, the patient, in a state of moderate severity, was transferred to the Research Institute of Emergency Care. I.I. Dzhanelidze.

Rice. 1. Computed tomogram. Damage to the right lobe of the liver, regarded as multiple cysts.

At the Research Institute, due to the presence of symptoms of peritoneal irritation along the right flank and suspicion of peritonitis, the patient underwent a laparoscopic operation, which revealed the presence of 250 ml of lysed blood in the peritoneal cavity, an enlarged liver, the lower edge of which was located 2 cm below the navel, signs of intrahepatic cholestasis. No visible damage found. The postoperative diagnosis was formulated as “toxic hepatitis, liver hematoma (?), small hemoperitoneum”.

Symptomatic treatment was carried out, the patient’s condition remained satisfactory, but on the 5th day from the moment of hospitalization it deteriorated sharply, unchanged blood began to flow through the drainage tube from the peritoneal cavity, peritoneal symptoms appeared, in connection with which the patient was taken to the operating room. During laparotomy, 1.5 liters of blood was found and evacuated in the peritoneal cavity, ruptures were found on the anterior surface of the liver, during the revision of which a cavity about 10 cm in diameter was found with blood leaking from it. Hemostasis was achieved by stitching the liver sections with elements of omentopexy, coagulation, using a hemostatic sponge, and plugging the rupture sites with five gauze swabs. Tissue fragments from the lesion were taken for biopsy. In the postoperative period, despite intensive therapy, the patient’s condition worsened and on the 10th day after hospitalization at the Emergency Research Institute, she died.

At the autopsy during an external examination of the corpse, in addition to well-defined muscles and yellowness of the skin and sclera, attention was drawn to the presence of traces of shaved bristles on the chin, enlargement of the labia and clitoris, atrophy of the mammary glands, represented by almost only nipples, indistinct subcutaneous fat base, thickness which in the epigastric region was 1.2 cm. In both pleural cavities, 100 ml of hemorrhagic fluid were found, in the epicardium, visceral pleura and parietal peritoneum, petechial hemorrhages. The sharply enlarged liver had a size of 34×28×19×13 cm and a weight of 3700 g. In its right lobe, after removing the tampons, a rounded cavity 8 cm in diameter with an uneven bottom of a bright yellow color was found (Fig. 2, a). On the section, the edges of the cavity, 1.5-2 cm wide, had the same color, were dryish, with a clear border with the rest of the tissue. In addition, on the lateral surface of the right lobe there was a vertical uneven gap about 10 cm long and up to 4 cm deep with a few blood clots and dirty yellow semi-liquid masses in the depth of the gap. In addition to the described changes, on the section (see Fig. 2, b) in segments VI-VIII there were many closely spaced cavities 1-1.5 cm in diameter with cloudy pus-like contents. The bottom and edges of the cavities about 0.5 cm wide had a bright yellow color. The border of these cavities with the adjacent tissue was clear. In the left lobe, the tissue in the section is homogeneous, brown, clayey.

Rice. 2. Actinomycotic liver abscesses. a – outside view; b – sectional view.

Elastic heart, 11×10×5 cm in size and weighing 280 g. A small amount of petechial and confluent hemorrhages were found in the endocardium of the left ventricle. The thickness of the myocardium of the left ventricle is 1.2 cm, that of the right ventricle is 0.2 cm. The myocardium in the section is brown, clayey, dull, homogeneous. In the lungs there was a picture of bilateral lower lobe focal pneumonia, the weight of the lungs was 940 and 1020 g. The spleen was elastic, cyanotic, the weight was 240 g and the sharp edge of the incision. In kidneys, the mass of which was 390 g, the changes corresponded to the picture of bilirubinuric nephrosis.

Manifestation of hemorrhagic syndrome, in addition to pinpoint hemorrhages in the serous membranes and endocardium, were traces of altered blood in the stomach, 300 ml of altered blood in the small intestine, and blood-stained feces in the large intestine, although no obvious source of bleeding could be found.

Changes in other organs included atrophy of the endometrium and ovaries, thinning of the adrenal cortex to 0.1 cm.

In a liver biopsy, which was examined on the day of the patient’s death, actinomycosis was revealed in the form of many cavities with neutrophilic leukocytes and drusen of actinomycetes (Fig. 3).

Rice. 3. Abscess with actinomycetes in the center. Stained with hematoxylin and eosin. ×100.

