What is Anabolic Steroid Toxicity?
Androgenic-anabolic steroids (AAS) are commonly used around the world as performance-enhancing drugs. These started being used in competitive sports and then spread to non-competitive athletes. Since the 1950s, the World Anti-Doping Agency banned AAS and has continued to add new methods and variations to the list. Based on estimates from the Centers for Disease Control and Prevention, it’s mainly adolescent males who use AAS.
The hypothalamus, a part of the brain, is a key player in our reproductive system. It communicates with other parts of the brain like the amygdala and the visual cortex, and releases a hormone called the Gonadotropin-releasing hormone (GnRH). This hormone is then carried to the pituitary gland, another part of the brain. Here, GnRH triggers the production of other hormones like the luteinizing hormone (LH) and, to a lesser extent, follicle-stimulating hormone (FSH). LH activates cells in the testes, where most of our androgens (the male hormones) are produced. Testosterone, an important androgen, in turn, controls the production of GnRH in the hypothalamus. This helps keep a balance in our body.
Testosterone is a strong natural male hormone and the basis for most AAS. By making small changes to testosterone’s structure, we can change the effects of AAS, like how strong it is, how it helps build muscles, and its level of toxicity. Testosterone and other types of AAS can increase muscle size by acting on muscle cell receptors and other proteins. They can also protect muscles from breaking down by interacting with other receptors and biological pathways related to brain function and metabolism.
Studies on long-term AAS users have shown an increase in muscle size. Both type I and type II muscles can significantly increase in size. Even though most of the muscle mass in power-lifters is type II, it was type I fibers that grew the most. Additionally, Type II fibers need less testosterone for growth compared to Type I.
AAS works to increase muscle size by boosting the production of proteins that help muscles contract. A single injection of testosterone enanthate can double this protein production by improving the rate of amino acid reuse, while not changing protein turnover. The increase in muscle size was much more than anticipated when combined with resistance training, going up to 36% in some cases. This increase was even bigger for type I muscle fibers.
Short-term use of AAS (300 mg per week for 20 weeks) boosts the number of satellite cells, a type of muscle stem cell. This is believed to happen because testosterone makes these stem cells divide and grow. Some of these new cells become inactive, while others continue to divide or form new muscle fibers. More studies are needed to fully understand this process, but research on mice showed that cells treated with testosterone had increased levels of certain muscle growth proteins. Testosterone also regulates fat breakdown and inhibits fat cell formation. Finally, AAS might be interacting with proteins on the surface of cells, triggering a series of events inside the cell.
What Causes Anabolic Steroid Toxicity?
Androgenic-anabolic steroids, often used because they can improve athletic performance and muscle size, have been studied in young, healthy males. These studies found that taking testosterone for 6 weeks led to growth in muscle mass and strength. Interestingly, this was true even if the men didn’t engage in resistance training, though muscle growth was slower when compared to those who did.
Importantly, the effects of testosterone supplements were connected both to the amount taken and changes in muscle “pennation” angle – the angle at which muscle fibers are aligned. Increases in muscle “fascicle” length and pennation angle make the muscle bigger, giving it the ability to contract with greater force.
Furthermore, lower levels of testosterone in older men are associated with a higher risk of atrial fibrillation (a type of irregular heartbeat). These lower levels also relate to coronary artery disease, a condition where the arteries supplying the heart become narrow. However it’s unclear whether the disease causes the low testosterone or vice versa. Nevertheless, a lower testosterone level indicates a greater risk of severe coronary artery disease and also mortality. Since the 1930s, testosterone has been used to treat angina (chest pain often caused by coronary artery disease), reducing the number of angina attacks and increasing the amount of time between them.
There is also a connection between type 2 diabetes and low testosterone levels. In fact, research has shown that total testosterone, free testosterone and DHT levels (all variations of the male sex hormone) decrease in people with type 2 diabetes. Thankfully, testosterone supplements can decrease the risk of developing type 2 diabetes, as they can increase metabolism and break down fats.
Testosterone levels are also found to be lower in people who are obese. In fact, testosterone supplements, given through 3 injections, helped significantly reduce a patient’s Body Mass Index (BMI) in 30 weeks. The effect of testosterone on fat metabolism, however, is still under investigation. Testosterone supplements are seen to improve some heart-related conditions such as prolonged QT and ST intervals (which are measurements in an electrocardiogram often seen increasing with aging and Cushing disease).
