How is anabolic steroid use different from testosterone replacement therapy?

One main reason testosterone replacement therapy (aka testosterone treatment) is surrounded by controversy is that testosterone can be abused, both in athletic populations and the general public.[1] Scientific evidence is undisputed that testosterone y potently enhances physical performance and increases muscle growth.[1-3]
 
The ethical issue of fair play in sports, coupled with the well-known adverse health effects of supra-physiological doses of anabolic steroids [4-14], has given medically legit testosterone replacement therapy (aka TRT, testosterone therapy or testosterone treatment) a bad reputation and is depriving many suffering men with testosterone deficiency from receiving medically needed testosterone treatment.[15] 
 
In this article I will point out the salient differences between use testosterone replacement therapy – a.k.a. testosterone therapy or testosterone treatment - and abuse of anabolic steroids, and explain why testosterone treatment - which per definition is medically provided and supervised - has no parallel with abuse of anabolic steroids.
 
 

What are anabolic steroids?

 
In order to understand the differences between testosterone treatment and anabolic steroid use, let’s first define what are anabolic steroids?
 
Anabolic-androgenic steroids (AAS), popularly known as “anabolic steroids”, “anabolics” or “steroids”, include synthetic derivatives of testosterone, which were originally developed in the late 1930s.[16-21] Testosterone in its natural unmodified form is also classified as an anabolic steroid, and listed among its synthetic derivatives as a banned substance by the World Anti-Doping Agency (WADA).[22] Natural testosterone and anabolic steroids are legally classified as Schedule III controlled substances, and thus require a doctor’s prescription when used for medical purposes. 
 

Are they any medical indications for use of anabolic steroids?

 
It may come as a surprise to most people that there are actually several medical indications for the use anabolic steroids [23, 24]; including sarcopenia and frailty [25-27], rehabilitation after hip fracture [28, 29] and after knee arthroplasty [30-32], treatment of osteoporosis and prevention of fractures [29, 33-45], wound healing [46, 47], leukemia [48, 49], treatment of muscle wasting [50, 51] and anemia [52] in dialysis patients, as well as treatment of wasting seen in patients with chronic obstructive pulmonary disease [53] and HIV.[54] Note that these benefits are seen in clinical populations of both men and women.
 
The fact that testosterone is classified as an anabolic steroid stirs up the already heated debates about testosterone therapy. However, testosterone deficiency is a syndrome that merits medical treatment, as lack of treatment results in well documented metabolic deterioration and illness.[55] 
 

New FDA warning on abuse and dependence of testosterone

 
The war on testosterone continues. On October 25th 2016 the FDA issued a class-wide labeling change for all prescription testosterone products, adding a warning about the abuse potential of testosterone products. This created media headlines touting that testosterone therapy is bad because it carries addiction risk.
 
As I explained in a previous article “Is Testosterone Replacement Therapy a Lifelong Treatment?”, testosterone therapy is in most cases a lifelong treatment. Not because hypogondal men who start testosterone therapy become “addicted” to it, but because it relieves symptoms caused by testosterone deficiency and thus improves wellbeing (as well as health status).
 

Salient differences between anabolic steroid abuse and testosterone therapy

 
Below I list a couple of important differences between testosterone therapy and abuse of anabolic steroids, to highlight why they should not be confused.
 
Dosages 
 
Testosterone therapy that is prescribed and monitored by a doctor has well-established safety (see my other numerous articles on the topic), abusers of anabolic steroids use many-fold higher dosages than the recommended clinical doses.[12] Doses up to 30 times greater than physiologic replacement doses have been reported.[56]
 
This results in supra-physiological blood levels. In the case of testosterone, typical blood levels are in the range of 3000 – 5000 ng/dL. Compare this to the high end of the healthy physiological range, which is approx. 1300 ng/dL (depending on what laboratory assay that is used, this value may vary +/- 200).
 
