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iamnikvanhelsing
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Its a long read but worth it.
Anabolic-androgenic steroids
Anabolic steroids, or more correctly, anabolic-androgenic steroids (AAS), are synthetic derivatives of the male sex hormone, testosterone. This hormone has two basic physiological effects:
an androgenic effect leads to the development of male features, eg facial and body hair growth, deepening of the voice, development of the testes and penis
an anabolic effect refers to its ability to build skeletal muscle tissue.
AAS are used by body builders and weightlifters to increase both lean muscle mass and strength and to decrease body fat, whereas athletes use AAS to increase erythropoiesis and thus enhance the oxygen-carrying capacity of blood to allow them to run faster.
Testosterone was first synthesised in 1935 and is said to have been used to increase the aggressiveness of German soldiers in the Second World War. The use of testosterone by athletes can be traced to the 1954 world weight-lifting championships in Vienna, where it was reported that a Soviet Union coach informed the US coach, Dr John Ziegler, that the Soviets were using testosterone1. On returning home, Dr Ziegler began using testosterone with weightlifters and it is believed that AAS use increased among Olympic athletes over the next 40 years.
AAS have been used medically in the treatment of aplastic anaemia, as well as to offset the protein catabolism that occurs after prolonged corticosteroid therapy and to promote weight gain, eg after surgery, chronic infections or severe trauma. The main current use, however, has been in the treatment of hypogonadal men, though there is much current interest in the use of AAS as a means of promoting weight gain in HIV patients.
The androgenic side effects of testosterone, especially in women and children, led to the development of synthetic steroids which, while retaining the anabolic properties, were less androgenic. In 1953, 19-nortestosterone (nandrolone) a derivative of testosterone was discovered and found to have three to five times the muscle building effects of testosterone. It became the first compound to be called an 'anabolic' steroid. All of the synthetic AAS that were subsequently developed were derivatives of testosterone or 19-nortestosterone.
While many of the testosterone derivatives are more anabolic than androgenic, there are no AAS that are purely anabolic or androgenic. Whether an anabolic or androgenic effect occurs will depend on the dosages used, though it should be stressed that all AAS are capable of producing androgenic effects if used in sufficiently high doses. It is worth noting that while AAS and glucocorticoids, such as cortisol and prednisolone, are chemically similar, they have opposite effects. Examples of oral and injectable AAS are shown in Table 1.
Mode of action
The exact mode of action which leads to an increase in muscle mass and strength remains unclear, but is probably a combination of increased protein synthesis and an anti-catabolic effect. During heavy resistance training (such as weightlifting), stress exerted on muscles induces the release of hormones such as cortisol, and prolonged release can cause skeletal muscle breakdown (hence the use of AAS after corticosteroid therapy). It is thought that AAS can inhibit the negative effects of cortisol, although exactly how this occurs is unknown.
Evidence for action
Two comprehensive reviews of the AAS literature published in 1984 and 1991 concluded that the drugs can increase lean muscle mass and decrease body fat, if used as part of a programme that includes structured training and an adequate intake of protein3,4. As a result, many AAS users consume large amounts of protein in the form of amino acid supplements, although there is little evidence that overloading with such supplements increases muscle mass.
One of the problems in assessing the efficacy of AAS in many of the published studies is that several of the important variables such as protein intake, diet, length of training experience of the athletes, dosages employed, drug combinations used and whether or not the studies were blinded, were not always controlled. Many studies have also been criticised for having a small number of subjects5.
There appears to be only two well designed, controlled studies which use dosages of AAS that are six times the therapeutic dose. The first of these studies demonstrated that AAS use in experienced body builders produced gains in lean body mass that were maintained for at least three months after discontinuation of drug treatment. Also all adverse effects, such as alterations in the level of HDL cholesterol, returned to normal six weeks after cessation of drug use6. The second study used testosterone 600mg per week and assigned the subjects into one of four groups: placebo with no exercise, testosterone with no exercise, placebo with exercise and finally testosterone with exercise. All of the subjects had previous experience of weight training and the results showed that those in the 'testosterone with exercise' group had greater increases in muscle size and fat-free mass than those in both groups who did not exercise, and greater increases in strength than the non-exercising groups. It was also reported that there were no effects on mood or behaviour in any of the groups7.
Psychological effects
Mood changes One study of AAS-using athletes found that 23 per cent of users reported major mood syndromes, eg mania, hypomania or major depression in association with their drug use8.