Patients with congestive heart failure (a condition where the heart is unable to pump blood effectively) often have lower testosterone levels too. Some studies suggest these low levels might be connected to the worsening of this heart condition. But, giving testosterone to patients didn’t alter the functionality of the left side of the heart. Instead, the levels of total testosterone and free testosterone were found to be indicators of congestive heart failure. Added benefits of testosterone supplements include increasing exercise tolerance in patients with this heart condition and chronic obstructive pulmonary disease (a type of lung disease), by possibly inducing an increase in Type I muscle fibber.
In regards to the liver, low testosterone levels often seen in chronic liver disease. In fact, 90 percent of men awaiting a liver transplant had a major drop in free testosterone. The severity of liver disease has showed an inverse correlation with testosterone levels, with liver disease-related mortality also inversely connected to testosterone levels. Accordingly, a 1 nmol/L drop of free testosterone is associated with an 8% increase in mortality.
Risk Factors and Frequency for Anabolic Steroid Toxicity
It’s estimated that between 1 to 3 million individuals in the United States misuse anabolic-androgenic steroids (AAS). The misuse of AAS is a growing issue, particularly among younger demographics such as high school students. This problem is even more prevalent in certain groups like weight lifters, bodybuilders, military personnel, law enforcement officers, and prison populations. A wide-scale study of 187 research reports in 2014 confirmed that AAS misuse is a significant global health problem. It is also worth noting that AAS use is more common in men (6.4%) than women (1.6%).
- Between 1 to 3 million people in the U.S. are estimated to misuse AAS.
- The number of AAS users is increasing, especially among adolescents and high school students.
- High prevalence of AAS use is found in weight lifters, bodybuilders, the military, law enforcement, and prison populations.
- AAS misuse has been identified as a serious global public health problem after analyzing 187 studies in 2014.
- The use of AAS in a lifetime is found to be higher in men (6.4%) compared to women (1.6%).
Signs and Symptoms of Anabolic Steroid Toxicity
Anabolic steroid toxicity, also known as steroid overdose, can lead to various health problems affecting different systems in our body. Here are simplified lists of potential issues related to different systems:
Cardiovascular Signs:
- High blood pressure due to increased resistance in blood vessels
- Increased risk of blood clots within the heart or veins
- Potential heart damage and inflammation leading to non-ischemic cardiomyopathy (a form of heart disease), heart attacks, or heart failure
- Unhealthy changes in blood lipid levels
- Excessive production of red blood cells
- Rapid development of coronary artery disease
Hepatic (Liver) System Signs:
- Cholestasis (stoppage or slowdown of bile flow)
- Nonalcoholic steatohepatitis (NASH, a type of liver disease)
- Direst toxicity to the liver
- Liver tumors
- Decreased SHBG (a blood protein that transports hormones)
- Enlarged liver
- Bile acid nephropathy (a kidney condition)
Endocrine (Hormonal) System Signs:
- Acne
- Gynecomastia (breast enlargement in men)
- Virilization (development of male characteristics in women)
- Irregular menstrual cycles in women
- Hypogonadism (underactive sexual organs)
- Decreased levels of “good” cholesterol (HDL)
- Premature closure of growth plate in bones
Neuropsychiatric (Brain and Mental Health) Symptoms:
- Major depression
- Body dysmorphic syndrome (an obsession with imagined flaws in appearance)
- Narcissistic personality disorder
- Aggression
- Dependence on steroids
- Anxiety
- Bipolar depressive disorder
- Suicidal tendencies
- Decreased ability to recognize patterns
Testing for Anabolic Steroid Toxicity
If your doctor suspects that you might be using anabolic steroids, they’ll first need to speak with you about your health history and conduct a physical examination. They will try to understand the timeline between your main health concerns, the symptoms you are experiencing, and when you have used the anabolic steroid. It’s also vital for them to identify which specific steroid you have been using, as this information can assist the doctor in deciding what further tests you might need.
However, testing for anabolic steroids can be tricky for doctors because there are over 170 types of these substances and no single fast test can detect them all. So, if your doctor strongly believes that a particular type of steroid is present in your body, they will need to confirm it using a more specific test called gas chromatography. This test might take a bit of time, depending on the capabilities of the hospital or lab.