Continuous vs. Cycling
 
Testosterone replacement therapy is in most cases a lifelong treatment aimed to replace dwindling testosterone levels associated with aging and aging-related morbidities. In contrast, users of anabolic steroids cycle their use of preparations. Use of anabolic steroids often occurs in repeated cycles of around 12 weeks, followed by periods of non-use (breaks).[56-58] 
 
However, it is becoming more and more common for anabolic steroid users to use anabolic steroids continuously - known as “cruising” - and on top of that add periodic cycles of other anabolic agents and/or increasing dosages – known as “blasting”. 
 
Risks vs. Benefits
 
The side effects of anabolic steroid use in high doses are well established in the medical research.[7, 8, 11, 14, 59-61] It is not hard to imagine the long-term negative health effects of cruising and blasting…
 
In contrast, long-term testosterone treatment is well-documented to be safe, and confers multiple health benefits.[55, 62, 63]  For more info on safety and benefits of testosterone therapy, see my previous articles:
 
 
 
 
 
Stacking: multi-drug combinations
 
Users of anabolic steroids frequently ‘‘stack’’ – i.e. simultaneously abuse – multiple synthetic derivatives of testosterone, a practice called polypharmacy.[57, 64-67] In addition to synthetic derivatives of testosterone, growth hormone and insulin are also commonly used.[66, 68] While polypharmacy may have synergistic effects on muscle growth and physical performance, it also results is worse and more dangerous side effects.[59, 69]
 
In contrast, testosterone treatment is commonly done with testosterone, although for some men, clomid, HCG or aromatase inhibitors may be better alternative treatments to elevate testosterone levels. For more, see my previous articles:
 
 
 
 
Personal characteristics of users
 
Abuse of anabolic steroids is strongly associated illicit drug use and substance dependence [65, 67, 70] and aggressive alcohol use.[71] Statements that that testosterone therapy – which per definition is medically provided and supervised - is bad because it carries addiction risk, is absurd.
 

Bottom Line

 
As I stated in a previous article “Testosterone Replacement Therapy - why is it so controversial?", just because something can be abused does not mean it has no medically legitimate use. Anything can be abused, even food! And if somebody has the urge to abuse something, that person will do so regardless of legal classification of the object of abuse.
 
When considering the tremendous health benefits of testosterone therapy in hypogonadal men, the controversial discussions about testosterone therapy are moot if put in perspective. For example, one may question how come tobacco and alcohol – two highly addictive and widely available substances of abuse with no medical indications whatsoever - are legal, despite the well documented harms?
 

References:

 

1.            Basaria, S., Androgen abuse in athletes: detection and consequences. J Clin Endocrinol Metab, 2010. 95(4): p. 1533-43.

2.            West, D.W. and S.M. Phillips, Anabolic processes in human skeletal muscle: restoring the identities of growth hormone and testosterone. Phys Sportsmed, 2010. 38(3): p. 97-104.

3.            Fitch, K.D., Androgenic-anabolic steroids and the Olympic Games. Asian J Androl, 2008. 10(3): p. 384-90.

4.            Angell, P., et al., Anabolic steroids and cardiovascular risk. Sports Med, 2012. 42(2): p. 119-34.

5.            Angell, P.J., et al., Anabolic steroid use and longitudinal, radial, and circumferential cardiac motion. Med Sci Sports Exerc, 2012. 44(4): p. 583-90.

6.            Angell, P.J., et al., Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician. Br J Sports Med, 2012. 46 Suppl 1: p. i78-84.

7.            Angell, P.J., et al., Ventricular structure, function, and focal fibrosis in anabolic steroid users: a CMR study. Eur J Appl Physiol, 2014. 114(5): p. 921-8.

8.            Baggish, A.L., et al., Long-term anabolic-androgenic steroid use is associated with left ventricular dysfunction. Circ Heart Fail, 2010. 3(4): p. 472-6.

9.            Deligiannis, A.P. and E.I. Kouidi, Cardiovascular adverse effects of doping in sports. Hellenic J Cardiol, 2012. 53(6): p. 447-57.

10.          Garevik, N., et al., Long term perturbation of endocrine parameters and cholesterol metabolism after discontinued abuse of anabolic androgenic steroids. J Steroid Biochem Mol Biol, 2011. 127(3-5): p. 295-300.