One commonly reported psychological adverse effect is the so-called '[ste]roid rage'. While increased levels of aggression in laboratory animals can be correlated with higher plasma levels of testosterone, the evidence from human studies is less conclusive. Other varying factors, such as original mental state, drug doses, drug combinations, duration of use and even the type and purity of the drugs, may also influence the development of mood disorders.
Interestingly, the authors of a study using testosterone enanthanate 200mg per week for up to 20 weeks, as a potential male contraceptive, concluded that the data ''suggests that concerns of adverse effects of exogenous testosterone on male sexual and aggressive behaviour have perhaps been overstated"9.
Dependence There has also been the suggestion that AAS are in some way addictive. The basis for this is that once AAS are discontinued, muscle mass is lost and this can lead to feelings of depression and a desire to continue to use them. Muscle mass occurs because once the exogenous testosterone is removed, the testes, which have often undergone some degree of atrophy, are no longer producing sufficient testosterone to sustain the increased muscle mass.
The concept of a steroid addiction hypothesis was first reported in 1989, when it was suggested that a high proportion of anabolic steroid users might develop a form of anabolic steroid dependence10. In addition, results from a year long study of AAS users attending a clinic found that many users reported feeling dysphoric once they stopped taking their drugs11. In 1995, Zoe Warwick, a former champion body builder and campaigner against the use of AAS, committed suicide and was diagnosed as suffering from exogenous androgenic misuse syndrome12. Despite this unfortunate case, there have been no reports of AAS dependence in women or children or even among patients who have been prescribed high doses of these drugs in the treatment of anaemia.
Physical side effects
The adverse effects of AAS have been greatly emphasised by the sporting authorities and used as a means of discouraging the wider use of the drugs, but the whole subject has attracted much controversy13.
There are potentially many side effects of using AAS (see Table 2) but most of these resolve once the drug is discontinued, although many of the effects in women appear to be irreversible. In 1997, it was reported that an East German female shotputter, Heidi Krieger, underwent a sex change operation which she claimed was a result of the AAS she was forced to take during training in 1982. Krieger claimed that the AAS had made her develop facial hair and an enlarged Adam's apple, and she suffered severe psychological problems14. Similar changes were reported by Christiane Knacke-Sommer, a former East German Olympic swimmer. Several coaches and doctors have been put on trial in Berlin.
There are many single reports in the literature that have been used as a basis for the case against AAS use and these have been reviewed elsewhere15. As shown in Table 2, for instance, AAS can elevate liver function tests and this can lead to the development of liver tumours. However, there are very few (no more than four) cases of tumours associated with AAS use by athletes. One such case report describes how a user took 700mg of oxymetholone a week continuously for five years. In contrast, a study using oxymetholone at 150 mg/day (normal dose being 1-5 mg/kg) for 30 weeks in patients with HIV did not produce any adverse effects on the liver16.
The frequency with which the possible side effects occur will depend on factors such as the combinations of drugs used (see Table 3), dosages employed, length of cycles and the individual response to the drug. In addition, many AAS are counterfeits and while some preparations will contain nothing more than the oil base itself, others will have varying mixtures of different agents and analysed samples have shown wide variation in composition. It is this unknown factor that poses the risk. Since there are many variables to consider, making meaningful predictions of the adverse effects is more difficult. One possible solution to the problems posed to AAS users might be to allow GPs to prescribe the drugs themselves and some success has already been achieved with this approach. In Australia, from 1987 to 1991, a group of anabolic steroid users were prescribed courses of methenolone 140mg per week for seven weeks17.
There are, unfortunately, no large long-term observational studies of body builders and weightlifters from the 1950s and 1960s, which would provide valuable insight into the lasting adverse effects of these drugs.
Steroids and the law
In the UK, AAS and anabolic agents such as clenbuterol and polypeptide growth hormones are classified as Controlled Drugs, attracting class C penalties. An amendment to the Misuse of Drugs Act created two separate parts to schedule 4, with all existing schedule 4 drugs being placed in part 2 and the AAS being placed in part 1. It is now an offence to export or import AAS, unless in a medicinal form or for personal use, without an appropriate licence. Simple possession of AAS is not illegal, but possession with intent to supply is an offence, irrespective of whether or not the supply was for profit this includes sharing the drugs with another person or even if the person is simply looking after the drugs for somebody else. In cases of possession with intent to supply, the amount of drugs found will be taken into consideration, though this might be difficult to prove given that many AAS users may possess large amounts of different drugs for their own use.
