Gym and Tonic: a Profile of 100 Male Steroid Users Br J Sports Med: First Published As 10.1136/Bjsm.31.1.54 on 1 March 1997

54 BrJ Sports Med 1997;31:54-58

Gym and tonic: a profile of 100 male steroid users Br J Sports Med: first published as 10.1136/bjsm.31.1.54 on 1 March 1997. Downloaded from

Nick A Evans

Abstract Table 1 Age distribution ofsteroid users Objective-To identify unsupervised anabolic steroid regimens used by athletes. Age (years) % ofsteroid users Methods-100 athletes attending four 16-19 10 were an 20-24 27 gymnasia surveyed using anony- 25-29 36 mous self administered questionnaire. 30-34 14 Results-Anabolic steroid doses ranged 35-39 10 40+ 3 from 250 to 3200 mg per week and users Total 100 combined different drugs to achieve these doses. Injectable and oral preparations were used in cycles lasting four to 12 population. A questionnaire was designed with weeks. Eighty six per cent of users admit- a simple, easy to answer format, to obtain spe- ted to the regular use of drugs other than cific information from users of anabolic steroids for various reasons, including steroids (fig 1). A cover note accompanied each additional anabolic effects, the minimisa- item providing additional information and tion of steroid related side effects, and assuring confidentiality and anonymity. Ques- withdrawal symptoms. Acne, striae, and tionnaires were distributed to four privately gynaecomastia were the most commonly owned gymnasia in three neighbouring coun- reported subjective side effects. ties, namely South Glamorgan, Mid Glamor- Conclusions-Multiple steroids are com- gan, and Gwent. Permission was granted in bined in megadoses and self administered each case from the gymnasium proprietor. in a cyclical fashion. Polypharmacy is Respondents were requested to seal completed practised by over 80% of steroid users. forms in an envelope before depositing them in Skeletal muscle hypertrophy along with a collection box at the gymnasium reception acne, striae, and gynaecomastia are fre- area. The questionnaires were left for 14 days quent physical signs associated with ster- in each institution. It was evident at this stage oid use. that the self administered questionnaire would (BrJ Sports Med 1997;31:54-58) produce a self selected group and a degree of

bias. This should not, however, affect the main http://bjsm.bmj.com/ Keywords: anabolic steroids; drug regimens; polyphar- objectives of the study. macy; physical signs.

Anabolic/androgenic steroids can promote Results increases in muscular size and strength when The first 100 completed questionnaires were combined with the appropriate training and entered into the study. All responders were Their use for this purpose is deemed male and the age range is shown in table 1. diet.1-3 on 20 August 2018 by guest. Protected copyright. unjustified by the medical profession because Thirty three per cent were competitive body- of numerous adverse effects. Despite this builders and 67% recreational athletes. Twenty advice, athletes in sports where size and one per cent of the group had been using ster- strength are paramount continue to use oids for less than one year and represent "new" steroids, seeking a competitive edge. Indeed, users. Sixty four per cent admitted a commit- up to 35% of athletes attending weight training ted steroid use of between one and five years, gymnasia in the United Kingdom use anabolic and the remaining 15% had been using steroids,4 and 4% of males at a British college steroids for six to 12 years (table 2). A weekly oftechnology admitted using these drugs.5 The steroid dosage of less than 500 mg was used by increasing number of published case reports 50% of the athletes in this sample, while 38% also suggests that steroid users often present to used between 500 and 1000 mg per week, and as a source the remaining 12% took in excess of 1000 mg Department of medical practitioners. However, of Trauma and reference, documentation of these unsuper- weekly. Combinations of different anabolic Orthopaedics, Cardiff vised steroid regimens is poor. This study pro- steroids were taken to achieve such doses by Royal Infirmary, vides a profile of 100 steroid users, revealing Newport Road, Cardiff the drugs and dosages currently being used in Table 2 Duration ofsteroid use CF2 lSZ, United the United Kingdom. Subjective side effects, Kingdom and asso- Duration (years) % of users N A Evans, specialist withdrawal symptoms, physical signs ciated with steroid use are also identified. < 1 21 registrar 1-2 13 2-3 26 Correspondence to: 3-4 15 Mr N A Evans. Methods 4-5 10 > 5 15 Accepted for publication Athletes currently using weight training gym- Total 100 15 October 1996 nasia in South Wales were chosen as the target Male steroid users 55