11.          Pope, H.G., Jr., et al., Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev, 2014. 35(3): p. 341-75.

12.          Kersey, R.D., et al., National Athletic Trainers' Association position statement: anabolic-androgenic steroids. J Athl Train, 2012. 47(5): p. 567-88.

13.          Hoffman, J.R., et al., Position stand on androgen and human growth hormone use. J Strength Cond Res, 2009. 23(5 Suppl): p. S1-S59.

14.          Achar, S., A. Rostamian, and S.M. Narayan, Cardiac and metabolic effects of anabolic-androgenic steroid abuse on lipids, blood pressure, left ventricular dimensions, and rhythm. Am J Cardiol, 2010. 106(6): p. 893-901.

15.          Morales, A., The long and tortuous history of the discovery of testosterone and its clinical application. J Sex Med, 2013. 10(4): p. 1178-83.

16.          Hoberman, J.M. and C.E. Yesalis, The history of synthetic testosterone. Sci Am, 1995. 272(2): p. 76-81.

17.          Dotson, J.L. and R.T. Brown, The history of the development of anabolic-androgenic steroids. Pediatr Clin North Am, 2007. 54(4): p. 761-9, xi.

18.          Kochakian, C.D., The evolution from "the male hormone" to anabolic- androgenic steroids. Ala J Med Sci, 1988. 25(1): p. 96-102.

19.          Joseph, J.F. and M.K. Parr, Synthetic androgens as designer supplements. Curr Neuropharmacol, 2015. 13(1): p. 89-100.

20.          Wu, C. and J.R. Kovac, Novel Uses for the Anabolic Androgenic Steroids Nandrolone and Oxandrolone in the Management of Male Health. Curr Urol Rep, 2016. 17(10): p. 72.

21.          Pan, M.M. and J.R. Kovac, Beyond testosterone cypionate: evidence behind the use of nandrolone in male health and wellness. Transl Androl Urol, 2016. 5(2): p. 213-9.

22.          WADA., The World Anti-Doping Code, in The 2015 Prohibited List - International Standard. 2015. p. http://www.usada.org/wp-content/uploads/wada-2015-prohibited-list-en.pdf.

23.          Basaria, S., J.T. Wahlstrom, and A.S. Dobs, Clinical review 138: Anabolic-androgenic steroid therapy in the treatment of chronic diseases. J Clin Endocrinol Metab, 2001. 86(11): p. 5108-17.

24.          Taylor, W.N., Anabolic Therapy in Modern Medicine 2002: McFarland.

25.          Morley, J.E., Anabolic steroids and frailty. J Am Med Dir Assoc, 2010. 11(8): p. 533-6.

26.          Bhasin, S., The brave new world of function-promoting anabolic therapies: testosterone and frailty. J Clin Endocrinol Metab, 2010. 95(2): p. 509-11.

27.          Bross, R., M. Javanbakht, and S. Bhasin, Anabolic interventions for aging-associated sarcopenia. J Clin Endocrinol Metab, 1999. 84(10): p. 3420-30.

28.          Farooqi, V., et al., Anabolic steroids for rehabilitation after hip fracture in older people. Cochrane Database Syst Rev, 2014. 10: p. CD008887.

29.          Hedstrom, M., et al., Positive effects of anabolic steroids, vitamin D and calcium on muscle mass, bone mineral density and clinical function after a hip fracture. A randomised study of 63 women. J Bone Joint Surg Br, 2002. 84(4): p. 497-503.

30.          Hohmann, E., et al., Anabolic steroids after total knee arthroplasty. A double blinded prospective pilot study. J Orthop Surg Res, 2010. 5: p. 93.

31.          Wu, B.W., et al., Randomized control trial to evaluate the effects of acute testosterone administration in men on muscle mass, strength, and physical function following ACL reconstructive surgery: rationale, design, methods. BMC Surg, 2014. 14: p. 102.

32.          Metcalfe, D., et al., Anabolic steroids in patients undergoing total knee arthroplasty. BMJ Open, 2012. 2(5).