Although there are no official statistics, AAS use in the UK is believed to be widespread. A study in 1993 estimated use at around 5 per cent among those using gyms and fitness clubs2 and various other studies have shown that AAS use is increasing and that in some cases the drugs are being used by club doormen, as well as policemen and rugby players.
Drug regimens
AAS are often used in fairly complicated regimes or cycles. During a cycle, it is not unusual for several different agents to be taken together continuously for up to 12 weeks at differing doses. This is followed by a rest period and the cycle is repeated two or three times per year. If the AAS are delivered via a depot injection, the drugs are held in the fat stores and released slowly over several months, which can create problems for athletes who might use the drugs when not competing, but still test positive several months later.
The dosages of AAS used are often well in excess of the recommended medical dosages. For example, the therapeutic dose of methandienone (Dianabol) is 5mg daily, whereas body building athletes might use up to 40mg daily. Similarly, testosterone enanthate is used in the treatment of hypogonadism at between 50 and 400mg every two to four weeks, whereas body builders might use up to 800mg per week.
Drug testing
Testing for AAS was introduced in 1976 using assays based on gas-chromatography and mass spectrometry (GC-MS) and this technique is now used routinely. Tests involve the detection of excessive anabolic steroid metabolites in urine as confirmation of the presence of exogenous AAS. Blood testing is permitted, but not used routinely.
The most commonly used procedure involves determining the ratio of testosterone to epitestosterone. Normally, the ratio of the two steroids in urine is 1:1 and so if additional testosterone is taken, the ratio increases. Since training can increase the natural levels of testosterone, there is a permitted maximum ratio of the two steroids of 6:1.
Since the main method of testing is urine, in an attempt to avoid detection, many athletes have resorted to a number of different methods ranging from direct substitution with another person's urine, use of diuretics (see Table 3) and use of blocking agents, such as probenecid, which prevents the excretion of AAS. However, diuretics, blocking agents and use of epitestosterone (to maintain the 1:1 ratio) have all been included on the sports authorities list of banned substances.
Recently, there has been an increase in the number of athletes testing positive for nandrolone, although many of them are adamant that they have not taken the substance. A steroid precursor to nandrolone is present in some food supplements taken by athletes and there is some evidence that nandrolone can be produced in the body in trace amounts. Since the GC-MS can detect substances at the nanogram level, there is a risk that athletes can test positive even when they have not knowingly used nandrolone and they therefore need to play close attention to their diets.
Pharmacy role
Pharmacists who are involved in needle exchange schemes may come into contact with AAS users who will request the large bore green (23G) or blue (21G) needles that are used for intramuscular injection. Most users will want objective information about the drugs they are taking and their potential for side effects. In addition, some users have a poor understanding of injection techniques and the risk associated with syringe sharing and cases of HIV have been reported among AAS users. It is worth exploring what services are available locally for AAS users, as it should be remembered that not all treatment agencies can advise on AAS use.
AAS users often do not perceive themselves as the typical 'exchange client'. This is an important challenge for pharmacists, as many users believe that AAS use is illegal and this could discourage them from obtaining clean injecting equipment, as well as the information and advice that they so desperately need.
