Before we get started, let’s begin by defining a few basic terms to make sure that we understand them before we dig any deeper. Oh, as an aside, “The Cannabinoid Hypothesis” is free on Kindle from 19 JUN 2013 to 23 JUN 2013 so grab a copy if you like dark medical fiction!
Hormone – A long-acting chemical messenger. A hormone is like a biochemical “office memo” that is produced by an organ somewhere in the body, travels through the bloodstream to reach the “mailbox” of a distantly located target organ, and then tells the target organ what to do. For instance, the biochemical messenger thyroid stimulating hormone is produced by the pituitary gland (a pea-sized gland in your brain), travels through the bloodstream to the thyroid gland (located in your lower neck), and then tells the thyroid gland to produce thyroid hormone – a hormone that has a plethora of effects including regulating your metabolism.
Hormonal Cascades – You’ll notice that both thyroid stimulating hormone (TSH) and thyroid hormone are hormones (thanks genius, right?). Thyroid hormone travels from the thyroid gland through the bloodstream and then acts on just about every other organ in the entire frickin’ body. This is a common and important theme. Most hormones act in cascades (hormone A effects the production of hormone B, hormone B effects the production of hormone C, etc.) and some of these cascades can be really long and complicated – don’t worry, this is a blog not a textbook and we’re going to stick with the meat and skip the potatoes! Knowing what a hormone is and what a hormonal cascade does is important because most of the performance-enhancing drugs (PEDs) that we’re going to discuss today are hormones.
One final comment/disclosure: I strongly believe that criminally prosecuting (persecuting?) the average Joe for using PEDs is a gross violation of personal liberties and, frankly, an irrational policy. I absolutely do not advocate the recreational use of any of these substances and I DO believe that athletes who surreptitiously use PEDs to gain an unfair advantage over their competitors should be severely punished for the same reason that a baseball player who corks his bat should be punished – it’s cheating. With that said, putting Moe the College Kid in jail for using steroids to get bigger biceps doesn’t make a lot of sense in my book – he’s not hurting anyone except for himself, and even that is debatable. And yet American society has no problem with Susie having a major elective surgery to enlarge her breasts and to reduce her nose, no problem with selling cigarettes at gas stations, and no issue with glamourizing boozing on national television during family programming like the Super Bowl…
Anabolic-androgenic steroids (AAS) cause muscle growth (“anabolism” roughly means “growth”) and also result in the development and accentuation of male sex characteristics (the androgenic effects—growing a beard, etc.). The term “steroid” simply refers to a common chemical structure/backbone that is shared by glucocorticoids, mineralocorticoids, and sex hormones – all of which are produced from choleSTEROL. In other words, not all steroids are AAS – actually most aren’t. When your kid was prescribed steroids for his asthma exacerbation he was prescribed cortiocosteroids (aka: glucocorticoids), which are anti-inflammatory stress hormones that actually are catabolic (catabolic roughly means “causes tissues to shrink”). Mineralocorticoids are extremely important regulators of sodium, potassium, and blood volume while estrogens and progesterones are the female sex hormones.
So returning to AAS, these drugs are all derivatives of the major male sex hormones, DHT and testosterone. Because both DHT and testosterone are highly androgenic — causing acne, hair growth in generally unwanted places, and deepening of the voice (etc.) — drug companies in the early half of the 20th century tried to develop derivatives that would retain the anabolic properties of the natural male sex hormones minus the undesirable androgenic side-effects. Dozens of derivatives were produced and here is a listing of some of them (these are all injectable drugs; we’ll talk about oral AAS in a moment):
Nandrolone Decanoate (aka: Deca) – The closest that the drug companies have yet to come to a purely anabolic steroid that is void of androgenic properties. This drug was formerly very popular among athletes but it has lost favor because its metabolites are detectable in the body for up to 18 months. Unlike most AAS, nandrolone isn’t metabolized to estrogen. The reason that AAS abusers get bloated is because most AAS are converted to estrogens before they are eliminated from the body and, as every woman knows, estrogens cause bloating.
This is an image of a bottle of Mexican veterinary nandrolone decanoate (aka: Deca). The “300” on the label means that it contains 300mg of nandrolone decanoate per milliliter of the oil solvent. Nandrolone is injected intramuscularly.
Testosterone Cypionate and Enanthate – These drugs are simply testosterone that has been conjugated (chemically linked) to a fatty ester. The fatty ester makes the testosterone less soluble in body fluids for the same reason that a drop of fatty oil floats on the top of a glass of water. This slows the active testosterone’s release into the bloodstream. Testosterone that isn’t linked to a fatty ester needs to be injected every day because it is rapidly absorbed into the body after being injected. In contrast, testosterone esters are released over the course of 3 days to several months, depending on the size of the fatty ester, allowing them to be administered much less frequently than straight testosterone. Sustanon is a well-known form of testosterone that is a mixture of four different types of esterified testosterones – one of the esters is released rapidly (testosterone propionate – released over the course of 3 days or so), two of the esters hang around in the body for a few weeks, and the final ester has a half-life of 4-6 weeks (testosterone undecanoate).