33.          Frisoli, A., Jr., et al., The effect of nandrolone decanoate on bone mineral density, muscle mass, and hemoglobin levels in elderly women with osteoporosis: a double-blind, randomized, placebo-controlled clinical trial. J Gerontol A Biol Sci Med Sci, 2005. 60(5): p. 648-53.

34.          Need, A.G., T.C. Durbridge, and B.E. Nordin, Anabolic steroids in postmenopausal osteoporosis. Wien Med Wochenschr, 1993. 143(14-15): p. 392-5.

35.          Geusens, P., Nandrolone decanoate: pharmacological properties and therapeutic use in osteoporosis. Clin Rheumatol, 1995. 14 Suppl 3: p. 32-9.

36.          Geusens, P. and J. Dequeker, Long-term effect of nandrolone decanoate, 1 alpha-hydroxyvitamin D3 or intermittent calcium infusion therapy on bone mineral content, bone remodeling and fracture rate in symptomatic osteoporosis: a double-blind controlled study. Bone Miner, 1986. 1(4): p. 347-57.

37.          Hamdy, R.C., et al., Nandrolone decanoate for men with osteoporosis. Am J Ther, 1998. 5(2): p. 89-95.

38.          Vanderschueren, D., et al., Sex steroid actions in male bone. Endocr Rev, 2014: p. er20141024.

39.          Snyder, P.J., et al., Effect of testosterone treatment on bone mineral density in men over 65 years of age. J Clin Endocrinol Metab, 1999. 84(6): p. 1966-72.

40.          Meriggiola, M.C., et al., Effects of testosterone undecanoate administered alone or in combination with letrozole or dutasteride in female to male transsexuals. J Sex Med, 2008. 5(10): p. 2442-53.

41.          Kenny, A.M., et al., Effects of transdermal testosterone on bone and muscle in older men with low bioavailable testosterone levels, low bone mass, and physical frailty. J Am Geriatr Soc, 2010. 58(6): p. 1134-43.

42.          Clarke, B.L. and S. Khosla, Androgens and bone. Steroids, 2009. 74(3): p. 296-305.

43.          Basurto, L., et al., Effect of testosterone therapy on lumbar spine and hip mineral density in elderly men. Aging Male, 2008. 11(3): p. 140-5.

44.          Anderson, F.H., R.M. Francis, and K. Faulkner, Androgen supplementation in eugonadal men with osteoporosis-effects of 6 months of treatment on bone mineral density and cardiovascular risk factors. Bone, 1996. 18(2): p. 171-7.

45.          Amory, J.K., et al., Exogenous testosterone or testosterone with finasteride increases bone mineral density in older men with low serum testosterone. J Clin Endocrinol Metab, 2004. 89(2): p. 503-10.

46.          Demling, R. and L. De Santi, Closure of the "non-healing wound" corresponds with correction of weight loss using the anabolic agent oxandrolone. Ostomy Wound Manage, 1998. 44(10): p. 58-62, 64, 66 passim.

47.          Demling, R.H. and D.P. Orgill, The anticatabolic and wound healing effects of the testosterone analog oxandrolone after severe burn injury. J Crit Care, 2000. 15(1): p. 12-7.

48.          Sotto, J.J., et al., [Androgens and prolonged complete remissions in acute non lymphoblastic leukemias. Results of a systematic treatment with stanozolol associated with chemotherapy (author's transl)]. Nouv Rev Fr Hematol, 1975. 15(1): p. 57-72.

49.          Hollard, D., et al., [Trial of androgen therapy in the treatment of non-lymphoblastic acute leukemia. First results]. Nouv Presse Med, 1976. 5(20): p. 1289-93.

50.          Chen, C.T., et al., Muscle wasting in hemodialysis patients: new therapeutic strategies for resolving an old problem. ScientificWorldJournal, 2013. 2013: p. 643954.

51.          Johansen, K.L., K. Mulligan, and M. Schambelan, Anabolic effects of nandrolone decanoate in patients receiving dialysis: a randomized controlled trial. JAMA, 1999. 281(14): p. 1275-81.