Table 3 List ofanaboliclandrogenic steroids used (proprietary names in brackets) the athletes in this sample. The most popular agents were intramuscular nandrolone deca- Anabolic steroids Androgenic testosterone esters noate (84%), testosterone esters (75%), and Br J Sports Med: first published as 10.1136/bjsm.31.1.54 on 1 March 1997. Downloaded from Nandrolone decanoate (Deca-Durabolin) Testosterone cypionate oral methandrostenolone (68%). Eighty five Stanozolol (Winstrol) Testosterone propionate (Virormone) per cent used both parenteral and oral Methandrostenolone (Dianabol) Testosterone blend (Sustanon 250) Methenolone (Primobolan) Testosterone heptylate (Theramex) preparations, 1 1% used solely injectable prepa- Trenbolone (Parabolan) Testosterone enanthate (Testaviron) rations, and 4% used tablets only. Most self Oxandrolone (Anavar) Testosterone undecanoate (Andriol) administered intramuscular were Oxymetholone (Anapolon) injections Drostanolone (Masteron) sited in the gluteal region, but the thigh and Boldenone (Equipoise)* deltoid were also used.

* Drugs other than anabolic steroids used by Veterinary steroid. this group are given in table 4. The frequency Table 4 Polypharmacy: drugs other than anabolic steroids of subjective side effects resulting from steroid used by athletes use is shown in table 5; only 12% denied any adverse symptoms. Less frequently reported Drug % of users side effects included dyspepsia, exacerbation of Clenbutarol 70 asthma, and tendon rupture. Eighty eight per Ephedrine 57 Human chorionic gonadotrophin 49 cent of users admitted withdrawal symptoms Tamoxifen 45 on cessation of steroid administration, with a Growth hormone 12 reduction in muscle size and strength reported Diuretics 22 Nalbuphine (Nubain) 6 by 72%, and reduced libido by 33%. Insulin 2 The exact population size could not be Thyroid hormone 2 determined accurately as attendance figures for Aminoglutethimide (Orimeten) 3 Esiclene 5 the two week period in each gymnasium were None 14 not recorded. Discussion Table 5 Subjective side effects associated with steroid use Two broad groups of testosterone derivatives are used by athletes: anabolic agents are Symptom % ofusers synthesised with reduced androgenic activity, Acne 54 whereas testosterone esters retain their full Gynaecomastia 34 androgenic effect (table 3). Scientific studies Striae 34 have attributed gains in muscle size and Testicular atrophy 40 None 1 2 strength to anabolic steroids, provided they are used in conjunction with an appropriate training programme and a high protein diet.' 3 Even the majority of users (88%). The lowest in the absence of such clinical data, 50 years of recorded weekly dose was 250 mg and the steroid use by athletes would imply a positive highest was 3200 mg. The duration of steroid benefit.6 The anabolic action of these drugs is http://bjsm.bmj.com/ administration (steroid cycle) was reported as mediated in two ways. An anticatabolic effect is follows: 4-6 weeks (28%), 8-10 weeks (39%), achieved by minimising the catabolic action of 12 weeks (33%). Forty eight per cent of the corticosteroids released during stress (athletic sample stated that their annual steroid use was activity). The second action is the maintenance less than six months, while the other 52% used ofpositive nitrogen balance by improving utili- steroids for more than six months each year. sation of ingested protein. Anabolic steroids Three athletes admitted continuous steroid use also have a state of motivating effects, inducing on 20 August 2018 by guest. Protected copyright. for 52 weeks of the year. Table 3 is a complete euphoria and diminished fatigue, thereby list of the anabolic/androgenic steroids used by enhancing training capabilities.2