Histological examination of the sectional material revealed multiple changes, the complex of which was due to the patient’s self-administration (introduction) of AAS.

So, in the liver, in addition to the already described actinomycosis, there were widespread dyscirculatory so-called centrilobular and bridging necrosis. The surviving hepatocytes were enlarged, had an average diameter of 44 microns (at a norm of 20-25), the nuclei in them were also large, with chromatin margination, with one, less often two nucleoli. The cytoplasm of hepatocytes contained small and medium fat vacuoles. The myocytes of the lumbar muscle had an average diameter of 118 microns (at a norm of 50-100), while in some of them it reached 190 µm. In the pancreas, attention was drawn to a sharp increase in the diameter of the islets of Langerhans, the maximum diameter of which was 650 microns, with an upper limit of normal of 225 microns. The anterior pituitary gland consisted exclusively of cells with eosinophilic cytoplasm. The thyroid gland is built from medium and large follicles, lined with a single-row cuboidal epithelium, filled with dense, locally cracked eosinophilic colloid in the preparation without resorption vacuoles. There were numerous white bodies in the ovary, a single small cyst lined with a single-row cuboidal epithelium and filled with weakly eosinophilic fluid. The distal tubules of the kidneys are obturated with numerous bilirubin casts. The white pulp of the spleen is represented by rare periarteriolar lymphoid clutches and single follicles without light centers. In the para-aortic lymph node, the tissue was sparse, without a clear pattern of follicles.

Thus, a post-mortem histological examination revealed working hypertrophy of skeletal muscles, dystrophic changes and hypertrophy of cardiomyocytes, numerous dyshormonal changes and signs of an immunodeficiency state, against which actinomycotic liver damage arose.

Postmortem diagnosis is formulated as follows:

Primary disease

Actinomycosis of the liver, purulent-necrotic form with a massive lesion of the right lobe.

Underlying disease

Secondary immunodeficiency due to long-term self-administration of anabolic hormones.

Complications

Parenchymal jaundice. Bilirubinuric nephrosis (kidney weight 390 g). Operation 05.06.15: diagnostic laparoscopy. Rupture of the right lobe of the liver with hemorrhage into the peritoneal cavity on June 10, 2015. Operation 06/10/15: laparotomy, bleeding arrest from liver rupture, liver tamponade, sanitation and drainage of the peritoneal cavity. Massive dyscirculatory necrosis of the liver. hemorrhagic syndrome. Bilateral lower lobe pneumonia. Bilateral hydrothorax, 100 ml.

Practice of non-medical use of anabolic drugs

An analysis of foreign literature showed that in order to achieve high results, these drugs are mainly used in the training process by bodybuilders, weightlifters, armwrestlers and kickboxers. At the same time, most of these drugs are banned for use in humans, are produced clandestinely and are purchased on the “black market”. At the same time, at present, in a number of countries, such as the USA, Brazil, Scandinavian countries, these drugs are increasingly used not by athletes, but by fitness enthusiasts. According to H. Pope et al. [1], the number of such persons in the United States, the vast majority of which are men, reaches 3 million people. According to other survey data, 2% of US university students have used AAS in the last 12 months [2]. On the contrary, the use of AAS is very rare among residents of East Asian countries such as China, Korea and Japan, possibly due to the fact that in their cultures less attention is paid to the condition of the muscles in men [3].

Athletes and amateur bodybuilders combine various steroids in cycles of increasing and decreasing concentrations. This is usually a combination of androgens and nonsteroidal drugs. The latter are chosen to provide a further anabolic effect (human somatostatin, insulin-like growth factor-1 and insulin) and to reduce the side effect of AAS, increase fat and water loss (diuretics, thyroxine, and β ₂ -adrenergic receptor agonists), reactivate endogenous testosterone production at the end of the cycle (gonadotropins) and reduce the risk of AAS detection in urine (diuretics) [4]. Bodybuilders also combine AAS with erythropoietin for training intensification and faster post-workout recovery.

AAS are administered orally, transdermally, or as intramuscular injections. A pooled analysis of the results of 10 studies showed that 25.4-39.7% (mean 32.5) of AAS users develop addiction, and these are almost exclusively men: out of 363 people with AAS addiction, only 2 were women. The number of people with AAS addiction among US residents is about 1 million [1].

AAS users often combine their use with opiates [5]. This allows them to continue exercising despite muscle and joint pain. Naturally, some of them become addicted to opiates [6].