52.          Paul, A.K., et al., Androgen versus erythropoietin for the treatment of anaemia of pre-dialysis chronic kidney disease. Mymensingh Med J, 2012. 21(1): p. 125-8.

53.          Pan, L., et al., Effects of anabolic steroids on chronic obstructive pulmonary disease: a meta-analysis of randomised controlled trials. PLoS One, 2014. 9(1): p. e84855.

54.          Saha, B., G.C. Rajadhyaksha, and S.K. Ray, Beneficial effects of nandrolone decanoate in wasting associated with HIV. J Indian Med Assoc, 2009. 107(5): p. 295-9.

55.          Morgentaler, A., et al., Fundamental Concepts Regarding Testosterone Deficiency and Treatment: International Expert Consensus Resolutions. Mayo Clin Proc, 2016. 91(7): p. 881-96.

56.          Perry, P.J., et al., Anabolic steroid use in weightlifters and bodybuilders: an internet survey of drug utilization. Clin J Sport Med, 2005. 15(5): p. 326-30.

57.          McCabe, S.E., et al., Trends in non-medical use of anabolic steroids by U.S. college students: results from four national surveys. Drug Alcohol Depend, 2007. 90(2-3): p. 243-51.

58.          Kersey, R.D., Anabolic-androgenic steroid use among california community college student-athletes. J Athl Train, 1996. 31(3): p. 237-41.

59.          Frati, P., et al., Anabolic Androgenic Steroid (AAS) related deaths: autoptic, histopathological and toxicological findings. Curr Neuropharmacol, 2015. 13(1): p. 146-59.

60.          Nieminen, M.S., et al., Serious cardiovascular side effects of large doses of anabolic steroids in weight lifters. Eur Heart J, 1996. 17(10): p. 1576-83.

61.          Payne, J.R., P.J. Kotwinski, and H.E. Montgomery, Cardiac effects of anabolic steroids. Heart, 2004. 90(5): p. 473-5.

62.          Haider, A., et al., Incidence of prostate cancer in hypogonadal men receiving testosterone therapy: observations from 5-year median followup of 3 registries. J Urol, 2015. 193(1): p. 80-6.

63.          Morgentaler, A., et al., Testosterone Therapy and Cardiovascular Risk: Advances and Controversies. Mayo Clin Proc, 2014.

64.          Turillazzi, E., et al., Side effects of AAS abuse: an overview. Mini Rev Med Chem, 2011. 11(5): p. 374-89.

65.          Ip, E.J., et al., The Anabolic 500 survey: characteristics of male users versus nonusers of anabolic-androgenic steroids for strength training. Pharmacotherapy, 2011. 31(8): p. 757-66.

66.          Baker, J.S., M.R. Graham, and B. Davies, Steroid and prescription medicine abuse in the health and fitness community: A regional study. Eur J Intern Med, 2006. 17(7): p. 479-84.

67.          Sagoe, D., et al., Polypharmacy among anabolic-androgenic steroid users: a descriptive metasynthesis. Subst Abuse Treat Prev Policy, 2015. 10: p. 12.

68.          Albertson, T.E., et al., The Changing Drug Culture: Use and Misuse of Appearance- and Performance-Enhancing Drugs. FP Essent, 2016. 441: p. 30-43.

69.          Pomara, C., et al., Neurotoxicity by synthetic androgen steroids: oxidative stress, apoptosis, and neuropathology: A review. Curr Neuropharmacol, 2015. 13(1): p. 132-45.

70.          Hakansson, A., et al., Anabolic androgenic steroids in the general population: user characteristics and associations with substance use. Eur Addict Res, 2012. 18(2): p. 83-90.

71.          Ip, E.J., et al., Characteristics and Behaviors of Older Male Anabolic Steroid Users. J Pharm Pract, 2015. 28(5): p. 450-6.

Last modified on Tuesday, 20 June 2017 00:49
Monica Mollica

Medical Writer & Nutritionist

MSc in Nutrition

University of Stockholm & Karolinska Institute, Sweden 

   Baylor University, TX, USA

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