Risks of AAS. Common side effects relates to AAS use and why to avoid them

Anabolic steroids are illegal for use without a prescription, and many of them are not even among the permitted medicinal products for humans, according to the Executive Agency for Medicines of the Republic of Bulgaria.

According to Bulgarian law (Art. 354 of the Criminal Code), possession of such a “strongly effective” substance without “proper permission” “is punishable by imprisonment for up to two years or a fine of one hundred to three hundred leva.”.

Furthermore, the use of substances falling into the category of anabolic steroids without medical supervision poses serious health risks. 

What exactly, we are about to reveal in this article, based on the most current scientific evidence about the dangers and side effects of anabolic steroids.

What is anabolic? 

Anabolic steroids (so-called anabolic androgenic steroids – AAS) are synthetic derivatives of the male sex hormone – testosterone (T). 

They were initially developed for their medical applications and mostly for indications such as:

• testosterone replacement therapy (TRT)
• preventing muscle mass loss in catabolic conditions such as surgeries, infections, cancer, etc. 

These drugs have a powerful anabolic effect on muscle tissue, combined with catabolic effects on adipose tissue. 

At doses significantly higher than therapeutic, they can have a dramatic anabolic effect on improving physical performance, increasing muscle mass, and burning body fat. 

Despite the benefits, serious negative health effects, both long-term and short-term, are also possible.

Are Anabolics Harmful?

Mild and temporary side effects of anabolic steroids

The term anabolic androgenic steroids describes their primary effects: anabolic and androgenic. 

The androgenic effects of testosterone are those that stimulate the development of male sexual characteristics. They are mediated by direct action on the androgen receptor in various tissues. 

The prostate, skin, liver, and sebaceous glands also possess 5α-reductase activity, which converts testosterone to dihydrotestosterone (DHT) with many times higher androgenic activity. [1]. 

This is usually an undesirable effect because it increases androgenic effects and therefore the risk of adverse reactions. Such side effects include:

• baldness
• prostate enlargement
• severe acne (although temporary, it can leave permanent scars)
• oily skin
• suppressed natural testosterone production and testicular shrinkage (atrophy), leading to infertility and impotence 

These effects are usually short-term and do not have serious health consequences, but in some cases they can persist long after the use of anabolic steroids has ceased. 

For example, studies have shown that the average time to restore fertility (reaching 20 million sperm per milliliter) in men who received testosterone injections for 3 to 6 months was [2]:

• 6 months for 67% from men
• 12 months for 23% from men
• 16 months for 6% from men
• 24 months for the remaining 4% of men

Anabolic steroids can also be aromatized to estrogens such as estradiol by enzymes synthesized in adipose tissue.

This can lead to increased serum estradiol in men and feminizing side effects – water retention, gynoid-type obesity and gynecomastia. 

Gynecomastia is the enlargement of the mammary glands in men. The treatment of this condition is entirely surgical. Although it is usually seen primarily as a negative cosmetic effect, it also increases the risk of breast cancer in men.

Serious Risks and Life-Threatening Side Effects of Anabolic Steroids

The most dangerous long-term side effects of prolonged use of anabolic steroids are an increased risk of heart attack or stroke and the risk of kidney or liver failure. Addiction is also possible.

Cardiovascular risk

The increased risk of heart attack is associated with several pathogenic mechanisms that can occur even with the use of drugs that are generally approved for humans, such as testosterone. 

However, this usually occurs when large doses are used, and leads to consequences including:

• Hypertension
• Changes in lipid profile (increased bad cholesterol – LDL; decreased good cholesterol – HDL)
• Atherosclerosis
• Increased blood clotting
• Left ventricular hypertrophy 

Studies have reported cases of cellular pathologies affecting the heart muscle after anabolic steroid use, similar to cases of cardiomyopathy and heart failure. 

In line with this, studies have revealed that the use of anabolic steroids is associated with an increased risk of myocardial infarction and sudden cardiac death. 

Furthermore, the results of some studies suggest that the increased cardiovascular risk persists long after steroid use has ceased. [3]. 

Liver risks

On the other hand, liver failure is primarily associated with the use of oral steroids, for example in the form of tablets or capsules.

This is because in order to be orally active and resistant to hepatic metabolism, steroids are modified into 17-α derivatives. 

17-α anabolic steroids can cause liver damage through several different mechanisms, including acute cholestatic syndrome (cholestasis), chronic vascular liver damage, and liver tumors. 

The occurrence of tumors has also been associated with unmodified and esterified testosterone preparations.

Are anabolic steroids addictive?

Anabolic steroids can be addictive, as some people continue to abuse them even after developing severe adverse effects.

If AAS use is suddenly discontinued, it can also lead to withdrawal and abstinence symptoms, such as:

• Anxiety
• Depression
• Decreased sexual desire
• Insomnia
• Fatigue
• Thoughts of suicide

Cases of AAS addiction are particularly common among people with bigorexia, a type of anxiety disorder also called muscle dysmorphia. [4]. 

Affected people have unrealistic beliefs that they are too thin and small, not muscular enough, or weak, even though this is not reality.

What are the types of anabolic steroids, hormones and other anabolic drugs?

Depending on what they are used for by athletes, anabolic steroids can be classified into 3 main categories: 

• Anabolics for muscle building
• Anabolic steroids for weight loss and fat loss
• Anabolic steroids for improving athletic performance

In reality, all anabolic steroids, even those that are called anabolics for weight loss, have different ratios of all 3 effects.

Another classification is determined by their route of administration – oral steroids or injectable anabolic steroids. This also plays a role in their metabolism and typical health risks.

Below we have listed examples of anabolic steroids with their specific side effects.