References available on request
Table 1: Examples of oral and injectables AAS used (brand names in brackets, includes overseas brands) Oral anabolic-androgenic steroid Injectable anabolic-androgenic steroids
Methandienone (Dianabol, Pronabol 5) Nandrolone (Deca-Durabolin)
Oxandrolone (Anavar) Testosterone enanthate (Testoviron)
Stanozolol (Stromba, Winstrol) Sustanon 100 or 250 (a mixture of testosterone propionate, phenylpropionate and isocaproate)
Testosterone undecanoate (Restandol, Andriol, Androxen, Nuvir) Boldenone undecanoate (Equipoise which is a veterinary steroid)
Oxymetholone (Anapolon 50, Anadrol 50) Testosterone propionate (Virormone)
Back to text
Table 2: Main side effects of anabolic-androgenic steroids Hypertension In general, this side effect is not a significant problem, but can occur and users should have their blood pressure checked regularly as a precaution
Increased cholesterol levels Both total and LDL cholesterol levels are raised
Gynaecomastia (development of male breasts) This occurs as excess androgens can be converted into oestrogenic metabolites. If the breast tissue develops for a long time, regression of tissue becomes more difficult. Users often take tamoxifen to counter this effect
Elevated liver function tests This commonly occurs when AAS are taken, particularly the oral agents. The significance of the changes are unclear as some evidence from long-term users suggests that no damage occurs. However, cases of liver cancer in athletes are reported in the literature
Testicular atrophy This is the basis for the development of the male contraceptive pill and the majority of studies have shown that once the drugs are stopped no long-term adverse effects occur
Baldness/acne Male pattern baldness occurs and is thought to be the result of excess dihydrotestosterone which is produced from testosterone. Again acne results from excess dihydrotestosterone acting on androgen receptors in the skin (this occurs normally during adolescence)
Early closure of the epiphyseal plates This results in a stunting of growth and hence there are particular dangers for adolescents using AAS. However, oxandrolone has been used clinically to treat growth retardation for up to four years without adverse effects
Back to text
Table 3 Drugs used in conjunction with anabolic-androgenic steroids Drugs used with anabolic-androgenic steroids Reason why drugs are used
Tamoxifen/Clomiphene Acts to antagonise the effects of oestrogenic metabolites formed when excess testosterone is used; also used to prevent gynaecomastia
Frusemide/diuretics Either used to reduce fluid retention (a side effect of AAS) or to enhance muscle definition prior to competitions. Diuretics (which are on the list of banned substances) are occasionally used to dilute urine to avoid AAS detection
Human chorionic gonadotrophin (HCG) Often used by males after completing a cycle to 'kick-start' the testes production of testosterone or to counter hypogonadism which occurs during a cycle
Caffeine/ephedrine/ clenbuterol These stimulants can increase free fatty acids in the plasma and hence are used as 'fat-burners'
Nulbuphine (Nubain) Suggested in 'steroid handbooks' as an antagonist of cortisol, although there is little evidence for this. In addition, the opiate properties can be used to allow users to train through the pain barrier
Human growth hormone Used to increase retention of nitrogen and amino acids. Growth hormone also has fat-burning effects
Insulin/insulin-like growth factor These agents are used to increase muscle mass (insulin is an anabolic hormone)
Phew!!! I'm knackered after reading all that!
Anabolic-androgenic steroids
Anabolic steroids, or more correctly, anabolic-androgenic steroids (AAS), are synthetic derivatives of the male sex hormone, testosterone. This hormone has two basic physiological effects:
an androgenic effect leads to the development of male features, eg facial and body hair growth, deepening of the voice, development of the testes and penis
an anabolic effect refers to its ability to build skeletal muscle tissue.
AAS are used by body builders and weightlifters to increase both lean muscle mass and strength and to decrease body fat, whereas athletes use AAS to increase erythropoiesis and thus enhance the oxygen-carrying capacity of blood to allow them to run faster.
Testosterone was first synthesised in 1935 and is said to have been used to increase the aggressiveness of German soldiers in the Second World War. The use of testosterone by athletes can be traced to the 1954 world weight-lifting championships in Vienna, where it was reported that a Soviet Union coach informed the US coach, Dr John Ziegler, that the Soviets were using testosterone1. On returning home, Dr Ziegler began using testosterone with weightlifters and it is believed that AAS use increased among Olympic athletes over the next 40 years.
AAS have been used medically in the treatment of aplastic anaemia, as well as to offset the protein catabolism that occurs after prolonged corticosteroid therapy and to promote weight gain, eg after surgery, chronic infections or severe trauma. The main current use, however, has been in the treatment of hypogonadal men, though there is much current interest in the use of AAS as a means of promoting weight gain in HIV patients.
The androgenic side effects of testosterone, especially in women and children, led to the development of synthetic steroids which, while retaining the anabolic properties, were less androgenic. In 1953, 19-nortestosterone (nandrolone) a derivative of testosterone was discovered and found to have three to five times the muscle building effects of testosterone. It became the first compound to be called an 'anabolic' steroid. All of the synthetic AAS that were subsequently developed were derivatives of testosterone or 19-nortestosterone.
While many of the testosterone derivatives are more anabolic than androgenic, there are no AAS that are purely anabolic or androgenic. Whether an anabolic or androgenic effect occurs will depend on the dosages used, though it should be stressed that all AAS are capable of producing androgenic effects if used in sufficiently high doses. It is worth noting that while AAS and glucocorticoids, such as cortisol and prednisolone, are chemically similar, they have opposite effects. Examples of oral and injectable AAS are shown in Table 1.
