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Anabolic Steroids and Sex: The Good, The Bad and the Libido. By Thomas O’Connor MD     5/28/16   Ok, this is going to be a... Anabolic Steroids and Sex

Anabolic Steroids and Sex: The Good, The Bad and the Libido.

By Thomas O’Connor MD     5/28/16 Doctor Thomas J. O'Connor MD


Ok, this is going to be a good one! My articles are never boring, as I discuss how anabolic/androgenic steroids-AAS cause medical issues like early cardiovascular disease, low testosterone, gynecomastia and sundry organ disease, but this article will BLOW UP for one reason only- SEX!!!!!

It is true; most men who seek-out my unique medical services come to me for SEX! Of course, they come in to discuss a specific issue related to AAS and their health, but 90% of the time-there is something related to sex in their motivation! Men come to me to get off gear and to see if they are candidates for testosterone therapy, as most men who use steroids for years will have Anabolic Steroid Induced Hypogonadism ASIH (Rahnema 2014, Guillherme 2011) and will require stable doses of physiologic medical grade testosterone for life. When guys are ready to get healthy for life, this is what I do! If you think about it, after years of gear, a man’s testosterone will be low. So be it. Why is this a problem, you ask? Well, it’s going to relate to SEX! The low testosterone state, in most cases, related to ASIH leads to a poor libido and is more severe than a man with “organic” low testosterone. The mechanism-of-action MOA for this is unknown. It may be that men, who use AAS, are injecting esters of testosterone and higher doses than standard replacement doses for prolonged periods. This leads to chronic higher free testosterone states and in the central nervous system CNS. These chronic high levels cause changes in parts of the CNS that lead to a “dependent” state on super physiologic testosterone doses for optimal sexual experience and over time there may be permanent damage in these areas that leads to severe low libido states once the AAS are stopped. One thing is for sure, men who live on AAS, do so mainly to preserve their sexual function, not just to “BE BIG”.

Steroids and Sex

Let’s face it, 99% of us live for SEX! Some of us are more sexual than others and there are many variables that relate to this SEX thing: age, hormonal status, medical disease(s), depression, personal preference and sexual history, orientation, relationship status, where you are in life-stress! In addition to many other factors that play a role in ones sexuality, but one thing is for sure- we are all having SEX! The importance of SEX stands alone, as none of us would be here for the lack of it.

Now we are ready to discuss SEX and Anabolic/Androgenic Steroids AAS. To the guy on the street who has no experience with AAS use, I can guarantee you that he has heard that AAS wreck a person’s SEX life. Is he correct? Or is it a matter of understanding the details? Here we go folks! Time to put on your thinking helmets, because I’m about to explain how AAS are associated with SEX and it’s not simple! Actually, as the Doc caring for men on steroids since 2003 and seeing my share of patients with sexual issues, I can tell you that “we” in the medical community do not fully understand the mechanism-of-action MOA behind AAS related sexual issues. Here is my take on it!

variety of AAS

We have to start with the AAS agents first hand- what are we looking at? There are a variety of AAS- Testosterone based like Testosterone Cypionate, Enanthate, Propionate in addition to testosterone derived drugs like Dianabol and Boldenone. We also have the Dihydrotestosterone DHT derived agents like Anadrol and Anavar in addition to the 19-nortestosterone (19-nor) AAS agents like Deca Durabolin and Trenbolone.

Apart from the specific chemical details that are very important to how these agents affect a man’s sexual being, the most important factor shared by all of these agents is that they will shut down a man’s natural testosterone production while taking the drug. This process mediates via the hypothalamic-pituitary-gonadal-axis HPGA. Of course the specific drug, dose and man-per-man specifics have to be considered. Drugs like Tren and Deca are well known to be very suppressive to the HPGA. We have had a classic term for this since the 1970’s called “Deca- Dick”.