The mechanism by which testosterone preparations lead to higher athletic performance is not well understood. The use of AAS leads to an increase in muscle mass due to hypertrophy of both type 1 and type 2 fibers, while neither the total number nor the percentage of these fibers changes [7].

Testosterone increases the level of somatostatin and insulin-like growth factor-1 in the blood, although somatostatin circulating in the blood is not an important mediator of the effect of testosterone on muscle mass, but insulin-like growth factor-1, acting on the corresponding receptors, is an important mediator of the myogenic effect of testosterone [8 ]. Testosterone also increases the number of mitochondria in myocytes and oxygen delivery to tissues by increasing the number of red blood cells, expanding the network of capillaries in muscles. It increases the level of 2,3-bisphosphoglycerate in the blood, which facilitates the transfer of oxygen by hemoglobin to tissues [9].

AAS stimulate erythropoiesis by increasing the sensitivity of the bone marrow to erythropoietin [10] and increasing the availability of iron for erythropoiesis [11]. They can also increase motivation and mood, which can indirectly affect athletic performance.

In addition to testosterone preparations, androgen receptor modulators are used that are prohibited for medical use [12]. Other drugs used for androgenic stimulation are exogenous human chorionic gonadotropin, antiestrogen such as tamoxifen, clomiphene and raloxifene, and aromatase inhibitors such as testolactone, letrozole and anastrozole, the administration of these drugs leads to an increase in serum testosterone levels [13 ].

Somatotropic Hormone (GH) stimulates lipolysis and fatty acid oxidation, providing energy and thereby preventing protein catabolism. At the body level, GH inhibits glucose oxidation and its utilization, although at the same time it enhances glucose oxidation by the liver. STH has an antagonistic effect on insulin, provides protein anabolism and reduces urea synthesis, inhibits protein oxidation, increases total body weight (due to extracellular fluid and cell mass), and reduces adipose tissue mass [14].

On the Internet, in addition to offers for the sale of recombinant GH, they offer peptides that regulate the synthesis of GH by the pituitary gland, ghrelin hormone mimetics and other growth factors.

Insulin, used along with AAS, enhances protein synthesis: its administration is accompanied by an increase in protein synthesis in myocytes by 70% [15]. At the same time, the authors believe that insulin directly stimulates protein synthesis, regardless of the transmembrane transport of glucose or amino acids.

The use of β-adrenergic receptor agonists is based on their ability to influence the increase in muscle mass by inhibiting protein catabolism and reducing the total body fat mass [16].

Negative effects of the drugs used. The negative impact of AAS is realized simultaneously in many directions. At the tissue level, it consists, when used in supraphysiological doses, in the activation of lipid peroxidation [17] and the acceleration of apoptosis in various tissues [18, 19].

One of the targets for AAS is the myocardium. In users of these drugs, the development of cardiomyopathy [20], myocardial infarction [21], and conduction disturbances [22] are described. So, in the study by H. Far et al. [23], when comparing 87 autopsy observations of AAS users with a control group of 173 deceased men, a significant increase in heart mass was demonstrated even in relation to total body weight. In another study, based on the material of 4 deaths in AAS users, ventricular myocardial hypertrophy was demonstrated in combination with cardiosclerosis and myocytolysis with the development of a cardiac-type terminal state [24]. Studies using echocardiography [25] and magnetic resonance imaging [26] in AAS users have shown signs of cardiomyopathy with a decrease in ventricular ejection fraction and diastolic dysfunction, while if functional changes are considered fundamentally reversible, then changes accompanied by cardiosclerosis are no longer present.

In addition to a direct effect on the myocardium, long-term use of AAS causes dyslipidemia in the form of a decrease in the ratio of high and low density lipoproteins in the blood [27], which is accompanied by more pronounced manifestations of atherosclerosis of the coronary arteries of the heart, changes in physiological parameters, including heart rhythm disturbances [28 ]. Thus, a survey of 143 weightlifters who used AAS for a long time revealed a greater amount of calcareous deposits in the coronary arteries of the heart than in men of their age in the population [29].

Of the deaths reported in the literature in AAS users, the majority of deaths are due to sudden cardiac death [30].

A number of studies have described the development of psychological and psychiatric symptoms in people using AAS. These deviations consist of manic or hypomanic symptoms, as well as depressive symptoms with AAS withdrawal, the manifestations appear to be dose-dependent and develop, as a rule, in individuals receiving more than 1000 mg of testosterone per week [31]. Behavioral changes were also observed in laboratory animals treated with supraphysiological doses of AAS [32]. Individuals using AAS have a tendency to criminal behavior and violent actions, including murder [33].

