by a similar period of steroid-free training known as an “off cycle”. This cyclical method is practised in order to prevent tolerance to the steroids, to reduce the risk of side effects from prolonged use, and to allow the hypothalamic- pituitary-gonadal axis (which, inter alia, controls endogenous testosterone production) time to resume normal function. However, there are a minority who use steroids on an almost continuous basis. Alongside cycling, users typically take two or more different steroids at the same time in a practice known as stacking. Based on the different pharmacokinetics and pharmacodynamics that steroids can exert, users believe stacking allows specific, additional or synergistic effects (although this rationale has not been evaluated empirically). Furthermore, the dose and regimen of the steroid(s) used in a cycle or stack may be manipulated throughout an on cycle for a variety of reasons (typically to prevent tolerance to a particular steroid). Drawing from a diverse pharmacopoeia, users may also take a combination of ancillary drugs, including other

performance-enhancing drugs (eg. clenbuterol, growth hormone, insulin); some users take drugs as prophylactics to steroid-induced side effects and others for their treatment. Steroid-induced side effects (eg. tamoxifen, human chorionic gonadotrophin); and, in some individuals, recreational drugs that may also function as performance-enhancing agents (eg. cocaine, amphetamine) or as relaxants (eg. cannabis) (Table 1). It is important to recognise, however, that there is considerable heterogeneity in the knowledge (gained from other steroid users in the gym, steroid handbooks, magazines and the internet) and experience (based on self-experimentation) among users, which ultimately affects how they use these drugs. Indeed, although there are some experienced users who have a sophisticated ethnopharmacological knowledge and understanding of the effects that these drugs have on the body (and who also view themselves as users, rather than abusers, of steroids), there are many others (in particular young users) who defer dose, regime and often administration to other users.

Adverse effect Acne

TABLE 2: ADVERSE HEALTH EFFECTS ASSOCIATED WITH ANABOLIC STEROID USE Comments

Large numbers of steroid users self-report acne. In some individuals this can be severe, such as acne conglobata or acne fulminans.

Androgenic alopecia (male pattern baldness)

Gynaecomastia

In those who are genetically susceptible, the use of steroids appears to speed up the progression of hair loss. (Conversely, many steroid users report increased growth of body hair when using steroids.)

Gynaecomastia is the growth of the glandular breast tissue in males caused by an imbalance in the ratio of oestrogen to testosterone. This is believed to have multiple causes, including the peripheral aromatisation of exogenous steroids to oestrogenic metabolites. Furthermore, many of the drugs commonly used by this population such as growth hormone, HCG and spironolactone, are also associated with gynaecomastia.

Genitourinary (men)

High levels of exogenous steroids can suppress endogenous testosterone production and spermatogenesis, leading to transient testicular atrophy. It can take many months for endogenous testosterone production and fertility to recover. Many users report increased libido while using steroids; conversely, when ceasing use libido is often transiently suppressed due to suppression of endogenous testosterone production. Users report erectile dysfunction both during on and off cycles. There has also been a case report of prostatic cancer in a long-term steroid user and a limited number of case reports of renal cancers.

Liver Cardiovascular Musculoskeletal Psychological

Specific concerns for young people

Specific concerns for females

Use of steroids, in particular oral 17a-alkylated steroids, has been associated with hepatic dysfunction and disease. A relatively common side effect of oral 17a-alkylated steroid use is jaundice. There have also been a small number of case reports of benign liver tumours, peliosis hepatis (blood-filled sacs in the liver) and hepatocellular carcinoma.

Use of steroids has been associated with a range of both acute and chronic cardiovascular pathological events, including hypertension, altered lipid metabolism, altered haemostatic system, cardiac arrhythmias, myocardial infarction, stroke, thrombosis, sudden cardiac death and cardiac hypertrophy.

There have been a number of case reports of damage to tendons/ligaments after steroid use. This could be a result of disproportionate growth of the muscle compared with the tendons/ligaments. There have also been case reports of rhabdomyolysis (breakdown of muscle).

Steroid use has been associated with hypomania, mania, increased aggression, violence and depression, particularly when ceasing use, due to suppression of endogenous testosterone production. It is unclear whether steroids have the potential to be physically addictive, but they are psychologically addictive.

Adolescence is a complex time of physical, emotional and psychological development, mediated in part by the endogenous equivalents of commonly used performance- and image-enhancing drugs such as testosterone, growth hormone and IGF-1. The use of supraphysiological doses of these drugs during adolescence potentially could disrupt the normal pattern of growth and behavioural maturation.

Given the low endogenous levels of testosterone in females, any increase through exogenous sources (steroids) can have a marked effect and lead to virilisation. Effects include hirsutism, deepening of the voice, amenorrhoea/anovulation, clitoral enlargement, atrophy of breast tissue and changes in libido. The impact of these effects can be pronounced and in some cases permanent.

24 sportEX medicine 2008:38(Oct):20-26