There are some welcome changes taking place in the medical community which indicate that the number of physicians knowledgeable enough, and interested in caring for Anabolic/Androgenic Steroid AAS users is likely to increase. A number of experts, including Dr.Shalender Bhasin, a leading AAS expert at Harvard University, have made clear the extent of the medical crisis involving AAS users whose numbers continue to grow and the ethical responsibility of physicians to meet this crisis by informing themselves about AAS and treatment protocols which have been demonstrated to provide safe and effective symptom relief for AAS side effects and to support cessation.(Canavan, 2013) A recent systematic review of AAS research encompassing all AAS studies conducted between 1965-2013 as well as voluntary interviews with users, has provided a guide for what physicians will need to know, as well as what AAS users should expect when they seek medical help. (Rahnema, 2014)
Still, while the clinical situation is improving for AAS users experiencing the psycho-endocrinal symptoms which are the main side effects of AAS, too many users remain unaware of the relationship between AAS use and these serious and potentially permanent effects. (Kovac, JR et al, 2014) This lack of awareness is regularly demonstrated in on-line AAS forums where posts reveal an alarming level of risk-taking in the substances users choose and the levels at which they are used. Despite the fact that expressions of regret for such choices are found regularly on these websites, these may not function as useful warnings to other users. Reports of dangerous practices persist.
While publications dedicated to AAS also demonstrate some increasing involvement by physicians in the care of AAS users, most users remain reluctant to seek out professional medical help for serious side effects. (Pope & Brower, 2004) They rely instead on information they find on the web and in the gym to guide them with use or when they want to cease using. The questionable reliability of such advice is demonstrated by the number of posts about serious and sometimes irreversible damage a user has sustained as a result of basing his choices on something they read on line. That is not to say that there are not competent advice givers on line–usually more seasoned users–who demonstrate broad knowledge of AAS.
It is these writers who are more likely to caution young men against beginning to use and to advise users with serious side effects to seek medical care.
So, getting reliable peer advice about AAS is clearly a hit and miss proposition. Why do so many users continue to risk serious harms by relying on this resource? Why would a man who is experiencing severe loss of libido and unabated depressed mood, Anabolic Steroid Induced Hypogonadism (ASIH)–a medical condition which is the primary psychoendocrinal effect of AAS use–not seek out a medical professional for help?
56% of AAS users have never disclosed their use to doctors.(Pope & Brower, 2004) Some clues to their reluctance can also be found on AAS peer websites: Exchanges between users reinforce disdain for doctors, based on negative experiences with these professionals whom they found to be uninformed and unempathic in the past, offering little beyond demands to just stop using, and failing to demonstrate adequate understanding of AAS and their side effects; and who failed to offer relief from unbearable withdrawal symptoms. Building upon previous research on the stigmatization of individuals with eating disorders, a study by researchers at three major Northeast medical universities found that medical providers perceived the eating disorder and AAS use patients less favorably than the cocaine user or healthy adult, suggesting that the two groups may be stigmatized by health providers. The authors concluded that, “Given the psychiatric and medical risks associated with AAS use and EDs, reducing bias may help reduce the personal suffering and public health burden related to these behaviors”. (Yu J. et al, 2015)
AAS users also often avoid seeking out medical care, or being open with their physicians because of their fears that doctors might report them for using illegal substances.
To remove such impediments to needed and appropriate medical help, the following are essential: Doctors must not only be knowledgeable about safe and effective treatment protocols, but must bring to the doctor-patient relationship unconditional regard for the patient, despite that doctor’s personal views about AAS. AAS users also often avoid seeking out medical care, or being open with their physicians because of their fears that doctors might report them for using illegal substances.
To remove these impediments to needed and appropriate medical help, the following are essential: Doctors must not only be knowledgeable about safe and effective treatment protocols, but must bring to the doctor-patient relationship unconditional regard for the patient, despite that doctor’s personal views about AAS. To receive the best medical care, patients need to be open with doctors about their use–what agents they have used, and for how long. Patients should inform themselves about, and determine whether their doctor also understands the strict laws regulating confidentiality of their medical information.
