We will now try to discuss the information and hopefully give a clearer picture of what clinical evidence there are at present.

6.1 Anabolic Steroids and the Liver

Anabolic Steroids are processed by the liver. As discussed earlier, C-17 alkylated oral steroids are unusually harsh on the liver. For this reason, even moderate short-term administration of these C-17 oral steroids can affect liver function tests. Elevated liver counts indicating liver toxicity have been reported in recent studies of somewhat moderate oral Anabolic Steroid therapy as reported in the on-line Medibolics, edited by Michael Mooney (www.medibolics.com). However, these elevated liver function readings will return to normal after cessation of a moderate, short-term steroid use. Further, it is recognized that intense weight training alone often causes changes in liver function tests. The enzyme levels that are tested in a certain blood sample for example may be a reflection of muscle damage OR the steroid injections themselves rather than actual liver damage (Yesalis, Second Edition, Anabolic Steroids in Sport and Exercise p. 193)

The more serious liver problems connected with Anabolic Steroid use include liver cancer and peliosis hepatitis; blood-filled sacs within the liver. But the majority of cases reporting liver problems have dealt with extremely sick and elderly patients treated with C-17 alkylated oral steroids for years of continuous use, and many of these patients had a particular type of anemia linked to liver tumors even without Anabolic Steroid therapy. A computer search of the medical literature performed by Friedl - looking for steroid-associated liver tumors could find only three in athletes (Friedl, Anabolic Steroid Abuse, p. 142-177, 1990). Of the three athletes, one was using 700 mg of oxymetholone a week for five straight years, and one had a tumor that was probably classic liver cancer and not a steroid-associated tumor. Virtually all of the reported liver problems seemed to occur with the 17 alpha-alkylated oral steroids. There have been no cysts or liver tumors reported in athletes using the injectable steroids. It has been noted that injectable steroids generally appear to have little effect on the liver at all (Haupt, American Journal of Sports medicine, 21, 1993, p. 469). There was only one case we could find involving a bodybuilder with peliosis. He recovered ( Cabasso, 1994, Medicine and science in sports and exercise 26, 2-4)

Recent studies continue to suggest that reports of serious adverse effects of Anabolic Steroids upon the liver in healthy athletes may be a bit overstated. In a study of athletes, of the 53 current or past steroid users who underwent laboratory testing, only one subject displayed an abnormal liver test (Pope & Katz, Archives of General Psychiatry, 51, 1994, p. 379);

Another study tested one of the most powerful and reputedly dangerously toxic Anabolic Steroids for 30 weeks on HIV positive men and women Oxymetholone a C-17 alkylated oral steroid, was administered in a dosage of over 1,000 mg per week (more than that used by many athletes, and for a much longer duration of uninterrupted use). The results were significant gains in lean muscle mass even without any weightlifting. Even more importantly and surprisingly there were no significant problems with liver function, water retention, or virilization side effects (Hengge et al., British Journal of Nutrition, 75, p.129-138, 1996).

As seen on the table we copied from Clinical Chemistry 43, p 1274, 1997. - only between zero and one percent of 191 male and 174 female athletes suffered from functional/structural liver damage + one case of severe liver damages. The percentage suffering from structural/functional liver damage were either

1. using coincident medication with contraceptive steroids
2. been using steroids over several years

or

1. using a high dosage per year (>1000 mg)

Birkeland at the hormone laboratory of Aker Sykehus says that all AS users will have changes in liver function tests, but that this is reversible, and probably not dangerous. Cancer is very rare, and it is probably not a result of AS use. It all depends on the dosage-

While the dangers of anabolics to athletes' livers appear to have been highly exaggerated, it must be recognized that an apparently healthy athlete with an existing but undiscovered liver problem could do serious damage to himself by self-administering C-17 oral anabolic steroids. For this reason alone, it would be quite irresponsible for any athlete to use Anabolic Steroids without having a physician regularly conduct blood tests to control liver function.

6.2 Anabolic Steroids and the Heart

How cardiac risk might be increased by the use of steroids is a subject of speculation and some controversy. High blood pressure is perhaps "one of the most exaggerated claims" of steroid-related health risks, and remains unconfirmed despite numerous studies (Friedl, Anabolic Steroid Abuse, 1, p 142-145).

There is evidence that certain Anabolic Steroids may actually reduce other health risk factors connected with heart diseases. Stanozolol for example, has shown to reduce the cholesterol, which may reduce the chance of ischemic heart disease and cerebrovascular disease ( Jurgens & Koltringer, Neurology, 37, 513-515, 1987) Other characteristics of steroid using male athletes tend to put them in a low-risk group for heart disease. They exercise regularly, have low percentage of body fat and smoke less. Thus, it remains to find evidence to conclude whether AS really produce a significant effect on an eventual heart disease for AS-users in the future.

Regarding cholesterol (serum lipids), other oral steroids in particular seem to cause a increase in cholesterol levels in some steroid users. However, changes in the cholesterol now appear to begin to recover within about a month after discontinued use, and, in fact, most studies do not report an increase in total cholesterol.There is also evidence that the estrogen inhibitors some bodybuilders use after a cycle to avoid "bitch - tits" negatively affects the cholesterol level (Friedl, 1990; Metabolism, 39, 69-74) and that this can be reason for some reports of high cholesterol in case studies of bodybuilders.