Mode of action
The exact mode of action which leads to an increase in muscle mass and strength remains unclear, but is probably a combination of increased protein synthesis and an anti-catabolic effect. During heavy resistance training (such as weightlifting), stress exerted on muscles induces the release of hormones such as cortisol, and prolonged release can cause skeletal muscle breakdown (hence the use of AAS after corticosteroid therapy). It is thought that AAS can inhibit the negative effects of cortisol, although exactly how this occurs is unknown.
Evidence for action
Two comprehensive reviews of the AAS literature published in 1984 and 1991 concluded that the drugs can increase lean muscle mass and decrease body fat, if used as part of a programme that includes structured training and an adequate intake of protein3,4. As a result, many AAS users consume large amounts of protein in the form of amino acid supplements, although there is little evidence that overloading with such supplements increases muscle mass.
One of the problems in assessing the efficacy of AAS in many of the published studies is that several of the important variables such as protein intake, diet, length of training experience of the athletes, dosages employed, drug combinations used and whether or not the studies were blinded, were not always controlled. Many studies have also been criticised for having a small number of subjects5.
There appears to be only two well designed, controlled studies which use dosages of AAS that are six times the therapeutic dose. The first of these studies demonstrated that AAS use in experienced body builders produced gains in lean body mass that were maintained for at least three months after discontinuation of drug treatment. Also all adverse effects, such as alterations in the level of HDL cholesterol, returned to normal six weeks after cessation of drug use6. The second study used testosterone 600mg per week and assigned the subjects into one of four groups: placebo with no exercise, testosterone with no exercise, placebo with exercise and finally testosterone with exercise. All of the subjects had previous experience of weight training and the results showed that those in the 'testosterone with exercise' group had greater increases in muscle size and fat-free mass than those in both groups who did not exercise, and greater increases in strength than the non-exercising groups. It was also reported that there were no effects on mood or behaviour in any of the groups7.
Psychological effects
Mood changes One study of AAS-using athletes found that 23 per cent of users reported major mood syndromes, eg mania, hypomania or major depression in association with their drug use8.
One commonly reported psychological adverse effect is the so-called '[ste]roid rage'. While increased levels of aggression in laboratory animals can be correlated with higher plasma levels of testosterone, the evidence from human studies is less conclusive. Other varying factors, such as original mental state, drug doses, drug combinations, duration of use and even the type and purity of the drugs, may also influence the development of mood disorders.
Interestingly, the authors of a study using testosterone enanthanate 200mg per week for up to 20 weeks, as a potential male contraceptive, concluded that the data ''suggests that concerns of adverse effects of exogenous testosterone on male sexual and aggressive behaviour have perhaps been overstated"9.
Dependence There has also been the suggestion that AAS are in some way addictive. The basis for this is that once AAS are discontinued, muscle mass is lost and this can lead to feelings of depression and a desire to continue to use them. Muscle mass occurs because once the exogenous testosterone is removed, the testes, which have often undergone some degree of atrophy, are no longer producing sufficient testosterone to sustain the increased muscle mass.
The concept of a steroid addiction hypothesis was first reported in 1989, when it was suggested that a high proportion of anabolic steroid users might develop a form of anabolic steroid dependence10. In addition, results from a year long study of AAS users attending a clinic found that many users reported feeling dysphoric once they stopped taking their drugs11. In 1995, Zoe Warwick, a former champion body builder and campaigner against the use of AAS, committed suicide and was diagnosed as suffering from exogenous androgenic misuse syndrome12. Despite this unfortunate case, there have been no reports of AAS dependence in women or children or even among patients who have been prescribed high doses of these drugs in the treatment of anaemia.
Physical side effects
The adverse effects of AAS have been greatly emphasised by the sporting authorities and used as a means of discouraging the wider use of the drugs, but the whole subject has attracted much controversy13.
There are potentially many side effects of using AAS (see Table 2) but most of these resolve once the drug is discontinued, although many of the effects in women appear to be irreversible. In 1997, it was reported that an East German female shotputter, Heidi Krieger, underwent a sex change operation which she claimed was a result of the AAS she was forced to take during training in 1982. Krieger claimed that the AAS had made her develop facial hair and an enlarged Adam's apple, and she suffered severe psychological problems14. Similar changes were reported by Christiane Knacke-Sommer, a former East German Olympic swimmer. Several coaches and doctors have been put on trial in Berlin.