The MOA for this may be related the suppression of endogenous testosterone in addition to the fact that Deca is reduced to dihydronandrolone DHN vs dihydrotestosterone DHT (DHT is in part what drives the libido in a naturally intact male) as we see with endogenous testosterone and testosterone based drugs. DHN crosses the blood-brain-barrier and can interact with androgen receptors in the sexual parts of the brain called the limbic area and either competes with DHT and testosterone or acts as a direct antagonist causing inhibitory actions and a low libido state. In addition to this we know that 19-nor drugs, like Deca and Tren are synthetic progestins and can cause increased prolactin production which can lead to diminished libidos and non-optimal CNS dopaminergic states. In the end, Deca and Tren Dick are real! I find it amazing that the remedy for this has been to take greater parts of testosterone-to-nandrolone doses- as most experienced men who use these drugs take and recommend a 1.5 to 2/1 ratio. This is Bro Science for sure, but in the streets it works!

Men almost never take a nandrolone agent like Deca or Tren without testosterone. And when they are “on” these drugs, sexual performance is usually not only preserved, but most men say they are hypersexual during this time! Forget the Deca-dick! It appears that the combination of a 19-nor drug and testosterone esters provide “over stimulation” to the sexual limbic brain. At least for a period of time, then things can come crashing down! I think that the body, including the CNS part of the human sexual brain is dynamic and is always in flux- trying to maintain balance by reacting to the constant changes of stimulation coming in, including hormonal chemistry(s). In this case, the initial stimulation and upregulation of the androgen receptors in the CNS leads to an initial upswing in libido, only to be followed by a crash as the body tries to provide balance to the artificial forces. Although it is true that some men can live on fixed doses of testosterone/nandrolone for prolonged periods and maintain a good libido. The question then is what are the health consequences of living on two AAS? Not to mention; net super-physiologic doses of androgen over prolonged periods? These are the questions I regularly discuss with my patients.

In addition to the shutting down of a man’s HPGA, when a man is “on steroids” the natural question is what happens when a man comes off the AAS? For most men, being “on” AAS leads to either ok or great sex, but remember, as discussed above, the type of AAS and how it is used, eg, specific AAS combinations and in what dose fractions plays a huge role in one’s sexual experience on ASS. Once a man stops AAS is where everything falls apart. This is what the guy on the street does not know or understand! What is going here? The HPGA has been dormant, while on gear and now that the AAS is removed from the system, it has to start back up again. This takes time and for men that have been on AAS for prolonged periods or have used very “suppressive” AAS, the restoration of the HPGA may be delayed for months and in many circumstances, may never return. This is what is now well known in the medical community as Anabolic Steroid Induced Hypogonadism ASIH. The detailed MOA regarding this pathophysiologic state is not fully known but may relate to the fact that the hypothalamus and pituitary go into a permanent dormant state called apoptosis and their production of gonadotropins, eg, LH and FSH are either inadequate or “qualitatively” functionally deficient in producing sustained testicular testosterone. The disease process lies somewhere between the hypothalamus, pituitary and cells that produce testosterone in the testicles. To counter this, and for the past 3 decades, men that have used AAS have used a treatment protocol called Post Cycle Therapy PCT in an attempt to hasten the restoration of the HPGA and minimize the devastating affects that AAS have on the body in the post- use period. The medical agents used for PCT are fertility medications of the class Selective Estrogen Receptor Modulator SERM, eg Tamoxifen and Clomid, Human Chorionic Gonadotropin HCG and various ant-estrogen medications, eg, Arimidex and Letrozole. There is evolving data to support the use of these agents in men suffering with chronic AAS use(Talih, Fatal 86 Monroe/Cleveland Clinic,2007; Hochberg et al, 2003; Spratt, 2012; Pope 86 Brower, 2008; Rahnema et al, 2014).  . It should be stated that although it is ethical for a physician to use these agents to assist any man coming off AAS, there use, including various PCT regimens have not been shown to produce sustainable endogenous testosterone levels or quality libido states in men who have used AAS chronically or suppressive AAS in the post AAS use period. Again, PCT is 100% ethical, but may not work in blocking the effects of AAS use over time.   I have seen thousands or men who have used AAS and have said to me, “Doc, I did my PCT, but now I feel terrible and my testosterone and sex is down! What happened? Why didn’t the PCT work?” The answer is, we just don’t know.