Figure 1 Gymnasium user questionnaire

Please tick, delete or write answers where appropriate. AGE MALE/FEMALE DO YOU COMPETE? HAVE YOU EVER USED ANABOLIC STEROIDS? Yes No WHEN DID YOU FIRST START USING THEM? WHICH STEROIDS DO YOU NORMALLY USE/PREFER? Dianabol Deca Testosterone Winstrol Others DO YOU USE: Tablets Jabs/Injections HOW MANY WEEKS DO YOU STAY "ON" STEROIDS? HOW MANY WEEKS DO YOU TAKE "OFF"? HOW OFTEN DO YOU USE STEROIDS EACH YEAR? GIVE AN EXAMPLE OF YOUR TYPICAL COURSE/STACK: jabs of every jabs of every tabs of every WHERE DO YOU INJECT? Buttock Thigh Shoulder Other DO YOU GET ANY OF THE FOLLOWING? "Gyno" _ Stretch marks Acne spots Testicle shrinkage WHAT HAPPENS WHEN YOU COME OFF STEROIDS? Lose size Lose strength _ Reduced sex drive Other WHICH OTHER DRUGS HAVE YOU USED? Ephedrine Clenbutarol Growth hormone Insulin HCG Tamoxifen Diuretics Thyroid Nubain Others 56 Evans

Table 6 Examples ofdrug regimens administered by new and veteran steroid-use,rs, and a users report using techniques such as loading typical precontest protocol. Approximate cost on the black market is provided in £ sterling doses and pyramidal dose tapering. Longer

for Br J Sports Med: first published as 10.1136/bjsm.31.1.54 on 1 March 1997. Downloaded from New user Dianabol 25 mg/d PO £40 acting agents, example Sustanon (a mixture Nandrolone decanoate 100 mg/week IM oftestosterone propionate 30 mg, phenylpropi- 4 weeks onate 60 mg, isocaproate 60 mg, and dec- Sustanon 250 mg/week IM £140 anoate 100 mg), used in the initial weeks, are Veteran user Nandrolone decanoate 200 mg/week IM 4 weeks substituted by shorter acting drugs mid-cycle Testosterone propionate 300 mg/week IM to prevent continued steroid action during the Stanozolol 150 mg/week IM off-cycle. Steroids which, anecdotally, cause 4 weeks Tamoxifen 20 mg daily throughout course less water retention, for example Primobolan HCG 6000 mg at end of course and Stanozolol, are chosen for precontest regi- 4 weeks rest period mens. Sustanon 500 mg/week IM £370 Competitive user Nandrolone decanoate 200 mg/week IM Dianabol 40 mg/d PO POLYPHARMACY 4 weeks Illicit drug use by the athletes in this study was Testosterone propionate 300 mg/week IM Primobolan 300 mg/week IM not confined to anabolic steroids, and 86% Clenbutarol 4 tablets (80 gg)/d + ephedrine 75 mg/d admitted using other drugs for different 4 weeks reasons (table 4). This figure is greater than Stanozolol 150 mg/week IM Masteron 300 mg/week IM previous estimates,4 and indeed the use of cer- Primobolan 300 mg/week IM tain drugs listed below has not previously been Clenbutarol + ephedrine as above documented in athletes. These "steroid acces- 4 weeks sory" drugs can be grouped according to their PO, orally; IM, intramuscularly. desired effects. Non-steroid agents with anabolic properties include clenbutarol, growth hormone, and ANABOLIC STEROID DRUG REGIMENS insulin. Clenbutarol is a 3, receptor agonist Cyclical drug administration was practised by used by 70% of this group for its ability to almost all the athletes in this study (97%). The stimulate protein deposition in skeletal muscle steroid cycle was usually a period of between (so called "repartitioning agent"), and also for four and 12 weeks, and was guided by personal its thermogenic properties, which increase experience or anecdotal evidence. After this energy expenditure, thereby reducing body period, athletes reported a plateau in subjective fat.'0 11 benefits which might be explained by steroid Growth hormone is taken by a smaller receptor saturation and downregulation. Side number of steroid users (12%), probably effects also become more apparent with time, because of its high black market price. One and toxicity may force termination of steroid competitive bodybuilder reported using subcu- administration. The time interval between taneous injections of 2 IU daily, which costs steroid cycles is more variable. Regular users around £400 per month. Insulin, for example will allow a four to six week gap to "clear the 1-2 units with meals, was also being used by http://bjsm.bmj.com/ system", whereas less frequent users may two competitors for a supposed anabolic effect. remain drug-free for months. This steroid gap It appears that the athletes in this sample appears to be influenced by a range ofpersonal used steroids as their primary anabolic agent, and financial factors. with clenbutarol, growth hormone, or insulin Steroid dosages are also variable, as might be being used as secondary anabolic drugs. expected with unsupervised drug administra- Ephedrine is a 12 receptor agonist used

