Acne
Acne is an obvious indicator of steroid use., teenage boys generally endure periods of irritating acne as their testosterone levels begin to peak, but this generally subsides with age. But when taking anabolic/androgenic steroids, an adult will commonly be confronted with this same problem. This is because the sebaceous glands, which secrete oils in the skin, are stimulated by androgens. Increasing the level of such hormones in the skin may therefore enhance the output of oils, often causing acne to develop on the back, shoulders, and face. The use of strongly androgenic steroids in particular can be very troublesome, in some instances resulting in very unsightly blemishes all over the skin. To treat acne, the athlete has a number of options. The most obvious of course is to be very diligent with washing and topical treatments, so as to remove much of the dirt and oil before the pores become clogged. If this proves insufficient, the prescription acne drug Accutaine might be a good option. This is a very effective medication that acts on the sebaceous glands, reducing the level of oil secreted. The athlete could also take the ancillary drug Proscar/Propecia (finasteride; 5-alpha-reductase enzyme inhibitor) during steroid treatment, which reduces the conversion of testosterone into DHT, lowering the tendency for androgenic side effects with this hormone. It is of note however that this drug is more effective at warding off hair loss than acne, as it more specifically effects DHT conversion in the prostate and hair follicles. High dose vit B5 intake has proven to be useful against acne. It is also important to note that testosterone is the only steroid that really converts to DHT, and only a few others actually convert to more potent steroids via the 5-alpha-reductase enzyme at all. Many steroids are also potent androgens in their own right, such as Anadrol and Dianabol. Thus they can exert strong androgenic activity in target tissues without 5-alpha-reduction to a more potent compound, which makes Propecia useless. Of course one can also simply take those steroids (anabolics) that are less androgenic. For sensitive individuals attempting to build mass, nandrolone would therefore be a much better option than testosterone.

Aggression
Aggressive behavior can be one of the scarier sides to steroid use. Men are typically more aggressive than women because of testosterone, and likewise the use of steroids (especially androgens) can increase a person's aggressive tendencies. In some instances this can be a benefit, helping the athlete hit the weights more intensely or perform better in a competition. Many professional power lifters and bodybuilders take a particular liking to this effect. But on the other hand there is nothing more unsettling than a grown man, bloated with muscle mass, who cannot control his temper. A steroid user who displays an uncontrollable rage is clearly a danger to himself and others. It is important to note that steroids do not turn a calm mannered individual in to a short tempered one, this is a view peddled by the media.

Anaphylactic Shock
Anaphylactic shock is an allergic reaction to the presence of a foreign protein in the body. It most commonly occurs when an individual has an allergy to things like a specific medication (e.g. penicillin), insect bites, industrial/household chemicals and foods (e.g. nuts). Symptoms include wheezing, swelling, rash, fever, a drop in blood pressure, dizziness, unconsciousness, convulsions or death. This reaction is not really seen with hormonal products like anabolic/androgenic steroids, but this may change with the manufacture of counterfeit pharmaceuticals. Being that there are no quality controls for black market producers, toxins might indeed find their way into some preparations (particularly injectable compounds). My only advice would be to make every attempt to use only legitimately produced drug products, preferably of First World origin. When anaphylactic shock occurs, it is most commonly treated with an injection of adrenaline.

Birth Defects
Anabolic/androgenic steroids can have a very pronounced impact on the development of an unborn fetus. Adrenal Genital Syndrome in particular is a very disturbing occurrence, in which a female fetus can develop male-like reproductive organs. Women who are, or plan to become pregnant soon, should never consider the use of anabolic steroids. It would also be the best advice to stay away from these drugs completely for a number of months prior to attempting the conception of a child, so as to ensure the mother has a normal hormonal chemistry. Although anabolic/androgenic steroids can reduce sperm count and male fertility, they are not linked to birth defects when taken by someone fathering a child.

Blood Clotting Changes
The use of anabolic/androgenic steroids is shown to increase prothrombin time, or the duration it will take for a blood clot to form. This basically means that while an individual is taking steroids, he/she may notice that it takes slightly longer than usual for a small cut or nosebleed to stop bleeding. During the course of a normal day this is hardly cause for alarm, but it can lead to more serious trouble if a severe accident occurred, or an unexpected surgery was needed. Realistically the changes in clotting time are not extremely dramatic, so athletes are usually only concerned with this side effect if planning for surgery.