Post cycle therapyI found the following citation on a highly reputable anabolic steroids blog regarding PCT:

“Once the use of the AAS is complete and all of the exogenous steroidal hormones have cleared your system, natural testosterone recovery will begin again. Natural recovery assumes no prior low testosterone condition. It also assumes no damage was done to the HPTA due to improper AAS use. While natural recovery will on its own, it will be slow. For this reason, most are encouraged to implement a PCT plan after AAS use. Such a plan will commonly include the SERM’s Nolvadex and Clomid, and often additional HCG. This will greatly speed up the recovery process, as well as its overall efficiency. It will not return your natural testosterone levels to normal on its own, if this is something you’ve been told, it is a myth. However, it will ensure you have testosterone for proper bodily function while your levels continue to naturally rise. Total recovery will still take months, but this will cut the total time down dramatically and ensure a smooth recovery.”

Clearly, the author needs to update this “statement” to include ASIH or does not see patients suffering from long term AAS use and does not understand the reality of ASIH. Although I am sure the intentions are pure.

Apart from the suppressive nature of AAS and HPGA, I would say that imbalances in other hormones play a role in the patho-physiology of how ASS affect sex. As stated above, the Limbic system of a man’s CNS is where sexuality originates and in this region of the brain exists specific areas and tracks that control our deepest sexual thoughts and impulses. I have interviewed thousands of men who use AAS and I am amazed at the variability of response to AAS and sex. There is no cookie-cutter approach to this for sure! Some men have told me that they feel best on 1,500 mg a week of AAS and others have said that 2 days after a small dose of 100 mg testosterone Cypionate provided for testosterone replacement, he feels poorly in libido and feels best just prior to the next injection nadir. Amazing! Steroids and Sex Steroidology

The other hormones and ratios that play a sexual role are estrogen/androgen, prolactin (as discussed above with the nandrolone based AAS), DHT and other CNS neurotransmitters like, serotonin, dopamine, norepinephrine and GABA. Another amazing fact is that many men who use AAS chronically, use a drug called Dostinex for sex. A dopamine promoter, used for hyperprolactinemic disorders, either from unknown medical conditions or from pituitary growths. The drug can block the effects of elevated prolactin levels secondary to AAS that cause this and lead to improved libidos. The side effects of this drug can be serious and lead to other medical conditions. As I have said before, is it worth it? A drug for a drug, yet for another drug!

Over the years I have made a several important discoveries related to AAS and sex. One of these is that men living on AAS and even on physiologic testosterone have at times poor erections, despite a perfect balanced hormonal milieu. Almost 100 % of men on chronic AAS and testosterone replacement will have atrophied testicles. It appears that these men can suffer from a venous leak state that can lead to poor quality erections. A brilliant Urologist explained it to me like this, “the testicles are like dampers at the base of the penis, when the testicle is shrunken and atrophied, the ability to hold back blood in the erect engorged penis may be reduced leading to a leak-like situation and poor sustained quality erections”. WOW!! This makes sense to me!!

Libido and steroidsWhat to do?   If you do not want to suffer with AAS related sexual issues, don’t ever do AAS! I am not being a wise-guy, but simply telling you that if you play, be prepared to pay. There is no free-lunch!

Almost all AAS related sexual issues will be related to libido. I find it funny that most doctors try to give AAS users Viagra for their sexual issues, when it is 100% useless! It’s not a failure of the man’s penis to produce nitric oxide! As discussed above, the HPGA is the main player here and in most cases, men in the post AAS period will suffer with Anabolic Steroid Induced HypogonadismASIH or a relative state as his CNS has been adjusted to higher levels of androgen while on AAS. Men can expect to be off AAS, in addition to PCT for up to 3 to 6 months to gain full restoration of the HPGA. If a man still has a poor libido at this point he should consider ASIH and seek a medical expert for diagnosis and treatment. In the end, any man who has been living on AAS for years and finds that he cannot get off these agents, for lack of libido, will have to be considered for life long physiologic testosterone replacement therapy, although the SERM, Clomid has to be considered as another potential medical agent that can help a man suffering with AAS related sexual issues. The seriousness of this cannot be over stated as this may be for life and will have implications to his cardiovascular and prostate health, not to mention other medical issues. Each man should have access to counseling by a medical expert who understands the medical-technical and socio-cultural aspects of what this man has been dealing with prior to making any definitive diagnosis and treatment plan.

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Dr Thomas O’Connor, MD