Many different hormones are naturally synthesized in the human body. Males produces testosterone in the testes and females produce estrogen and progestin in the ovaries. These hormones are used by the body for the development of secondary sexual characteristics. Females also produce a small amount of testosterone via the adrenal gland and ovaries. These hormones have both androgenic and anabolic properties. The androgenic part of the compound promotes the male sex characteristics, such as body hair growth, deepening of the voice, and increased muscle mass. The anabolic compounds enhance tissue metabolism. Many times these drugs are referred to as anabolic/androgenic steroids (AAS) by the athlete or public when they are being discussed for their ergogenic properties.
Internet Resource Box
For position statements on anabolic steroids, see:
American College of Sports Medicine: http://www.aesm-msse.org
National Strength and Conditioning Association (NSCA): http://www.nsca-lift.org
In males, as previously discussed, testosterone is produced in the testes. In females, endogenous testosterone begins in the form of androstenedione and is converted to testosterone as needed. Testosterone is carried in the blood by one of three methods: via sex hormone-binding globulin (SHBG); bound to albumin; or if not bound, in what is called a "freeform" or unbound state. When carried by SHBG, testosterone is tightly bound and is not readily available for use by the tissues in the body. About 30 percent of male-available and 58 percent of female-available testosterone is carried by SHBG. A second method of testosterone movement in the body is via a loose bond to albumin. In males 67 percent of testosterone is carried in this manner, and in females 40 percent of testosterone is loosely bound to albumin. The remaining 3 percent for males and 2 percent for females is free and available to the system. The loosely bound and free testosterones are the most readily available forms for utilization by the body. As can be observed through outward secondary sex characteristics, males have much more testosterone readily available for utilization.
Both sexes naturally produce androgenic and anabolic compounds. Male and female hormones can also be synthetically produced and used for many different types of medical disorders, which will be discussed later. There has yet to be a synthetic steroid that does not produce both androgenic and anabolic properties in the person abusing them. Therefore both genders can experience the development of secondary sex characteristics of the opposite gender if these hormones are "out of sync" in the body or the person is abusing these drugs. Steroid abuse will be discussed in more detail further on in this chapter.
Throughout recent history, AAS have been used by some to gain an advantage over their competitors or enemies. The illicit use of AAS has been documented in war and athletic competition by numerous authors. It is reported that steroids were used to increase the size and aggressiveness of the German soldiers in World War II.42 As mentioned, the use of steroids for performance enhancement in athletes can be documented back to the 1970s in East Germany. In the 1960s and 1970s, the sports medicine teams for some Eastern- Bloc countries (East Germany, Poland, and others) were providing steroids to young athletes to increase size and improve performance in all types of sports. Ungerleider56 reported that steroids were given to these Eastern-Bloc athletes unknowingly. They were told that the pills and shots they were receiving were vitamins that would help their athletic performance. When these athletes found out that they were receiving large doses of steroids, it was usually too late. Many of the female athletes had experienced the masculinizing effects of the steroids. Athletes were also experiencing the physical and mental problems associated with steroid abuse that will be discussed in the adverse effects section.
Because excessive use of steroids is illegal, it is virtually impossible to do scientific testing on athletes using steroids that accurately accounts for the true amounts they use on a daily, weekly, or monthly basis. Most of the information athletes receive about using steroids to generate muscle size and strength comes from people trying to sell steroids, such as teammates or friends who are also using steroids illegally. It is not reasonable to expect persons who are using drugs illegally to maintain accurate and reliable records over many years and then share that information with persons who may oppose the illegal use of these drugs. Essentially, we are aware that AAS will generate muscle mass, but we do not know how much a person needs to take in order to achieve significant gains. To prescribe steroids in the amounts typically used by athletes to build strength and increase body mass would be unethical and illegal in a legitimate scientific research project.