These are just a few examples of the plethora of anabolic hormones that the pharmaceutical industry has developed over the decades, but they all have one major drawback, they must be injected and nobody likes to get a shot. The reason that you can’t take testosterone cypionate or nandrolone decanoate orally (at least not if you want it to work) is that these drugs are broken down by the liver before they make it into systemic circulation — in other words, before they reach the rest of the body. The drug companies solved this dilemma by chemically modifying testosterone derivatives via a process called 17-alpha-alkylation. What this means in English is that the testosterone derivative has been chemically modified to make it much harder for the liver to break it down – the downside of this is that 17-alpha-alylated drugs are toxic to the liver. A few examples of orally-active 17-alpha-alkylated AAS are D-bol (aka: dianabol), Anadrol, and Anavar. All of these drugs have the potential to seriously damage the liver.
This is dianabol (D-bol) produced in Thailand — often referred to as “Thai pinks.” D-bol is a oral 17-alpha-alkylated anabolic steroid that is toxic to the liver. It also has a particularly high affinity for aromatase, the enzyme that converts some anabolic steroids to estrogen (but not all of them), resulting in the classic “moon face” and bloating of anabolic steroid users.
The medical uses of AAS include: 1. hormone replacement in men with disorders of the endocrine (hormone producing) system; 2. for a rare disease called hereditary angioedema; 3. to enhance healing in some surgical patients (especially severely burned patients); 4. and to encourage weight gain in people with wasting diseases like cancer and AIDS. AAS are generally pretty safe when used under a physician’s supervision, even when they are used for years and years without respite. Common side-effects include increased acne, increasing the rate of the benign enlargement of the prostate that naturally happens over time in all men, increasing the rate of hair loss on the scalp in men who are genetically predisposed to male pattern baldness, increased male pattern hair growth in places where most people don’t want it (the back, the shoulders, etc.), and a decrease in good cholesterol (HDL) with a simultaneous increase in bad cholesterol (LDL). These cholesterol abnormalities can increase the risk of heart disease if a person chronically uses AAS (we’re talking years to decades of use in most cases).
A bit of humor. While steroid use dose cause hair growth in undesirable places, including the back, this gentleman clearly has a genetic disorder of some sort (a bit of dark medical humor). Female users of anabolic steroids (yes, they do exist) can become masculinized and grow beards, an enlarged clitoris, etc.
Recreational users of oral AAS can cause liver cysts and these cysts can, albeit extremely rarely, rupture and bleed. On rare occasions this can be fatal, but the same side-effect can also occur (again, rarely) with birth control pills – orally-active female hormones. Oral AAS are toxic to the liver and prolonged abuse can absolutely cause liver damage. The biggest dangers of injectable AAS are infection due to poor injection technique, sharing needles (yes, I am aware that this is really uncommon among steroid users), and due to contaminated drugs straight from the factory – something that can occur with medications produced by reputable pharmaceutical companies but which is particularly a risk for illicit AAS users because many of the drugs that they use are actually veterinary drugs produced in shady factories in Mexico. Long term use of AAS causes the body to quit producing its own androgenic hormones. Since the testicles produce androgens in males, long term use (and/or abuse) of AAS causes your nuts to shrink! The common belief that AAS shrink the penis is not true, by the way.
Despite the widespread conviction in The United States that AAS abuse can cause cancer and “roid rage,” the scientific literature doesn’t confirm this and it probably isn’t true*. A very common “side-effect” of AAS abuse is muscle growth – anyone who tells you that they don’t work is either lying to you or has never opened the pages of a bodybuilding magazine while killing time in the checkout aisle at the grocery store. This muscle growth can actually be a problem in serious abusers of AAS because their muscles often grow faster than their tendons (the connective tissues that attach muscles to bones), predisposing steroid abusers to tendon ruptures – a potentially serious type of injury that can sometimes result in permanent disability. Other problems with walking around weighing 50 or 100lbs more than your body is naturally supposed to weight included an elevated blood pressure, strain on the heart, and premature joint damage that can lead to arthritis.
A ruptured right biceps tendon — notice the balling of the right biceps compared to the left biceps.