Side Effects of Oral Steroids

Side effects of Stromba (Winstrol, Stanozolol)

These are some of the most popular anabolic steroid pills. Stromba has been used in human and veterinary medicine, but currently the drug is only available in pharmacies in a few countries.

Stanozolol is 5α-reduced, which means it has lower androgenic activity than testosterone or dihydrotestosterone. Thus, it has less effect on the skin, hair, or prostate.

Because of this, it also does not aromatize, so it does not convert to estrogen and there is no risk of gynecomastia water retention.

The most common side effects associated with Stromba use include suppression of natural testosterone production in men, virilization in women, and liver toxicity. Stanozolol can lead to hypogonadism, impotence, prostate enlargement, and infertility.

The most serious of these is liver damage. There have been cases of liver adenoma turning malignant after using Winstrol. [5].

Side effects of Superdrol (Methasterone)

This oral anabolic has never been used in medical practice and has never been approved by the FDA or EMA as safe.

This product is extremely toxic to the liver and there have been numerous cases of cholestatic hepatitis, some of which have been fatal. [6], [7], [8], [9], [10]. 

In addition to severe liver toxicity, it also leads to the typical side effects of anabolic steroids, including acne, hair loss, gynecomastia, impotence, infertility, prostate enlargement, etc.

Side effects of Anadrol (Oxymetholone, Anapolon)

The substance is FDA-approved for certain medical conditions. However, the large doses commonly used to enhance physique and performance by athletes can lead to liver toxicity. [11].

It also leads to androgenic effects in sensitive tissues, such as acne, hair loss, gynecomastia, and masculinization in women.

Side effects of Methane, Dianabol (Methandienone)

This anabolic product is no longer used in medical practice. It has both estrogenic effects, such as gynecomastia, and androgenic effects, such as acne, hair loss, and increased body hair. [12]. 

Studies again report the occurrence of steroid liver damage even in cases of medical use that involved only moderate doses. [13]. 

Side effects of Metandren (Methyltestosterone)

It was one of the first synthetic anabolic steroid tablets developed and is still used in medicine for patients with delayed puberty or menopausal symptoms.

However, some of the common side effects include liver toxicity leading to jaundice and cholestatic hepatitis.

Metandrene can also cause estrogenic and androgenic effects such as gynecomastia, acne, hair loss, etc.

Side effects of injectable steroids

Side effects of Testosterone esters

Testosterone and its many esters (testosterone undecanoate, testosterone enanthate, testosterone cypionate, testosterone propionate – Omnadren) are legal when prescribed by a doctor.

Testosterone is approved for treatment of specific indications such as: [14]:

• hormonal problems (delayed puberty or hypogonadism)
• specific types of anemia
• loss of muscle mass due to cancer, AIDS, surgeries, burns, radiation, etc.
• hereditary angioedema

Testosterone is also the oldest and most popular anabolic steroid used as a performance-enhancing drug. However, it has all the typical side effects that are common to most anabolics.

These include acne, hair loss, increased facial and body hair, oily skin, etc. and suppression of natural testosterone production, which causes hypogonadism and infertility. Testosterone is actively aromatized, which leads to estrogenic effects such as gynecomastia and water retention.

Even when administered as testosterone replacement therapy in medical settings and at lower doses, studies show that it significantly increases the risk of myocardial infarction. [15].

This is partly related to the negative effect of testosterone on the lipid profile and levels of good cholesterol (HDL) [16]. Other large cohort studies also confirm an increased risk of heart attack and stroke following high-dose testosterone replacement therapy. [17]. 

Testosterone may also increase cancer growth in patients with prostate cancer. [18]. 

Side effects of Trenbolone Acetate

This anabolic was not developed or intended for humans. It is used in veterinary medicine to stimulate muscle growth in cattle.

In addition to its powerful anabolic effects, trenbolone also has strong androgenic activity. [19]. It is about 3-5 times more androgenic than testosterone.

This causes side effects such as acne, hair loss, increased facial and body hair, oily skin, etc. It also suppresses natural testosterone production, leading to hypogonadism. 

In addition, it also has a strong progestogenic effect, so despite the lack of estrogenic activity, gynecomastia is still possible.

Trenbolone also has one of the most dramatic effects on the lipid profile, significantly lowering HDL and increasing LDL cholesterol. It is one of the most taxing steroids on the cardiovascular system. [20]. 

Trench can also cause the typical "trench cough," but the mechanism of occurrence is still unknown.

Side effects of Nandrolone (19-nortestosterone) and its esters: Durabolin and Deca Durabolin

Nandrolone esters – Durabolin (Nandrolone Phenylpropionate) and Deca Durabolin (Nandrolone Decanoate) are used in medicine to treat anemia and cachexia, as well as symptoms of menopause in women.

It has a weaker androgenic effect and a strong anabolic effect. Nandrolone esters are resistant to aromatization, so they do not have estrogenic side effects. [21].

However, serious long-term effects such as cardiovascular toxicity, hypogonadism, and infertility are possible. 

It has been found to significantly lower HDL [22]. Cases of erectile dysfunction have also been reported.

Side Effects of Anabolic Steroids in Women

The main side effect in women is called virilization. [23]. This is a condition in which a woman develops typical male characteristics, such as a deeper voice and facial hair.

Side effects of anabolic steroid use in women include:

• Hirsutism – facial hair and excessive body hair
• reduced breast size
• enlarged clitoris
• severe acne
• deepening of the voice
• changes in sexual desire
• menstrual problems
• hair loss and male pattern baldness

Even „female“ steroids, such as Anavar (Oxandrolone), which have a very weak androgenic effect, can still cause varying degrees of virilization. [24].

Women may also suffer from an increased incidence of thrombosis and cardiovascular disease, similar to men. If used in children and adolescents, anabolic steroids can lead to growth retardation. [24].