Steroid Use and Women’s Health

An interview with selected medical practitioners



The prevalent use of pharmaceuticals as enhancers of performance or appearance in the athletic arena is well-known. However, the legal and moral issues surrounding their use prevent users from access to credible and reliable medical information on health issues associated with their use. Medical practitioners cannot legally or ethically prescribe them for use by athletes and the doctors themselves are often inadequately informed about the physiology of the drugs. This is especially true when you consider the various dosing schemes and polypharmacology that is often employed by athletes, especially bodybuilders. Even the published scientific information available to them is not free from bias. Although newly published studies are reporting more objective conclusions regarding increases in muscle mass and strength, the health risks associated with the supraphysiological doses and durations used by many athletes remain unknown.

Regardless, these drawbacks have not deterred many male athletes and bodybuilders from experimenting with illicit drugs to enhance their performance or appearances. Before anabolic-androgenic steroids (AAS) were legally classified as Schedule III controlled substances in 1990, the occasional athlete could obtain AAS for ‘injuries’ by a few practicing MDs, but they were never freely dosed like antibiotics. In these cases, the physicians could monitor the users’ physical status. However, even then most AAS were illicitly obtained outside of medical approval and supervision. Obviously, the reclassification of AAS drove their use by athletes even more underground than before.

Not only do AAS increase muscle mass, they reduce the muscle breakdown that often results from overtraining and extreme dieting by enhancing recovery, and they are useful for recovering from injuries. Both men and women in sports have proved their efficacy by decades of use. However, the legal ramifications of their use have relegated that users experiment without medical supervision and monitoring.

Self-prescribed dosages and stacking regimens based on anecdotal testimony and amateur science are easily accessible by males in the athletic world. This prevails especially in bodybuilding where the use of AAS is more commonplace than in other sports-related activities. Couched chatter in the locker room, internet/usenet forums, affordable steroid handbooks, magazine articles; there are sources of information on steroid use everywhere. However, that information is typically male-dominated: use of drugs for men and accumulated by men.

The Amazonian female bodybuilders of several years ago attained their muscularity with the use of AAS to augment their training and diets. The heyday of the female extreme muscularity has now faded to smaller muscled women bodybuilders and fitness competitions. The Bev Francis and Vicki Gates physiques have been replaced with big-breasted women who perform dazzling acts of gymnastics or show how well they can diet. Despite the smaller female physiques of today, the use of drugs continues. The top competitors are the cream of the crop. In order to gain that competitive edge, they still resort to the aid of drugs, including AAS.

Information on the use of AAS for women is less reliable and credible than that for men. Women have been coached on their use by their boyfriends or other men in their immediate circles of gym partners. Chatter amongst women relating experiences can be found in some usenet groups, but the issues are still vague. Much of the disseminated information is based on the use of AS by men without consideration and knowledge of the differences in physiology: the hormonal milieu of women is very different from that of men. Nevertheless, women using or considering using AAS are not likely to approach their family practitioner for advice or medical supervision. The stigma associated with AAS use is stronger for women than men and the medical aspects associated with them are also less known.

To provide women with credible knowledge about the health issues associated with using AAS, the author interviewed four physicians and academic authorities specifically addressing female concerns. The interviewees are from North America and Europe representing a cross-section of international experience with women athletes. The names of the interviewees are withheld and replaced with a letter designated by the author. Each offers their response to a series of questions that were based on concerns voiced by women or known medical concerns.

Question: Given the sensitive nature of not only anabolic steroid (AS) use but especially use by a female, how can a woman approach a physician for monitoring her health during AS use?

Dr. A: This is very hard. You must make sure that the physician is knowledgeable and also not judging. It is very hard to find a physician that is open for this type of monitoring, unless you explain to the physician why you are doing it and that you are also willing to work and listen to him, and make the necessary changes with him.

Dr. B: Difficult to do as there is still a medical stigma associated with having anything at all to do with anyone using anabolic steroids. At present there are a few doctors that I know of that are facing discipline as a result of involvement with anabolic steroid using athletes. If you do manage to see a doctor with liberal views on the subject, these doctors would be much less likely to monitor their use in females, given the androgenic nature of these compounds.