Based on our present information, cardiac risks seem to be primarily related to high dosages in the absence of a physician monitoring. Jose Antonio, Ph.D., a nationally recognized authority on drugs in sports who has written a monthly column for Flex magazine, cites a study examining serious cardiovascular side effects in four weightlifters using "massive amounts" of steroids (Antonio, 1998). While there is little doubt that the health problems of these men were caused by their Anabolic Steroid abuse, these were clearly mega-dose abusers. "High dose equals high risk," notes Dr. Antonio, but "low-dose androgens (e.g., 200-600 mg per week for 10 weeks) pose little threat to health." Another aspect is that use of amphetamines and diuretics, very commonly used by athletes wanting to burn off their body fat, have to be considered as contributing to sudden deaths. It is very likely that these substances can provoke a heart attack e.g. If there is increased incidence of heart disease in people using AS, it is likely to be detected only in a properly designed epidemiological study. The facts will be hard to figure out however, what percentage can be linked back to AS, and what to other compounds. Poly-pharmaci (using lot of different medications, some against side effects, some against the side effects of these medicaments again, etc) is common among heavy users of AS, and it is they who are in the high-risk group. (Gallaway, the steroid Bible)

6.3 Anabolic Steroids and the Prostate

A real concern is the potential adverse effect of excessive androgens on the prostate gland. While there is one case report of prostate cancer in a bodybuilder (Roberts & Essenhigh, Lancet, 2, p. 742, 1986), no studies have shown an increased risk or incidence of prostatic cancer or hypertrophy with androgen use or indicated that androgens per sepredispose to these conditions (Matsumoto, Journal of Clinical Endocrinology and Metabolism, 70, p. 282-287, 1990). Many male contraceptive studies using up to 200 mg/week for over a year show no evidence of prostate stimulation. This does not necessarily mean that much higher dosages, especially of highly androgenic compounds, might not adversely effect the prostate, especially in older men. It is not known if athletes who have used steroids for long periods will have more prostatic problems as they grow older. A retrospective study in the future might reveal this. As stated in Chapter 4, paragraph 4.12, about potential side effects on the prostate, the prostate is Androgen sensitive, and administration of exogenous testosterone when cancer or other pathology is present will worsen the condition.

6.4 Anabolic Steroids and Aggressive/Psychiatric Symptoms

Enormous media attention has been focused upon the reported adverse psychiatric effects especially violent behavior of steroid use. "Roid rage" is the descriptive term for steroid-induced spontaneous, highly aggressive behavior (Yesalis & Cowart, 1989, Human Kinetics, The steroids game). A few researchers have suggested that psychiatric symptoms including increased aggression are a common side effect of Anabolic Steroid use. For example, a flawed 1988 study suggested that psychiatric disorders occur with unusual frequency among athletes using anabolics (Pope & Katz, 1988, American Journal of Psychiatry, 145 pp. 487-490). But the conclusions of these researchers have been regarded with skepticism by other experts . Only an extremely small percentage of users appear to experience mental problems that needs clinical treatment ( Yesalis et al, Journal of the AMA, 270, 1993) Even among those affected, the impact of previous mental illness or abuse of other drugs is still unclear. Some long-time steroid users have never suffered any emotional instability, or anything more than transient physical effects and many steroid users describe non-violent feelings of euphoria, well-being and enhanced self-confidence as common effects . Studies involving high doses of steroids, less than bodybuilders use, but more than many athletes in other sports uses, suggests that the aggressive behavior perhaps have been overstated ( Yesalis & Bahrke, 1995, Sports Medicine, 19, p.326-340)

In one study to determine the psychiatric effects of steroid use on athletes, no significant differences could be found between users and non-users. The facts that steroids have been used by tens of thousands if not hundreds of thousands of athletes over two decades and that behavioral effects are only recently being discovered (in small numbers) tend to support that feelings of aggression may not be observed in the majority of steroid users. (Bahrke, et al., 1990, pp. 834-835, Sports Medicine, 10). The researchers do not rule out, however, the possibility that in a small minority of predisposed individuals, steroid use may be sufficient to push them over the edge and contribute to irrational or violent behavior. Many experienced steroid users have found that steroids enhance certain preexisting personality problems. Angry and combative users will become angrier and more combative; however, while normal guys will train more aggressively, they won't generally become violent.

When psychiatric problems do occur in study subjects, there seems to be a direct correlation between dosage and prevalence of syndromes. For example, no significant psychiatric effects have been noted where reported mean weekly dosage was 318 mg (heaviest user was 620 mg/wk) (Bahrke, et al., 1992, p. 717-724, American Journal of Sports Medicine, 20). But where reported dosage exceeded 1,000 mg/wk, 11 out of 25 subjects (44%) exhibited mood disorders (Pope & Katz, 1994, p. 380, Archives of General Psychiatry, 145). While, based on this and other studies, there is a dose-related connection between steroid use and psychiatric effects, it must be added that not all steroid users exhibit such symptoms; in fact, nearly 90% of light and moderate dosage users in this particular study exhibited no mood disorder symptoms at all. But as underlined by Kåre Birkeland and Egil Haug at the hormone laboratory, there seems to be a connection between AS mixed with other substances, especially alcohol, which can induce the feared state of "roid rage". This is because of alcohol's inhibitioning effect of the impulse control.