Therefore, in this chapter, we will discuss the prescription of steroids for medicinal purposes and the amounts reportedly abused by some athletes who were willing to divulge information regarding their steroid use. The major difficulty in analyzing self-reported data from illegal drug users is that there is no way to determine if the self reported amounts are correct. This makes it difficult to get objective information for the athletic trainer. The authors of this chapter find it very difficult to believe that information gathered from athletes using drugs is accurate and without bias. We do know that athletes who abuse steroids are taking more than the prescribed therapeutic dosages recommended for the treatment of diagnosed disease processes or other problems that can be treated by medicinal steroid use. The most common types of AAS are outlined in Table 11–1.
Table 11-1Common Types of Anabolic Steroids Used by Athletes ||Download (.pdf) Table 11-1 Common Types of Anabolic Steroids Used by Athletes
|Generic Name ||Common or Brand Name ||Medicinal Purpose ||Recommended Dosage ||Reported Dosages by Athletes* ||Reference |
|Oral Preparations |
|Fluoxymesterone ||Halotestin/Android-F ||Hypogonadism ||5–20 mg/day || || |
|Mesterolone ||Hypogonadism ||50–100 mg/day |
|Methandrostenolone ||Dianabol ||Postmenopausal osteoporosis ||5–20 mg/day ||40 mg/day ||bb |
|Oxandrolone ||Anavar/Oxandrin ||Anorexia in surgical candidates ||5–10 mg/day ||25 mg/day ||aa |
|Oxymetholone ||Anadrol-50 ||Severe anemia ||50–150 mg/day ||1 mg/kg/day ||aa |
|Stanozolol ||Winstrol ||Prophylactic use against hereditary angioedema ||2–6 mg/day ||150 mg/week ||bb |
|Ethylestrenol ||Maxibolin |
|Injectable Preparations |
|Nandrolone deconate ||Decadurabolin ||Severe anemia ||50–200 mg/week ||600 mg/week ||aa |
|Control of metastatic breast cancer |
|Stanozolol ||Winstrol ||Veterinary use only ||100–300mg/week ||aa |
|Trenbolone ||Parabolan ||Veterinary ||304 mg/week ||aa |
|Boldenone ||Equipose ||Veterinary || ||250 mg/week ||aa |
|Testosterone ||Depo-Testosterone ||Androgen replacement therapy ||50–400 mg/week ||1000 mg/week ||aa |
|Delatestryl ||Inoperable breast cancer |
|Male hypogonadism |
|Sustanon 250 ||Testosterone Blend ||Available only via underground sources ||500 mg/week, some reports of 1000 mg/week ||bb || |
|Contains 4 different types of testosterone: |
|1. Propionate |
|2. Phenylpropionate |
|3. Isocaproate |
|4. Deconate |
Individuals who use excessive dosages of steroids as part of their weight-training activities follow what is called a stacking protocol or cycling. A stacking protocol consists of simultaneously using multiple types of steroid drugs in high doses. The cycling of drugs means that the athlete follows a timed cycle that begins with small doses and increases to very high doses, then tapers off to a drug-free period. Examples are given in Tables 11–2 and 11–3. The concepts of stacking and cycling drugs have been around for many years. These practices are believed to enhance the effectiveness of the total combination of steroids taken during the cycle. Some users believe that the stacking protocol can reduce some of the adverse effects produced by one or more of the more potent steroids being taken. Again, the recommended length of cycle, combination of steroids used, and daily dosing procedures vary depending on whom you talk to and what they have experienced or learned secondhand about these techniques. According to "experts," cycles range from 8 weeks to a year in length. Users may not take steroids every day, but instead may have weeks "on" and weeks "off" that correspond to the type of steroids being taken and the perceived reason for taking each drug.