Dr. C: First, a female athlete considering the use of AS should try to find a physician with a distinct background in the sport of bodybuilding or power lifting. These will be the ones who are most open minded when it comes to use of performance enhancing drugs. She should tell the physician about her intentions for using AS and should show him that she has accumulated quite a bit of knowledge about risks and side effects of these substances on the female body. Then the MD will see that she has decided to do so not because of spontaneous thoughts but based on a longer lasting decision process. She should clearly state that she doesn’t want any AS prescribed (which is illegal in most states) but just monitoring her health for safety reasons.

Even with these cautions women should be aware of the fact that most physicians won’t follow her arguments and will deny any cooperation. So she probably has to speak with several of them until she will find one who is open minded enough for health monitoring of a female athlete taking AS.

Question: Any steroid use could potentially have wide-ranging effects on various biological systems, including metabolic (e.g. insulin sensitivity), endocrine, and cardiovascular. What type of tests/assays should be recommended during and after use? How important are baseline (before use of AS) tests?

Dr A: First you should always have baseline labs, they are the must important labs, because it will let the physician know how good, bad or ok you are doing, you should monitor them depending in your dosages, changes of drugs or cycles and if you are sexually active. Tests to be run are:1-Liver Profile, CBC, Lipid screen, TSH, T4, T3, free and total testosterone, PSA [prostate-specific antigen] if a male, estrogen, LH and FSH, physical exam including pap smear if not done before. I include CRP and homocysteine, and Hgb 1 AC , and finally depending if the patient is using prohormones I will check those and, believe it or not an EKG for baseline heart and a good blood pressure reading.

Dr. B: Baseline tests are useful, as they’ll give you the normal lay of the land before you interfere with the landscape. I usually recommend a complete blood count, LH, FSH, free or bioavailable, and total testosterone, SHBG, TSH, T3, T4, liver and kidney function tests, total, HDL, LDL cholesterol, glycosylated Hb, lipoprotein(a), C-reactive protein, homocysteine

Dr. C: Baseline tests are of utmost importance to be aware of any pre-existing health problems. If there are any problems, AS use should be discussed with the female athlete again or the changes in the parameters have to be reevaluated very carefully every few weeks while on cycle.

Important tests are liver markers (gamma-GT, GOT, GPT, Cholinesterase, GlDH), parameters for kidney function (creatinine, BUN), blood cell count (erythrocytes, leucocytes, platelets, hematocrit), blood sugar after overnight fasting as well as an oral glucose tolerance test, creatine kinase (CK), blood lipids (total cholesterol, HDL, LDL, triglycerides, lipoprotein(a), hormone concentrations (estrone, estradiol, testosterone (all total, bound and free), SHBG, LH, FSH).

Question: Considering that most users of AS typically ‘stack’ compounds by using more than one AS simultaneously, one author suggests assaying for total, bound and free testosterone concentrations during any type of AS use . The reasoning for this is that regardless of the AS used the endpoint (i.e. the increase in the three chemistry measures) is still the same. Do you agree with this?

Dr. A: Yes I do because you will have a baseline of where you were before and where you should be. Also there is a balance between these values and I will know what that ratio is.

Dr. B: This guy must be on drugs. How can you get increases in testosterone with the use of anabolic steroids? They depress the HPTA and lower testosterone levels. The only time you’re going to get an increase in serum testosterones is if you use injectable/oral/topical testosterone.

Dr. C: No, I don’t. In my experience most assays can discern between testosterone and synthetic analogues, meaning that while on a cycle of synthetic AS the testosterone concentrations will decrease markedly because of the negative feedback, while the concentration of the synthetic analogue will be high (if specifically measured). When using testosterone as the only steroid (will be the exception with women) measuring the testosterone concentrations would be sufficient. Evaluating the SHBG is sometimes useful as well, as AS decrease the binding protein markedly (esp. stanozolol). A lowered SHBG is a quite good marker if someone is taking AS (SHBG is below the reference range even after a few days of even low doses of AS).

Question: In light of #3, would use of the non-aromatizing AS change your response to the question? If so, what other markers would be informative?

Dr. A: No, you must also protect yourself as a physician.