tion. In this sample, 50% of steroid users chose medically as a bronchodilator and vasocon- on 20 August 2018 by guest. Protected copyright. doses of less than 500 mg per week. Of the strictor sympathomimetic during anaesthesia. remainder, 38% use a weekly dose of between Fifty seven per cent of the athletes in this sam- 500 mg and 1000 mg, whereas a smaller group ple used ephedrine as a stimulant to aid (12%) of mainly competitive bodybuilders athletic performance, and also as a thermo- were using in excess of 1000 mg per week. genic fat reducing agent. Some athletes reported using 1 mg kg-' per day Anticatabolic agents are also used to provide as a basic regimen. anabolic-like effects. Aminoglutethimide Combining two or more different types of (Orimeten), used by 3% of the sample, is a steroid was practised by 88% of the users in steroid antagonist which preferentially blocks this sample. Steroid "stacking" affords larger corticosteroid pathways, shifting the testoster- doses and theoretical synergistic actions. Popu- one to cortisol ratio in favour of anabolism. lar combinations used by this group include The parenteral analgesic nalbuphine (Nubain) anabolic and androgenic agents, injectable and was used by 6% to relieve musculoskeletal pain oral preparations, and long and short acting and for a proposed "stress reducing" anticata- drugs. Individual steroid regimens were based bolic action. As with all morphine derivatives, on personal experience, information obtained however, repeated administration may cause by word of mouth from other users, or from drug dependence.'2 various steroid handbooks."9 Black market Additional drugs are used before bodybuild- drug availability may also affect choice. ing competitions to enhance skeletal muscle Examples of administration protocols are visibility. L-thyroxine (for example, 200 ,ug provided in table 6, which compares the daily) may be used in the four to six weeks regimen of a new user with that of a veteran leading up to a contest to reduce the amount of user, and also shows the precontest drug subcutaneous body fat. Clenbutarol and ephe- protocol of a competitive bodybuilder. Veteran drine have thermogenic effects and are also Male steroid users 57

used for this purpose. Diuretics (for example, Discontinuation of anabolic steroids can result frusemide 20-40 mg) alleviate steroid induced in symptoms of withdrawal and dependence.2223