Table 11-2Steroid Cycling Example ||Download (.pdf) Table 11-2 Steroid Cycling Example
|Week ||Winstrol mg/week ||Primobolan mg/week ||Clenbuterol tablets/day |
|1 ||100 ||100 ||1 tid |
|2 ||200 ||100 ||1 tid |
|3 ||200 ||200 || |
|4 ||300 ||200 || |
|5 ||300 ||300 ||1 tid |
|6 ||200 ||200 ||1 tid |
|7 ||200 ||200 || |
|8 ||100 ||100 || |
|9 || || ||1 tid |
|10 || || ||1 tid |
Table 11-3"Super Cutting Cycle" Example ||Download (.pdf) Table 11-3 "Super Cutting Cycle" Example
|Week ||Mon ||Tues ||Wed ||Thurs ||Fri ||Sat ||Sun |
|1 ||100 mg P || || || || || || |
|2 ||100 mg P || ||150 mg D || || || || |
|3 ||150 mg P || ||200 mg D || || || || |
| || || ||50 mg W || || || || |
|4 ||150 mg P || ||200 mg D || ||50 mg W || || |
| ||50 mg W || ||50 mg W || || || || |
|5 ||200 mg P || ||200 mg D || ||50 mg W || || |
| ||50 mg W || ||50 mg W || || || || |
|6 ||200 mg P ||50 mg W ||150 mg D || ||50 mg W || || |
| ||50 mg W || ||50 mg W || || || || |
|7 ||150 mg D || ||150 mg D || ||50 mg W || || |
| ||50 mg W || ||50 mg W || || || || |
|8 ||150 mg D || ||150 mg D || ||50 mg W || || |
| ||50 mg W || ||50 mg W || || || || |
|9 ||150 mg D || ||150 mg D || ||50 mg W || || |
| ||50 mg W || ||50 mg W || || || || |
|10 ||100 mg D || ||50 mg W || || || || |
| ||50 mg W || ||50 mg D || || || || |
|11 ||5000 IU HCG || || || || || || |
|12 ||5000 IU HCG || || || || || || |
The propagation of steroid abuse via Internet resources is astonishing. One has only to look for a matter of minutes on the Internet to find dozens of Websites promoting steroid use for a variety of objectives. Many Websites have steroids for sale and contain stacking regimens and question- and-answer pages. The use of commercial Websites as a source of information for athletes using steroids is unconscionable. These Websites can be very convincing, and a novice athlete could be easily persuaded to use steroids to gain muscle strength and body mass.
Physiological Effects of Steroids
It is difficult to document all of the physiological effects of steroids through scientific research, but many athletes can provide testimonials regarding the increase in body mass associated with steroid abuse. Usually, individuals use AAS to increase muscle strength by increasing muscle protein synthesis, inhibiting the catabolic effects of glucocorticoids, and increasing the aggressive behavior tendencies of the individual, thereby inclining him or her to train harder. Kadi et. al.30 reported that taking steroids and participating in strength training increases the size of the muscle (hypertrophy) and the number of muscle fibers (hyperplasia). One must recognize that this study was conducted using subjects (weightlifters) who claimed that they had abused steroids for an average of almost 10 years. The investigators did not make any comparisons of the genetic makeup of the subjects. Some researchers would like to link steroid users' increase in strength to the increase in resistance training that is often associated with the abuse of AAS. Other researchers believe that the increase in strength correlates directly with the use of excessive doses of AAS. They posit that the steroids increase muscle mass; after an athlete has gained muscle mass, he or she is able to lift more weight.
Published clinical studies demonstrate that an increase in the size of a person occurs after the medicinal use of steroids, such as by a physician for growth delay in an adolescent. It is well documented that a person will get bigger when he or she uses supraphysiologic doses of AAS.7,30,35 However, it is not well documented that the person will generate more strength. In published research, it has been demonstrated that when a person is abusing AAS, typically he or she is also performing a great deal of resistance training on a very regular schedule. This was demonstrated by Bhasin et al.,7 who demonstrated that either steroid use alone or resistance training alone will individually increase strength in some athletes. However, when steroids and resistance training were combined, the strength gains were greater than those achieved with either of the individual treatments.
It is also suggested that steroids may provide a decrease in reflex latency. A study conducted by Ariel and Saville3 indicated that there is a quicker patellar reflex response by the muscle from a stimulus in the athlete using AAS. This would indicate that athletes requiring quick reflex movements might benefit from the use of steroids. Almost any athlete would benefit from being quicker in his or her reflex activity; obvious examples include baseball players, hockey goalies, and volleyball players.