Dr. C: The use of a non-aromatizing AS will lower the natural testosterone production as well, but not that markedly, because estradiol is a quite strong suppressor of LH/FSH release in the hypophysis, at least in men. Measuring the estradiol concentration will give a good picture of the aromatase activity in the body in men. Therefore, while on a cycle of non-aromatizing steroids, estradiol will be low (below normal because of lowered natural release). While on a cycle of aromatizing AS, estradiol will often be above the norm, depending on the aromatase activity in the body. In women estradiol also stems from the ovaries. If estradiol is increased in a female athlete one can also assume a high aromatization activity in the body, because the natural estradiol production in the ovaries is lowered while on AS.

Question: Prohormone use is typically considered benign in the weightlifting circles and their efficacy in men is debatable. Prohormone supplementation may result in greater increases in testosterone (or nortestosterone) in women because their baseline level of androgens is much lower than that of males’ and they exhibit preferential conversion of androstenedione to testosterone. What cautions would you specifically recommend for women who use prohormone supplementation?

Dr. A: Must have a baseline. Also some side effects are equal to the steroids, and believe it or not, keep a check on their moods. Also make sure you can’t get pregnant. They are not benign they are active compounds that we still don’t know enough about them.

Dr. B: The same as using anabolic steroids. Be careful of the virilizing effects. If you don’t want your voice to deepen, more facial hair, less hair on top, and a bigger clitoris, then be very careful in using either the prohormones or AS.

Dr. C: I would advise a female athlete to start with a nor-testosterone prohormone, using low dosages in the first 2-3 weeks and watching herself carefully for signs of virilization (lowering of the voice, acne, increased body hair growth etc.). Keeping cycles short (4-6 weeks) with sufficient breaks should help to avoid such side effects. But every physician has to keep in mind that the onset of virilization symptoms can differ tremendously between women, depending on genetic factors and others.

Question: Reproduction function is a health concern for both men and women who use AAS. The most prevalent side effect of AS use by women is changes in menstrual cycles. Many women bodybuilders experience menstrual irregularities or amenorrhea (absence of menstrual cycle for six months or more). Are there differential effects based on the type of AS used, or is it primarily a dose and duration issue?

Dr. A: Actually both; what type how much and even route has a different effect

Dr. B: Dose and duration overshadow anything else.

Dr. C: In my experience the main factor is the individual responsiveness that determines the severity of symptoms. Besides that the androgenic index of a particular AS is very important to anticipate the magnitude of side effects. With testosterone esters or trenbolone side effects will occur the earliest and the most severe. But even with more anabolic steroids with a less androgenic index side effects will occur with a higher dose and longer duration of use. From empirical evidence the lowering of the voice is one of the earliest signs female athletes will encounter.

Question: What type of monitoring would be best for menstruation status?

Dr. A: A baseline here is important, and also you should know when you get those measurements so you are not measuring two different levels at different times.

Dr. B: Monitoring for menstrual status is useless while using anabolic steroids since any testing is meaningless. Attaining pre-steroid status should be the main concern regardless of the dosages used and duration of use.

Dr. C: Besides the reports of the female athletes, hormone concentrations of estradiol, progesterone, LH and FSH are important markers for menstruation status.

Question: Given the high propensity and prevalence of menstrual dysfunction occurring with AS use, what approaches can be used to normalize menstruation after cycles of AAS use? Which approach has the highest success?

Dr. A: It depends on the above and what your goals are after and how long. Sometimes you might not be able to fix somebody, and to normalize them you are forced to use hormones again, including HCG, estrogen, DHEA, test and progesterone and sometimes thyroid and herbs.

Dr. C: In my experience with female athletes there is no real pharmaceutical solution. In many cases just ceasing AS use and waiting for normalization of menstrual function is the most practical way.

Question: Loss of bone mineral density is highly associated with amenorrhea. Can any precautions be taken against loss of BMD?

Dr. A: No fucking way you are losing BMD during steroids, they are the best to increase BMD.

Dr. B: BMD is associated with levels of both estrogen and androgens – in both men and women.

Dr. C: I would advise the female athlete to pay attention to the acid balance of the body (use of buffering agents, e.g. potassium citrate) and to keep the intake of green veggies with a high calcium content high. On the other hand AS have high calcium retaining properties and females involved in strength sports have stronger bones, therefore I don’t see a real concern about bone mineral density with females using AS.


Question: How does AS cycle length correlate with symptom development of endocrine dysfunction (see above)? How does the duration of use compare with cycles commonly used by male athletes?