Treatment Options for Anabolic Steroid Toxicity
If someone is thought to have overused anabolic steroids, which are drugs used to build muscle mass, the first action is to stop using the drug. The next steps largely involve support, such as making sure vital signs like heart rate and breathing are stable, while waiting for test results.
The healthcare provider will then decide on additional treatment based on the specific harm caused by the anabolic steroid use. This is because the signs of toxicity or harm from the drug can affect different organ systems in the body.
Some research has shown that multivitamins that include vitamins B1, B6, B12, nicotinamide, and linoleic acid can help protect liver cells (hepatocytes) from damage caused by anabolic steroids.
What else can Anabolic Steroid Toxicity be?
The conditions that could be mistaken for the toxicity caused by anabolic steroids are many since these steroids can affect various organs in the body. Some of these conditions include:
- Adrenal gland tumors
- Eating disorder (Anorexia)
- Liver disease (Cirrhosis)
- Conn syndrome – a condition that affects the adrenal glands
- Excessive hair growth caused by medication
- Jaundice caused by drugs
- Hemolytic anemia – a condition in which red blood cells are destroyed faster than they can be made
- Liver cancer
- Hepatitis – inflammation of the liver
- Ovarian cancer
- Precocious puberty – early onset of puberty
- Thromboembolic state – a condition in which blood clots form in the bloodstream
- Vasculopathy – a disease affecting the blood vessels
- Viral myocarditis – inflammation of the heart muscle caused by a virus.
What to expect with Anabolic Steroid Toxicity
Spermatogenesis, the process that produces sperm, is driven by two hormones from the pituitary gland (located in your brain): Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH). This process can be slowed down or stopped by high levels of testosterone and a hormone called inhibin.
Androgenic-anabolic steroids (also known as AAS2), which are synthetic versions of testosterone, have a similar effect. In fact, they can significantly reduce sperm production by suppressing the natural production of LH and FSH. Men who use these steroids often have considerably low sperm counts, and the sperm that is produced moves less effectively.
If steroid users stop taking AAS for more than four months, their sperm counts usually return to normal, even if they used AAS for years.
A common side effect of AAS misuse is gynecomastia, a condition in which the breast tissue in men expands. This happens because of an increase in the response to estrogen, a female hormone, which can occur because AAS alters the normal hormonal balance in the body. Interestingly, the amount of estrogen receptors (which are proteins that recognize and respond to estrogen) was found to be elevated in both steroid users with early-stage breast tissue growth and patients with benign (non-cancerous) breast tissue growth not related to steroid use.
The most effective way to treat gynecomastia is to stop using steroids. If this doesn’t reverse the condition, surgery to remove the excess tissue could be considered.
Possible Complications When Diagnosed with Anabolic Steroid Toxicity
The negative effects of using anabolic steroids can be severe and range from psychological to physical conditions.
The complications can include:
- Long-lasting depressive symptoms, potentially years after usage
- Male breast enlargement (gynecomastia) which may need surgical removal
- Increased and potentially irreversible hair growth in women (hirsutism)
- The formation of liver tumors
- If steroids are injected, there’s a risk of contracting serious diseases like HIV or Hepatitis C
- Heart muscle disease (cardiomyopathy)
Every steroid usage carries its risks and potential harm, and these listed are some of the most severe ones.
Preventing Anabolic Steroid Toxicity
There are many campaigns designed to teach athletes in training about the risks of using performance-enhancing drugs like anabolic steroids. Most major sports organizations regularly test their players for these illegal substances. However, it’s important to understand that not every single type of anabolic steroid can be caught in testing. Even so, sports organizations are always adding new types of steroids to their list of banned substances.
Your doctor may suspect that you’re using these illegal drugs if you show certain signs such as:
- Competing in a sport where increased strength, speed, and agility gives you an advantage
- Being male
- Having larger muscles or gaining muscle at a rapid rate
- Experiencing an increase in acne
- Oligospermia (having fewer sperm than normal)
- Gynecomastia (the development of excess breast tissue in men)
- Showing signs of early puberty
- High hematocrit levels (a measure of the proportion of your blood made up by red blood cells)
- Hirsutism in women (excessive body or facial hair)
Your doctor should educate you about the risks and effects of using anabolic steroids and warn you that possessing these substances is a crime. It’s also against the rules of most sports organizations to use these substances.