water retention on the day of competition. Esi- Seventy per cent ofthis group reported subjective Br J Sports Med: first published as 10.1136/bjsm.31.1.54 on 1 March 1997. Downloaded from clene (formebolone) is injected directly into a loss of muscle size and strength with cessation of muscle belly, causing local inflammation and steroid use, and such dissatisfaction with body thereby temporarily increasing its size over a size and "reverse anorexia" represent potent psy- period of 24 to 48 hours. chological fuel for resumption ofsteroid adminis- Medication is also used to reduce side effects tration.24 Depression has also been associated and minimise withdrawal symptoms associated with steroid withdrawal.23 The androgenic ac- with steroid use. The antioestrogen drug tions of these drugs enhance sexual desire,25 and tamoxifen was used by 45% of the athletes in as would be expected, drug discontinuation this sample to prevent or treat gynaecomastia. caused reduced libido in one third ofthis sample. Human chorionic gonadotrophin (HCG) is used at the end of a steroid cycle to kick start suppressed endogenous testosterone produc- tion in an attempt to reduce withdrawal symp- PHYSICAL SIGNS toms. Skeletal muscle hypertrophy and the triad of It is apparent that the use of certain drugs acne, gynaecomastia, and striae (fig 2) are listed above for medically unsound reasons physical signs present in one third of this group may be of more concern than the use of of steroids users. Indeed, combinations of anabolic steroids. The unsupervised use of these features appear in over 80% of this sam- diuretics, insulin, thyroxine, clenbutarol, and ple. Testicular atrophy may represent an nubain may precipitate a range of acute medi- additional sign of steroid use. cal emergencies. With 88% of steroid users experiencing steroid related side effects and 86% misusing other drugs, users may often have reason to seek ADVERSE EFFECTS AND WITHDRAWAL SYMPTOMS medical advice. However, given its covert Numerous side effects have previously been nature, an individual may not admit to associated with anabolic steroids, including unsupervised drug use. Identifying the physical liver enzyme derangement,2 altered serum signs of steroid use should arouse suspicion lipids, hypertension,' clotting abnormalities,'4 and direct the clinician to the source of the prostatic hypertrophy,'5 and behavioural problem. changes.' Such effects are reversible on cessation of drug use, but may not be obviously apparent to the steroid user. The athletes in CONCLUSION this study, however, frequently noticed subjec- Medical practitioners should be aware of the tive side effects including acne (54%), gynae- patterns of anabolic steroid use, and of the comastia (34%), striae (34%), and testicular other drugs used unsupervised to enhance ath- shrinkage (40%). Even though such symptoms letic performance and body image. Recognis- http://bjsm.bmj.com/ are common, they are usually considered ing physical signs and making an appropriate minor and acceptable to the steroid user. Only drug inquiry will allow a more complete 12% denied any steroid induced side effects. clinical assessment by the doctor confronted by The striae are usually sited in the deltopectoral a steroid user. and axillary regions (fig 2). Case reports have also linked steroids with liver tumours,2 myocardial infarction,' cardiomegaly,'8 tendon 1 Bhasin S, Storer TW, Berman N, Callegari C, Clevenger B, on 20 August 2018 by guest. Protected copyright. rupture,' and subfertility.20 Injection site prob- Phillips J, et al. The effects of supraphysiological doses of testosterone on muscle size and strength in normal men. N lems may also occur.2' EnglJ Med 1996;335:1-7. 2 Haupt HA, Rovere GD. Anabolic steroids: a review of the literature. Am J Sports Med 1984;12:469-84. 3 Millar AP. Licit steroid use-hope for the future. BrJt Sports Med 1994;28:79-83. 4 Perry HM, Wright D, Littlepage B. Dying to be big: a review of anabolic steroid use. BrJ_ Sports Med 1993:26:259-61. 5 Williamson DJ. Anabolic steroid use among students at a Brit- s.,.,,.,,~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... ish college of technology. BrJ7 Sports Med 1993;27:200-1. .2FigureSteroidat.d.e...... t. 6 Hoberman JM, Yesalis CE. The history of synthetic testosterone. SciAm 1995;272:60-5. ~~~~~~~ .~ ~~~~~~~~~~~~~~~~~~.. ..-....,Ra: : '" ...... ':'' 7 Phillips WN. Anabolic reference guide, 6th ed. Golden, Colorado: Mile High Publishing, 1991.

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