Dr. A: The duration is usually less and the amount less depending on the sport. The longer [the duration] the worse the side effects if you are going to have any, and also how much.

Dr. B: The more you take and the longer you take it , the more symptoms you’ll have and the tougher it will be getting your system back to normal.

Dr. C: The cycle length is a very important factor for development of endocrine dysfunction. I would advise females to keep cycle length below 6 weeks for avoiding such side effects. In my opinion women should use AS for shorter periods than men with longer breaks, as my experience shows that hormonal imbalances are more severe with females.

Question: Virilization is partly dependent upon the androgenic properties of the AS used. However, the undesirable side effects also depend on dose and duration as well. It is suggested that some virilization is reversible and others irreversible. How can virilization such as hair growth and voice changes be minimized?

Dr. A: With lower dosages and shorter cycles, or using different type of AAS with lower androgenecity like anavar primo and winstrol. Remember though that side effects are dependant on genetic predisposition

Dr. B: First of all I find that there isn’t much difference in the various anabolic steroid preparations if what you’re looking at is the anabolic response you’re getting. You need to take more of the less androgenic compounds to get the same anabolic effects as the more androgenic compounds. And when you take more of the less androgenic compounds you also get significant and comparable androgenic effects.

Dr. C: The most important point is to keep dosages low, cycle length short and breaks between cycles at least as long as the duration of the intake. The genetic susceptibility is probably the main factor for developing virilization symptoms. After onset of lowering of the voice or increased body hair growth AS use should be stopped immediately. In these cases the side effects are reversible nearly every time.

Question: Liver function and toxicity are a concern for any person using AS. The oral C-17 alkylated AS are more associated with liver toxicity than the injectable non-alkylated AS. What liver function (LF) markers should be monitored?

Dr. A: All, GGT, AST, Alt, alkaline phosphate, cholesterol, and even sometimes pancreatic enzymes .You can also monitor IGF-1 if you want to.

Dr. B: I usually recommend a liver function screen including several of the enzymes.

Dr. C: Important liver markers are GOT, GPT, GlDH, Cholinesterase, gamma-GT. Besides that a sonography of the abdomen twice a year helps to discover morphological changes (e.g. peliosis hepatis) of the liver early enough.

Question: Some LF markers are elevated in response to exercise. How does the clinician differentiate elevations in LF markers due to exercise and AS use?

Dr. A: That is why the baseline is so important; exercise, diet meds, sleeping and stress affect liver enzymes.

Dr. C: The muscle enzyme creatine kinase in the blood is important for differentiation between liver pathologies and elevated transaminases because of heavy training. A high creatine kinase coupled with moderately elevated GOT and GPT usually is just a sign of muscle cell damage and not of liver problems.

Question: Use of AS can lead to unfavorable changes in serum lipid profiles. Changes documented include increased LDL and decreased HDL; however, there is no consensus regarding detrimental changes in trigylceride and cholesterol levels. What lipid markers should be monitored?

Dr. A: All of the above and sometimes homocysteine and CRP. Cholesterol levels are affected though, depending how long and how much, usually come down. The total, that is. LDL does not truly increase but the ratio. Some people require little lipoprotein a.

Dr. B: The main ones are the LDL and HDL. If they’re out of whack then measures should be taken to bring them in line. Total cholesterol and triglycerides levels are more affected by genetic predispositon and diet.

Dr. C: The triglyceride values are often increased with AS use as well, probably because of the decreased insulin sensitivity. A high intake of fish oil (10-15 g / day with 3-5 g of EPA + DHA) can counteract that effect in most cases. Usually the total cholesterol shows no change because the lowering of the HDL cholesterol fraction is of about the same magnitude as the increase of the LDL cholesterol fraction. Lipoprotein (a) (one of the detrimental blood lipids) often decreases while using AS and should be monitored as well.

Besides these lipid parameters, homocysteine and c-reactive protein should be monitored as well because of the importance of these markers for beginning arteriosclerosis.

Question: Apparently, there is some debate on the effect of AS on cardiac hypertrophy. Some case studies have reported hypertrophy and cardiomyopathy. However, studies also demonstrate that resistance training itself can induce cardiac hypertrophy independent of AS use. As well as in men, cardiac remodeling has been documented in female weight lifters. At what point should the clinician be concerned with cardiac remodeling? What type of test can be performed to track morphological changes?