For patients who are attempting to wean from AAS, doctors are advised to provide whatever medications and other measures are needed to support safe and effective withdrawal, providing these to a patient until normal hormonal levels are restored. Close monitoring is required to adjust treatment until normal levels are restored. (Hochberg et al, 2003; Zitzmann & Nieschlag, 2000; Talih et al, 2007; Spratt, 2012; Rahnema et al, 2014) When normal levels are not restored, and permanent Hypogonadal-Pituitary-Testicular damage is indicated, testosterone replacement therapy may need to be considered. These protocols which are supported by a number of leading experts are essential in order to avoid the potential cycle of reuse when unsupported withdrawal becomes unbearable (Brower, 2009; Kanayama et al, 2015), and to prevent permanent damage when appropriate supportive treatment is not provided in a timely manner. (Rahnema et al, 2014; Stephens et al, 2013) As physicians become familiar with the foregoing recommendations, “cold turkey” approaches to cessation which expose patients to distressing and potentially dangerous hormonal collapse should eventually go the way of other insupportable medical protocols of the past.
And just as it is the physician’s professional responsibility to arm him/herself with knowledge about the side effects of AAS use, it is the user’s personal responsibility to learn as much as he can about these agents. That is, to consult reliable sources of information about the make-up of any of the powerful agents he is thinking about taking into his body, and the potential risks associated with this choice. The short term side effects of using AAS become evident very soon. Self-treating to counteract these may provide cover for a while, but as the Anabolic Doc has been preaching, “There is no free lunch”.(O’Connor, 2012) Taming the effects of powerful drugs by using equally powerful drugs, guided by Internet recipes is a risky brew. Too often, as I have reported in previous columns, the paradoxical result is serious long lasting, even permanent harm to the body in which so much time, money and effort has been invested.
If a user decides to seek medical help for his symptoms or to help him wean safely and effectively, how can he determine whether his physician has adequate knowledge, empathy and availability to partner with him in his way back to health? As with most other important partnerships in life, the direct approach is the one most likely to yield the most information, and as a result, the best outcome. This approach requires the patient to be open about his/her use–what agents were used, how long, and the effects of these on his body, mind and relationships. In the ensuing discussion, you should directly inquire about how much the physician knows about your problem, and how interested he/she is in working with you to solve it. You and your doctor should also recognize that treating the psychoendocrinal side effects of AAS, particularly ASIH, requires not only timely medical intervention, but also close monitoring of the patient’s response to these. Patient response to treatment is very individual. The implication of this is frequent, regular contact with your physician until health is restored. Difficulty getting appointments with your physician should be a warning sign which doesn’t bode well for the outcome you are seeking.
And a final word: Judgments about your choice to use have no place in this professional relationship. Medical advice, yes; judgments, no. If your physician does not seem to be well informed about AAS and its serious side effects, and doesn’t seem open to a true partnership, or isn’t sufficiently available to provide timely treatment monitoring, it’s worth seeking out another opinion. The side effects of AAS are serious; they require serious attention.
Thomas O’Connor, MD
Brower, KJ.”Anabolic androgenic steroid abuse and dependence in clinical practice”, Physician Sports Medicine 2009; 37:131-40
Pope G & Brower, KJ. “Treatment of anabolic-androgenic steroid related disorders”, Chapter 17, The American
Psychiatric Publishing Textbook of Substance Abuse Treatment, ed. Marc Galanter & Herbert Kleber, 2008
Canavan, N. “Endocrine society pumped up to raise steroid abuse awareness”, Medscape, Dec 17, 2013
Hochberg, A et al. “Endocrine withdrawal syndromes”, Endocrine Reviews, Aug 2003 (4)z;523
Kanayama G et al. “Prolonged hypogonadism in males following withdrawal from anabolic androgenic steroids:an underrecognized problem”, Addictions, Feb 2015
Kelleher et al. “Blood testosterone therapy:a European perspective”, J Endoc & Metab, 2004
Kovac, JR et al.”Men regret anabolic steroid use due to a lack of comprehension regarding the consequences on future fertility”, Andrologia, 2014
O’Connor, T. “No Free Lunch”, Muscular Development”, March 2012
Rahnema C et al. “Anabolic steroid induced hypogonadism: diagnosis and treatment”, Fertil Steril Vol 101, No.5 May 2014
Spratt, D. “Considering tapering testosterone replacement in certain patients”, Endocrine Reviews September, 2012
Stevens, et al.”Persistent primary hypogonadism associated with anabolic steroid abuse”, Fertil Steril May, 2011
Talih, F et al. “Anabolic steroid abuse: psychiatric and psychological costs”, Cleveland Clinic Journal of Medicine May, 2007
Turek, P. “Getting off the Juice”, The Turek Clinic website.
Yu, J et al. “Healthcare professionals’ stigmatization of men with anabolic androgenic steroid use and eating disorders”, Journal of Drug Issues, Aug 5, 2015, Sage publications
Zitzmann, M & Nieschlag, E. “Hormone substitution in male hypogonadism, Molecular and Cellular Endocrinology 161 (2000) 73-88