The effect of supraphysiologic doses of AAS on aerobic performance is not clear. Over the years, research studies have indicated that there does not appear to be a positive effect on aerobic performance.4,17,52 However, athletes will explain that steroids give them a psychological advantage that assists them through the aerobic work and that they feel more vigor, energy, and aggressiveness as they exercise. The psychological aspect of the use of AAS is difficult to measure objectively. The use of AAS by endurance athletes has not been documented to improve their performance because the effects of steroids appear to be more generalized to the strength-training athlete.
Adverse Effects of Steroids
The adverse effects of steroid abuse can be similar in males and females. However, in some athletes, AAS can produce adverse effects that are very specific to the individual. Many times the adverse effects common to both male and female athletes can have long-term consequences on the internal organs of the body. Other types of adverse effects are specific to the male or the female steroid abuser and have signs and symptoms that are more outwardly observable.
In studies conducted on mice, it was demonstrated that testosterone propionate impairs the capillary function in cardiac tissue, which can lead to blood flow difficulties, especially during physical activity.54 This decrease in blood flow may be one of the factors contributing to sudden death from cardiac failure in steroid abusers. Additionally, an athlete with a compromised cardiovascular system may be subject to a cerebrovascular accident. In addition to vascular and cardiac problems, the athlete can experience damage or drastic changes to other organs and systems.
Another problem that appears to cause difficulty for both genders is the damage to the liver by steroids from first-pass metabolism. Oral steroids are much more toxic and damaging to the liver than injectable steroids as a result of first-pass metabolism. Oral steroids are broken down in the gastrointestinal tract and delivered to the liver via the vascular network. The liver has the job of cleaning the impurities from the blood before it is circulated throughout the body, providing nutrients and oxygen to the rest of the body. The AAS are recognized as impurities, and the liver tries to metabolize these foreign substances and remove them from the blood. However, the liver cannot take all the impurities out of the blood, so some of the oral steroids get through to the other parts of the body. The steroids that are removed for processing are hard on the liver, and can ultimately cause severe and irreparable damage. Over time, the liver becomes chronically damaged and ceases to function properly. Continuing steroid use may cause such conditions as jaundice, peliosis hepatis (bloodfilled cysts), and tumors.
Injected steroids appear to be much more effective in building muscle. Steroids taken via intramuscular injection are not subjected to first-pass metabolism, but directly enter the blood and site of action. Therefore they are available to the muscle tissues in much greater amounts. The liver eventually does process some of the injected steroids that remain in the vascular system as blood is returned to the liver to be cleaned. In The Underground Steroid Handbook it is mentioned that injectable steroids are much more effective in making the athlete bigger faster. Of course, information provided by this and other nonscientific resources may contain misunderstandings and half-truths. It is easy to understand how a naïve athlete can be led to believe that the authors of these resources are telling the truth in all respects regarding the illegal use of steroids for performance enhancement.
Internet Resource Box
The Underground Steroid Handbook, by an anonymous author, can be obtained through a number of Websites. However, it is not considered a scientific or reliable source of steroid information.
The kidneys also play a role similar to that of the liver in cleansing impurities from the blood. When excessive levels of steroids are passed through the kidneys, this too can result in chronic dysfunction. Conditions such as hyperinsulinism, decreased high-density lipoprotein concentrations, and increased blood pressure are not uncommon in an individual with an AAS abuse problem.
Many, if not all, of the studies of problems associated with the abuse of AAS have focused on male athletes. However, when a female abuses AAS, the physical changes that can occur are typically irreversible. This does not mean that the physical adverse effects are always reversible in males who abuse AAS. Males must realize that when they abuse steroids, their body will go through changes that may not reverse on discontinuation of steroid abuse. For this reason, it is better to discuss the adverse effects of AAS abuse on males and females in separate subsections.
Implications for Activity
Athletes using hormones or prohormones will most likely become bigger, stronger, and faster in their sport. The use of these drugs appears to be common in all sports, from football to track and field. Athletes need to understand that these drugs have many different adverse effects that can affect their participation, from extreme aggressiveness, which may lead to sportsmanship issues, to tendon rupture during activity. The use of hormones definitely affects the participation of the athlete in both positive and negative ways.