Dr. A: You must have a baseline EKG, and if you have symptoms, then I will be concerned and I will order an echo or what I think is necessary depending on the symptoms.

Dr. B: Although several reports over the years have suggested that anabolic steroids have detrimental cardiac effects, I’m not convinced since studies in humans don’t account for the many variables that can affect cardiac muscle, including the type of steroid used, stacking of steroids, genetic predisposition, etc. In fact it’s quite possible that the cardiac remodeling that occurs secondary to steroid use may be protective since MI in males up to the age of 75 is associated with a more favorable outcome.

Dr. C: There should be a careful monitoring of heart morphology by sonography. Wall thicknesses (septum and posterior wall) as well as inner diameter of the left ventricle are important parameters. The ratio of the sum of septum as well as posterior wall thickness and inner diameter of the left ventricle (called hypertrophy index) is important for disclosing concentric heart enlargement. Besides that diastolic function as a marker of stiffness of the heart should be monitored.

Question: A meta-analysis of studies suggests that the type of resistance training program can influence the type of cardiac remodeling, demonstrated by changes in left ventricle (LV) geometry . Although nearly 40% of all resistance-trained athletes had normal LV geometry, eccentric hypertrophy was more associated with bodybuilders, whereas concentric hypertrophy was found more often in Olympic lifters. Powerlifting was associated with normal geometry. However, regardless of the type of resistance training, AS use tended to cause marked concentric hypertrophy. Is there any way to differentiate between cardiac hypertrophy induced by resistance training and by AS use?

Dr. A: No, only you have been working out for a while and you have baseline echos. In addition, that is why you must have a baseline before AAS.

Dr. C: In my experience the hypertrophy index of the heart (see above) in male athletes seldom reaches values above 42 % when examining strength athletes training without AS. AS use is often coupled with values between 42 % and 50 %.

Question: Are there any special implications of the above that pertain to women?

Dr. A: No, they are the same as men.

Dr. C: I don’t have enough data about female athletes, but I suspect that the hypertrophy index is a useful diagnostic tool here as well. Values above 40 % with females would make me suspecting AS use.

Question: The belief that AS use increases risk or even causes cardiovascular heart disease prevails through the lay and medical communities. This is based on evidence suggesting that AS stimulates platelet aggregation, increased coagulation enzyme activity and coronary artery vasospasm. Another association reported by AS users is elevation in blood pressure. Are these symptoms and changes a concern for female as well as male users of AS?

Dr. A: Yes, it is, but because the dosages are smaller you see less side effects. But if you have any cardiac history in the family, then you must be very careful especially if a member like the father mother or siblings died at early age.

Dr. C: There is no reason to suspect that females shouldn’t be concerned with these changes.

Question: Does polypharmacy, in other words, the use of other drugs along with AS, exacerbate the effects of AS on the heart?

Dr. A: Most definitely; the more drugs the more side effects.

Dr. C: The concomitant use of growth hormone, clenbuterol and high-dose thyroid hormones will probably exacerbate the side effects on the heart in male and female users of AS.

Question: How can persistent effects on the heart be ascertained after discontinuation of AS use?

Dr. A: Baseline EKGs, homocysteine, CRP, and stress test if necessary.

Dr. C: The probably best method for evaluating persistent effects on the heart is ultra sonography coupled with duplex sonography. With these methods wall-thickness and diastolic function should be measured. These are the most often detrimental changed parameters even after longer discontinuation of AAS use.

Question: AS use has been linked with some types of cancer in men. Tumors or carcinomas have been reported in the livers and prostates of men who were long-term AS users. A few cases of hepatic tumors were also reported in females prescribed androgens for therapeutic purposes. In vitro studies associate androgen levels with increased proliferation and decreased cell death. Epidemiological studies show a correlation between high androgen levels and increased risk of epithelial ovarian cancer disease . Do you feel that increased cancer risk is a concern for female AS users?

Dr. A: No, unless using IGF-1, GH or insulin combination, or if you have a cancer history that is dependent on hormonal properties like breast cancer.

Dr. C: In my opinion there is not enough data for women up to now to draw definite conclusions and there won’t be in the next years because of the lack of long-term studies. But the possibility for an increased cancer risk certainly exists in female users.