As I said before, using prescription drugs without a physician’s supervision is a really bad idea. With that said, the common notion the AAS are deadly drugs that ruin lives is also largely a fiction. Used medically, AAS are very safe medications and even gross abuse rarely causes major health problems. Can abuse of AAS cause health problems? Absolutely! I’m just saying that most people who abuse these drugs most commonly suffer from rather minor side-effects at most and that the stereotypical portrayal of deadly “steroids” doesn’t have a very sound basis in scientific reality. If a patient came into my office and said, “Doc, I use steroids, I smoke (a legal poison), and I frequently drive around town with a blood alcohol level of 0.07 (very dangerous, but also legal) – which should I quit first for my health?” I’d tell him that quitting smoking was priority #1, quitting impaired driving was priority #2, and quitting AAS abuse was a distant third.
In case you were wondering, yes, both of the bodybuilder images have been enhanced to make them look even more ridiculous — to each his/her own!
Okay, so that’s anabolic-androgenic steroids. Next time we’ll cover EPO (erythropoietin) and in Part #3 we’ll cover legal performance enhancing supplements including creatine, HMB, nitric oxide boosters, and whey protein. Hope to see you there!
*There have been a few studies that demonstrated increased emotional lability in AAS abusers. However, these studies suffered from small sample sizes and from numerous other flaws. One of the major problems with studying the mood effects of AAS abuse is that it’s safe to assume that most people who want to look like a bodybuilder in the first place have pre-existing psychiatric issues. Studying the emotional effects of AAS abuse in this patient population is sort of like studying the psychiatric effects of dieting using a sample of anorexics – you’d undoubtedly conclude that dieting causes severe psychiatric disturbances because everyone in your sample is already disturbed! AAS probably have some psychiatric side-effects; in fact, it would be rather shocking if they didn’t since people with high levels of male hormones (men) tend to be different psychologically than people with lower levels of these hormones (women). However, the psychotic “roid rage” syndrome is completely unproven and, in my experience, almost certainly a myth. There are over 1 million current and former abusers of AAS in The United States alone and “roid rage” attacks, while a convenient legal defense strategy in the courtroom, are about as common as Big Foot sightings – when is the last time that a legitimate one happened in your town, because I guarantee you that your town has steroid abusers living in it…
Deca Image: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=nandrolone&oq=nandrolone&gs_l=img.3..0l10.70421.72422.0.72522.214.171.124.0.0.0.71.4126.96.36.199.eqrwrth..0.0…1.1.17.img.ut8Pss9tOno&bav=on.2,or.r_qf.&bvm=bv.48175248,d.dmQ&fp=13dc04e8b48effa6&biw=922&bih=531&facrc=_&imgdii=_&imgrc=dL1dULNpDGqX7M%3A%3BO6GuoanSUrNvYM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252Fc%252Fc5%252FDECA_QV_300.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ADECA_QV_300.jpg%3B405%3B586
Guy with Ridiculously Large Lats Image: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#facrc=_&imgdii=_&imgrc=hZsOCJchxdDYYM%3A%3BBYZg-6aMeou4eM%3Bhttp%253A%252F%252Ffarm1.staticflickr.com%252F104%252F287569669_0670f4d966_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fmawkroy%252F287569669%252F%3B550%3B367
Guy with Hairy Back Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Funiqueblogofawesome.blogspot.com%2F2012%2F07%2Fyou-crazy-little-coconuts.html&h=0&w=0&sz=1&tbnid=fqWDyLcy9RC-TM&tbnh=192&tbnw=256&prev=%2Fsearch%3Fq%3Dhairy%2Bback%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=hairy%20back&docid=jidzrZkryZisOM&hl=en&ei=8pPDUYHbMYbo8wS55ICACA&ved=0CAEQsCU
D-bol Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fhubpages.com%2Fhub%2FDianabol-Side-Effects&h=0&w=0&sz=1&tbnid=UEOCRGyduzQErM&tbnh=173&tbnw=208&prev=%2Fsearch%3Fq%3Dd-bol%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=d-bol&docid=hLK3uWlhS1cQPM&hl=en&ei=tpTDUZLCO4bs8wSyuoD4Cw&ved=0CAEQsCU
Bicep Tendon Rupture: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=tendon+rupture&oq=tendon+rupture&gs_l=img.3..0l9j0i5.2096.4771.2.49188.8.131.52.0.0.0.103.917.15j1.16.0.eqrwrth..0.0…1.1.17.img.3kvqHsEqgqA&bav=on.2,or.r_qf.&fp=13dc04e8b48effa6&biw=1600&bih=752&facrc=_&imgdii=_&imgrc=kOrcm-fbmFMy-M%3A%3B1Z0qBbmEyEePWM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F8%252F8d%252FBicepstendon10.JPG%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ABicepstendon10.JPG%3B2970%3B2183
Guy with Ridiculous Pecs Image: http://bigteenbodybuilder.deviantart.com/art/West-Coast-Daddy-Re-Morph-164856324
Dr. Leonardo Noto
Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.
Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).
Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!
The opinions voiced on this medical blog are solely the author’s own and they do not necessarily reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.