Muscle dysmorphophobia has been shown to be a common symptom in AAS users [34]. Since AAS use on the feedback principle is accompanied by a picture of hypogonadism, which, if the drugs are discontinued, can last weeks and even months and be accompanied by increased fatigue, loss of libido and depression, former users start taking AAS again to eliminate these phenomena.

Due to the fact that supraphysiological doses of AAS entail an acceleration of apoptosis in the cells of the central nervous system [35], this is accompanied by impaired memory of spatial images, demonstrated in AAS-treated weightlifters [36].

The presence of high concentrations of testosterone in the blood is accompanied by a feedback principle of a decrease in stimulation of the gonads by the hypothalamic-pituitary system in men who have an increase in sexual activity in the early stages of taking AAS. In the future, this is manifested by the appearance of bald patches, inhibition of spermatogenesis, testicular atrophy, infertility and erectile dysfunction, which, according to some authors, are reversible after discontinuation of drugs [37], and according to others, they may be irreversible even if the function of the hypothalamus and pituitary gland returns to normal [38]. Taking AAS in men is often accompanied by gynecomastia and the appearance of acne on the skin. Taking AAS in women leads to ovarian hypofunction, which is manifested by menstrual disorders up to the development of amenorrhea, hirsutism, a change in (reversible) voice, and in severe cases, bone mass deficiency [37]. Some researchers, as a consequence of long-term use of AAS by men, point to the possibility of the occurrence of benign hyperplasia and prostate cancer against this background [39].

Long-term use of AAS is accompanied by impaired immunity [40]. They are based on a violation of the synthesis of immunoglobulin, including class A [41, 42], an increase in the blood levels of IL-1β, TNF-α, a decrease in the production of IL-6, -2, -4, -5, IFN, a decrease in the activity lymphocytes, especially natural killer cells, impaired differentiation of T-lymphocytes [41], impaired synthesis and excretion of superoxide anion, decreased oxidative activity of neutrophilic leukocytes despite the observed activation of phagocytosis [43].

Qualitative characteristics of the drugs used. The development of an artificial disease in AAS users is due not only to supraphysiological doses of AAS, but also to the quality of the drugs used, 80% of which are purchased on the black market, while 90-99% of steroids sold via the Internet are fake. Steroids and other muscle-building hormones make up two of the six groups most commonly counterfeited [44]. The main producer of raw materials for fakes is China, and the manufacturers are the USA, Canada and Mexico. A study of 2818 drugs sold in Brazil showed that almost half of them did not contain the claimed substance, and 28.3% contained substances not indicated on the labels [45]. Forensic chemical analysis of 40 anabolic steroids, carried out by German specialists, did not detect the claimed substance in them in 37.5% of cases [46].

An analysis of drugs conducted in 2007 showed that in 35% of cases the dose of AAS ranged from 102 to 459% of that indicated on the labels, unidentifiable steroid components were found in 60% of the samples, and heavy metals were found in 21% [47]. The official website of the Food and Drug Administration (FDA, USA, 2011) indicates that injectable AAS sold on the “black market” in fact often turn out to be sesame or corn oil, water with artificial sweetener, magnesia or diluted milk. The outcome of such injections is unknown. Finally, a specially conducted microbiological study [48] showed that such injectable preparations often turn out to be contaminated with saprophytic bacteria living on the skin.

As practice shows, familiarization with Western values, among other things, entails a number of negative influences. Not only professional, but also “domestic” use of AAS is taking on the character of an epidemic, the victims of which, apparently, will increasingly have to be faced by pathologists and forensic experts, therefore, ideas about the multiorgan pathology that occurs when using AAS should contribute to the correct assessment of certain clinical situations.

No conflict of interest.

The main producer of raw materials for fakes is China, and the manufacturers are the USA, Canada and Mexico. A study of 2818 drugs sold in Brazil showed that almost half of them did not contain the claimed substance, and 28.3% contained substances not indicated on the labels [45]. Forensic chemical analysis of 40 anabolic steroids, carried out by German specialists, did not detect the claimed substance in them in 37.5% of cases [46].

An analysis of preparations conducted in 2007 showed that in 35% of cases the dose of AAS ranged from 102 to 459% of that indicated on the labels, unidentifiable steroid components were found in 60% of the samples, and heavy metals were found in 21% [47].