One of the most talked-about adverse effects of steroids is their effect on the endocrine system. If exogenous testosterone is being taken into the body, there is no need for the endocrine system to produce testosterone. Therefore, the testicles may cease to produce sperm in the AAS abuser. Alternatively, AAS abuse can cause oligospermia (small number of sperm), azoospermia (lack of sperm in the semen), decrease in testicular size, and decreased production of testosterone. It is suggested that these effects will reverse when the exogenous testosterone is withdrawn, but there are no guarantees. Another well-documented side effect in the male AAS abuser is gynecomastia, female-type breast enlargement. Gynecomastia is not reversible, and some AAS abusers have their mammary glands surgically removed so that they do not continue to enlarge. Other steroid users augment their cycle or stacking with the drug Clomid, which is intended to counteract the actions of steroids that result in female-type breast growth.
The AAS abuser should also be prepared for premature balding; severe acne problems on the face, chest, or back; premature closure of growth plates in adolescents; enlargement of the prostate; impotence and decrease in libido; glucose intolerance, insulin resistance; ataxia; and tendon rupture in addition to the previously mentioned hepatotoxicity, increased risk of cardiovascular disease, and gynecomastia.15,33,38 These are the adverse effects documented in the scientific literature. The undocumented adverse effects are just as significant but have not been reported in reputable scientific journals because of the inherent restrictions on how this type of research would have to be conducted (i.e., excessive amounts of the drug would have to be taken by human subjects to produce reproducible and credible results).
Adverse Effects in Females
Females also experience significant adverse effects from AAS abuse. The most common effect is masculinization. When a female takes large doses of the male hormone testosterone, over time she will begin to exhibit many male characteristics. Women may develop facial hair (hirsutism), male-pattern baldness, and a deepened voice tone. They may also develop an enlarged clitoris, along with a decrease in breast size, menstrual cycle changes, and amenorrhea. 33 These changes are typically irreversible. Many of the problems males experience (described in the previous subsection) are also common in female AAS abusers. These can include acne problems, reduction in libido, and mood swings.
Adverse Effects in Adolescents
Adolescent athletes who abuse steroids have a significantly greater problem because AAS abuse can lead to premature closure of epiphyseal growth zones. This is a long-term side effect that can result in smaller adult stature. Obviously, this is the opposite effect that is desired: the athlete will not be bigger; he or she will be shorter.
What to Tell the Athlete
It may be true that the abuse of AAS will increase muscle mass and strength, but the adverse effects of AAS must be described to the athletes under your supervision. The premature deaths of several athletes have been attributed to steroids. The athletic trainer should do everything possible to discourage the illegal use of steroids by athletes in any sport. Some tips for the athletic trainer when educating the athlete about these drugs include:
AAS are Schedule III controlled drugs, and distribution of these drugs without the proper license is a felony in the United States.
The use of AAS is banned by the National Collegiate Athletic Association (NCAA), the International Olympic Committee (IOC), the National Basketball Association (NBA), and the National Football League (NFL), among other sports governing bodies.
Many athletes believe that the adverse effects of AAS will reverse on discontinuation. Reversal of the adverse effects of AAS is not guaranteed when the therapeutic dosage is exceeded.
Scenario from the Field
A 14-year-old male was seeing a physical therapist for a shoulder problem. The visits to the physical therapy office went on for a period of months. During the time the boy was visiting the clinic, he was working with an athletic trainer on shoulder exercises. The athletic trainer noticed over the first month how muscular the boy was becoming, and was impressed with his overall conditioning progress. However, the boy continued to get much bigger and then started to get serious acne on his back, chest, and face. The athletic trainer questioned the boy in confidence, and he admitted that he was using steroids to "get bigger." When questioned why he wanted to get bigger, the young man responded that "girls really like muscular guys and I want to be liked by the girls." This indicates that high-school and college athletes are using steroids not only to enhance athletic performance, but for any number of other reasons.