There are many single reports in the literature that have been used as a basis for the case against AAS use and these have been reviewed elsewhere15. As shown in Table 2, for instance, AAS can elevate liver function tests and this can lead to the development of liver tumours. However, there are very few (no more than four) cases of tumours associated with AAS use by athletes. One such case report describes how a user took 700mg of oxymetholone a week continuously for five years. In contrast, a study using oxymetholone at 150 mg/day (normal dose being 1-5 mg/kg) for 30 weeks in patients with HIV did not produce any adverse effects on the liver16.
The frequency with which the possible side effects occur will depend on factors such as the combinations of drugs used (see Table 3), dosages employed, length of cycles and the individual response to the drug. In addition, many AAS are counterfeits and while some preparations will contain nothing more than the oil base itself, others will have varying mixtures of different agents and analysed samples have shown wide variation in composition. It is this unknown factor that poses the risk. Since there are many variables to consider, making meaningful predictions of the adverse effects is more difficult. One possible solution to the problems posed to AAS users might be to allow GPs to prescribe the drugs themselves and some success has already been achieved with this approach. In Australia, from 1987 to 1991, a group of anabolic steroid users were prescribed courses of methenolone 140mg per week for seven weeks17.
There are, unfortunately, no large long-term observational studies of body builders and weightlifters from the 1950s and 1960s, which would provide valuable insight into the lasting adverse effects of these drugs.
Steroids and the law
In the UK, AAS and anabolic agents such as clenbuterol and polypeptide growth hormones are classified as Controlled Drugs, attracting class C penalties. An amendment to the Misuse of Drugs Act created two separate parts to schedule 4, with all existing schedule 4 drugs being placed in part 2 and the AAS being placed in part 1. It is now an offence to export or import AAS, unless in a medicinal form or for personal use, without an appropriate licence. Simple possession of AAS is not illegal, but possession with intent to supply is an offence, irrespective of whether or not the supply was for profit this includes sharing the drugs with another person or even if the person is simply looking after the drugs for somebody else. In cases of possession with intent to supply, the amount of drugs found will be taken into consideration, though this might be difficult to prove given that many AAS users may possess large amounts of different drugs for their own use.
Although there are no official statistics, AAS use in the UK is believed to be widespread. A study in 1993 estimated use at around 5 per cent among those using gyms and fitness clubs2 and various other studies have shown that AAS use is increasing and that in some cases the drugs are being used by club doormen, as well as policemen and rugby players.
Drug regimens
AAS are often used in fairly complicated regimes or cycles. During a cycle, it is not unusual for several different agents to be taken together continuously for up to 12 weeks at differing doses. This is followed by a rest period and the cycle is repeated two or three times per year. If the AAS are delivered via a depot injection, the drugs are held in the fat stores and released slowly over several months, which can create problems for athletes who might use the drugs when not competing, but still test positive several months later.
The dosages of AAS used are often well in excess of the recommended medical dosages. For example, the therapeutic dose of methandienone (Dianabol) is 5mg daily, whereas body building athletes might use up to 40mg daily. Similarly, testosterone enanthate is used in the treatment of hypogonadism at between 50 and 400mg every two to four weeks, whereas body builders might use up to 800mg per week.
Drug testing
Testing for AAS was introduced in 1976 using assays based on gas-chromatography and mass spectrometry (GC-MS) and this technique is now used routinely. Tests involve the detection of excessive anabolic steroid metabolites in urine as confirmation of the presence of exogenous AAS. Blood testing is permitted, but not used routinely.
The most commonly used procedure involves determining the ratio of testosterone to epitestosterone. Normally, the ratio of the two steroids in urine is 1:1 and so if additional testosterone is taken, the ratio increases. Since training can increase the natural levels of testosterone, there is a permitted maximum ratio of the two steroids of 6:1.
Since the main method of testing is urine, in an attempt to avoid detection, many athletes have resorted to a number of different methods ranging from direct substitution with another person's urine, use of diuretics (see Table 3) and use of blocking agents, such as probenecid, which prevents the excretion of AAS. However, diuretics, blocking agents and use of epitestosterone (to maintain the 1:1 ratio) have all been included on the sports authorities list of banned substances.