Question: As with the use of any injection, there is a concern about diseases associated with injectable AS agents. Hepatitis C, B and HIV have been associated with people who inject AS (hepatitis more prevalent) . Would you recommend testing for these diseases?

Dr. A: Unless you are a fucking moron, I don’t see why. The only one I will worry about is infection at the site.

Dr. B: You don’t have to test for them if you’re not stupid. Don’t share bottles or needles! On the other hand in the past few years there have been at least two reports of septic shock and a gluteal mass in bodybuilders using AS. Also keep in mind that any injection results in a local inflammatory response and scarring, with the degree of both depending on response to both the drug injected and the medium the drug is dissolved/suspended in.

Dr. C: In my experience needle sharing between female athletes is very seldom. I’d ask the athlete if she was sharing needles in the past and if not, I won’t test for these diseases.

Question: The lay opinion is that AS use induces mood changes and aggressive behavior. Psychiatric symptoms reported range from mania to hypomania and depression to addiction. The debate in the literature centers on objectivity in studies. It cannot be discounted that individuals with a positive psychiatric history may be more susceptible to changes in mood and aggression. Additionally, tendency of use and/or abuse of AS may be higher in individuals with pre-existing psychiatric disorders. Dr. Robert Sapolsky at Stanford University once commented on the issue of testosterone’s effects on mood and behavior: "It’s like turning up the volume of the noise on the radio." What can the clinician be aware of or watchful for that may indicate negative psychological effects or addiction?

Dr. A: This is the must common side effect that I see in any AS user, not physical but emotional: depression, lack of sleep and more aggressiveness. Is this due to the type of person that uses AAS? I don’t think so because I see this with prohormones also.

Dr. B: I’ve been careful to downplay the psychological and addictive effects of steroids since it’s so overplayed in the media and in articles. It’s true that the use of anabolic steroids may accentuate aggressive and other tendencies, but part of this is a result of the "expectation" that steroids will do this. Also the increase in confidence coupled with changes brought about by intense exercise will also contribute to the changes that people feel in their confidence and ability to handle things.

Dr. C: This kind of effect is very difficult to determine. I think that talking to the relatives of the athlete gives the best impression. In many cases AS using women don’t recognize their mood changing themselves. Therefore, asking persons who are in a close contact with the female athlete about behavior changes is the best way to go. Unfortunately it is often very difficult to get in contact with friends or relatives of the patient.

Dr. D: There are numerous self-report measures that have been used to pick up on changes in affect, cognition, or self-reported behavior. Note, however, that to use these on a continuous basis assumes close and ongoing monitoring of psychological health in the same manner that one would want to monitor physical health during cycles in the most optimal circumstance. Several different measures that involve self-ratings of positive and negative affect and reports of cognition and behavior might show the onset of changes in psychological function. However, the correlations between these measures and behavior, for instance, the relationship among measures of hostility or aggression and actual aggressive behavior, is not that high. Studies that have shown changes in measures of psychological function, including aggression, have not found concomitant increases in observations of aggressive behavior by clinicians or others close to the proband. Nonetheless, optimal close monitoring might also involve others in the individual’s social network that can provide more objective reports of behavior changes.

Regarding addiction, given that AS are not addictive in the sense that they have strong psychoactive effects nor do they seem to create a physiological dependence, indicators of addiction are likely to be more behavioral in nature. Psychological addiction to AS is likely to manifest itself in the inability to maintain scheduled dosage and on/off cycles due to disruptions in body image and other self-evaluations during off cycles and subsequent emotional disturbances associated with these changes. The best means for monitoring this possibility will, as above, involve long term monitoring of the psychological health of the user and their ability to maintain any prescribed regimen. In this case, clinicians might also best monitor ongoing reports of body image disturbance, as well as track dosing patterns in relation to preplanned regimens. Any deviations from dosing plan, or planned off periods, changes in body perception, might signal the beginning of a psychological reliance on AS.

The author thanks the interviewees for their candid responses. Hopefully this article will partially fill the gap in providing women with credible information on the use of AS and associated health concerns. However, this does not replace personal and individualized monitoring and counseling by a practicing medical caretaker. Nevertheless, any individual, male or female, should educate themselves before deciding to experiment with AS.