6.5 Anabolic Steroids and Psychological Dependence

There is some evidence that Anabolic Steroid use can lead to psychological dependence in certain individuals. Whether the dependence is due to chemical effects upon the brain or simply because of the positive reinforcement occasioned by a more muscular physique is not known. Whatever the cause, this may be the most dangerous aspect of steroid use for those it affects. The cessation of steroid use, especially after a long cycle, often leaves the user in a state of low testosterone levels. Their own production is temporarily shut down. Cortisol levels are getting higher than the testosterone levels, and a state of Catabolism is induced. For individuals with an inadequate sense of self, the loss of some portion of the steroid gains can be psychologically devastating to the ego. These individuals can be unable to resist immediately resuming steroid use. Further, as the goal of hard-core bodybuilders is not optimal muscle size, but maximal muscle size, dosages can become excessive. While many athletes successfully use steroids intermittently and with moderation, it is a sobering thought that there are certain individuals who start out on low risk, short-term cycles and ultimately end up using massive dosages for years of uninterrupted use. It might be theorized that the problem of dependence on steroids by certain bodybuilders has less to do with the nature of the substance than with the psychological profile of the users. Although Anabolic Steroids may be a problem, its prevalence and symptology is impossible to establish scientifically with the literature at hand. Estimates of 300.000 AS users yearly in the U.S, reveals that there is an extremely small percentage that needs treatment for issues like dependence. According to material we read, further research based upon larger groups is needed in order to draw any conclusions (Bark, 1993, Journal of AMA, 270, 1217-1221)

6.6 Other Adverse Effects of Anabolic Steroids

Connective tissue injuries. The medical literature regarding the suggestion of increased athletic injuries caused by Anabolic Steroid use is not sufficient. It is not unreasonable to expect muscle and tendon tears in hard-core strength athletes, regardless of steroid use. However, the exceptional frequency and severity, often requiring surgical reattachment of such injuries in professional level bodybuilders do raise suspicions as to the possibility that steroids, diuretics, or other drugs may be implicated. Former Mr. Olympia Doorman Bates has suffered training-related injuries to the chest, leg and biceps, and retired after a major triceps injury. Pro bodybuilder Al Gurney reportedly completely tore the quadriceps muscles in both legs when he fell while simply walking! Whether these injuries are steroid-related is unknown, although some animal studies have suggested that steroids may cause tendon degeneration and increased risk of tendon rupture. It may be reasonable to assume that, like many adverse steroid effects, connective tissue injuries are mostly associated with high-dose, over a long period of time. Some evidence suggests that long term use can cause tendons to loose their elasticity (Miles et al., 1992, Journal of bone and joint surgery, 74, 411-22). This comes mainly from animal studies of mice treated with one certain steroid. It resulted in collagen abnormalities. This can increase the risk of a tendon rupture (, 1987, International orthopedics, 11, 157-162). Another aspect that might be an explanation, perhaps in conjunction with the two previous, is the fact that AS mainly affects the muscle belly in particular, and not the connective tissue as much. This might cause too strong muscle for the tendon, thus increasing the risk of a rupture (Gallaway, 1997, The steroid bible) This was also the explanation from The hormone Laboratory of Aker Sykehus.

Table adapted from Clinical Chemistry 43, 1997.

Some of the documented damaging side effects observed in male and female GDR athletes during treatment with AS, notably Turinabol:

Damaging side effects	% of athletes affected	Dosage category
Jumping events, heptatlon/decathlon
Muscle tightness	65	1,4,5
Body weight increas	23	1,4,5,6
Muscle cramps	15	1,3
Irregular mestruation, incl amenorrhea	15	1,6,7
Acne and hirsutism	10	7,8
Alteration of libido, potency, fertility	8	1,5,7,8
Edema	2	1
Diarrheas, constipation	2	1,6
Functional/structural liver damage	0-1	7,8,5

Summarization of adverse effects from administration of AS to 191 male and 174 female athletes.

Other damaging side effects reported by "Unofficial Collaborators" in Stasi reports:

1. Deaths - 2 bodybuilders, one hammer thrower
2. Gynecomestasia - 12 reported surgical opertaions with removal of excess tissue
3. Severe liver damages, necessating hospitalization
4. Excessive hirsutism
5. Acne, folliculitis
6. Amenorrhea
7. Polycystic ovarian syndrome
8. Deepening of the voice
9. Nymphomania
10. Loss of libido ( males only)
11. Arrest of body growht ( in adolecents)

Categories: 1 = >15 mg/day; 2 = < 5 mg/ day; 3 = short treatment intervals + 14 days; 4 = long treatment intervals + 28 days; 5 = coincident medication with contraceptive steroids; 6 = fist - time medication; 7 = high dosage per year > 1000 mg; 8 = long treatment period - several years.