Recently, there has been an increase in the number of athletes testing positive for nandrolone, although many of them are adamant that they have not taken the substance. A steroid precursor to nandrolone is present in some food supplements taken by athletes and there is some evidence that nandrolone can be produced in the body in trace amounts. Since the GC-MS can detect substances at the nanogram level, there is a risk that athletes can test positive even when they have not knowingly used nandrolone and they therefore need to play close attention to their diets.
Pharmacy role
Pharmacists who are involved in needle exchange schemes may come into contact with AAS users who will request the large bore green (23G) or blue (21G) needles that are used for intramuscular injection. Most users will want objective information about the drugs they are taking and their potential for side effects. In addition, some users have a poor understanding of injection techniques and the risk associated with syringe sharing and cases of HIV have been reported among AAS users. It is worth exploring what services are available locally for AAS users, as it should be remembered that not all treatment agencies can advise on AAS use.
AAS users often do not perceive themselves as the typical 'exchange client'. This is an important challenge for pharmacists, as many users believe that AAS use is illegal and this could discourage them from obtaining clean injecting equipment, as well as the information and advice that they so desperately need.
References available on request
Table 1: Examples of oral and injectables AAS used (brand names in brackets, includes overseas brands) Oral anabolic-androgenic steroid Injectable anabolic-androgenic steroids
Methandienone (Dianabol, Pronabol 5) Nandrolone (Deca-Durabolin)
Oxandrolone (Anavar) Testosterone enanthate (Testoviron)
Stanozolol (Stromba, Winstrol) Sustanon 100 or 250 (a mixture of testosterone propionate, phenylpropionate and isocaproate)
Testosterone undecanoate (Restandol, Andriol, Androxen, Nuvir) Boldenone undecanoate (Equipoise which is a veterinary steroid)
Oxymetholone (Anapolon 50, Anadrol 50) Testosterone propionate (Virormone)
Back to text
Table 2: Main side effects of anabolic-androgenic steroids Hypertension In general, this side effect is not a significant problem, but can occur and users should have their blood pressure checked regularly as a precaution
Increased cholesterol levels Both total and LDL cholesterol levels are raised
Gynaecomastia (development of male breasts) This occurs as excess androgens can be converted into oestrogenic metabolites. If the breast tissue develops for a long time, regression of tissue becomes more difficult. Users often take tamoxifen to counter this effect
Elevated liver function tests This commonly occurs when AAS are taken, particularly the oral agents. The significance of the changes are unclear as some evidence from long-term users suggests that no damage occurs. However, cases of liver cancer in athletes are reported in the literature
Testicular atrophy This is the basis for the development of the male contraceptive pill and the majority of studies have shown that once the drugs are stopped no long-term adverse effects occur
Baldness/acne Male pattern baldness occurs and is thought to be the result of excess dihydrotestosterone which is produced from testosterone. Again acne results from excess dihydrotestosterone acting on androgen receptors in the skin (this occurs normally during adolescence)
Early closure of the epiphyseal plates This results in a stunting of growth and hence there are particular dangers for adolescents using AAS. However, oxandrolone has been used clinically to treat growth retardation for up to four years without adverse effects
Back to text
Table 3 Drugs used in conjunction with anabolic-androgenic steroids Drugs used with anabolic-androgenic steroids Reason why drugs are used
Tamoxifen/Clomiphene Acts to antagonise the effects of oestrogenic metabolites formed when excess testosterone is used; also used to prevent gynaecomastia
Frusemide/diuretics Either used to reduce fluid retention (a side effect of AAS) or to enhance muscle definition prior to competitions. Diuretics (which are on the list of banned substances) are occasionally used to dilute urine to avoid AAS detection
Human chorionic gonadotrophin (HCG) Often used by males after completing a cycle to 'kick-start' the testes production of testosterone or to counter hypogonadism which occurs during a cycle
Caffeine/ephedrine/ clenbuterol These stimulants can increase free fatty acids in the plasma and hence are used as 'fat-burners'
Nulbuphine (Nubain) Suggested in 'steroid handbooks' as an antagonist of cortisol, although there is little evidence for this. In addition, the opiate properties can be used to allow users to train through the pain barrier
Human growth hormone Used to increase retention of nitrogen and amino acids. Growth hormone also has fat-burning effects
Insulin/insulin-like growth factor These agents are used to increase muscle mass (insulin is an anabolic hormone)
Phew!!! I'm knackered after reading all that!