Cancer
Although it is a popular belief that steroids can give you cancer, this is actually a very rare phenomenon. Since anabolic/androgenic steroids are synthetic version of a natural hormone that your body can metabolize quite easily, they usually place a very low level of stress on the organs. In fact, many steroidal compounds are safe to administer to individuals with a diagnosed liver condition, with little adverse effect. The only real exception to this is with the use of C17-alpha-alkylated compounds, which due to their chemical alteration are somewhat liver toxic. In a small number of cases (primarily with Anadrol) this toxicity has lead to severe liver damage and subsequently cancer. But we are speaking of a statistically insignificant number in the face millions of athletes who use steroids. These cases also tended to be very ill patients, not athletes, who were using extremely large dosages for prolonged periods of time. Steroid opponents will sometimes point out the additional possibility of developing Wilm's Tumor from steroid abuse, which is a very serious form of kidney cancer. Such cases are so rare however, that no direct link between anabolic/androgenic steroid use and this disease has been conclusively established. Provided the athlete is not overly abusing methylated oral substances, and is visiting a doctor during heavier cycles, cancer should not be a concern.

Cardiovascular Disease
The use of anabolic/androgenic steroids may have an impact on the level of LDL (low density lipoprotein), HDL (high density lipoprotein) and total cholesterol values. HDL is considered the "good" cholesterol since it can act to remove cholesterol deposits from the arteries. LDL has the opposite effect, aiding in the buildup of cholesterol on the artery walls. The general pattern seen with steroid use is a lowering of HDL concentrations, while total and LDL cholesterol numbers increase. The ratio of HDL to LDL values is usually more important than one's total cholesterol count, as these two substances seem to balance each other in the body. If these changes are exacerbated by the long-term use of steroidal compounds, it can clearly be detrimental to the cardiovascular system. This may be additionally heightened by a rise in blood pressure, which is common with the use of strongly aromatizable compounds.

It is also important to note that due to their structure and form of administration, most 17-alpha-alkylated oral steroids have a much stronger negative impact on these levels compared to injectable steroids. Using a milder drug like Winstrol (stanozolol), in hopes HDL level changes will also be mild, may therefore not turn out to be the best option. One study comparing the effect of a weekly injection of 200mg testosterone enanthate vs. only a 6mg daily oral dose of Winstrol makes this very clear. After only six weeks, stanozolol was shown to reduce HDL cholesterol by an average of 33%. The HDL reduction with the testosterone group was only 9%. LDL (bad) cholesterol also rose 29% with stanozolol, while it actually dropped 16% with the use of testosterone. Those concerned with cholesterol changes during steroid use may likewise wish to avoid oral steroids, and opt for the use of injectable compounds exclusively. We also must note that estrogens generally have a favorable impact on cholesterol profiles. Estrogen replacement therapy in postmenopausal women for example is regularly linked to a rise in HDL cholesterol and a reduction in LDL values. Likewise the aromatization of testosterone to estradiol may be beneficial in preventing a more dramatic change in serum cholesterol due to the presence of the hormone.

Since heart disease is one of the top killers worldwide, steroid using athletes (particularly older individuals) should not ignore these risks. If nothing else it is a very good idea to have your blood pressure and cholesterol values measured during each heavy cycle, being sure to discontinue the drugs should a problem become evident. It is also advisable to limit the intake of foods high in saturated fats and cholesterol, which should help minimize the impact of steroid treatment. Since blood pressure and cholesterol levels will usually revert back to their pre-treated norms soon after steroids are withdrawn, long-term damage is not a common worry.

High Blood Pressure/Hypertension
Athletes using anabolic/androgenic steroids will commonly notice a rise in blood pressure during treatment. High blood pressure is most often associated with the use of steroids that have a high tendency for estrogen conversion, such as testosterone and Dianabol. As estrogen builds in the body, the level of water and salt retention will typically elevate (which will increase blood pressure). This may be further amplified by the added stress of intense weight training and rapid weight gain. Since hypertension can place a great deal of stress on the body, this side effect should not be ignored. If it is left untreated, high blood pressure can increase the likelihood for heart disease, stroke or kidney failure. Warning signs that one may be suffering from hypertension include an increased tendency to develop headaches, insomnia or breathing difficulties. In many instances these symptoms do not become evident until BP is seriously elevated, so a lack of these signs is no guarantee that the user is safe. Obtaining your blood pressure reading is a very quick and easy procedure (either at a doctors office, pharmacy or home); steroid-using athletes should certainly be monitoring BP values during stronger cycles so as to avoid potential problems.

If an individual's blood pressure values are becoming notably elevated, some action should/must be taken to control it. The most obvious is to avoid the continued use of the offending steroids, or at least to substitute them with milder, non-aromatizing compounds. High blood pressure medications such as diuretics, can dramatically lower water and salt retention. Catapres (clonidine HCL) is also a popular medication among athletes, because in addition to its blood pressure lowering properties it has also been documented to raise the body's output of growth hormone.

Kidney Stress/Damage
Since your kidneys are involved in the filtration and removal of by-products from the body, the administration of steroidal compounds (which are largely excreted in the urine) may cause them some level of strain. Actual kidney damage is most likely to occur when the steroid user is suffering from severe high blood pressure, as this state can place an undue amount of stress on these organs. There is actually some evidence to suggest that steroid use can be linked to the onset of Wilm's Tumor in adults, which is a rapidly growing kidney tumor normally seen in children and infants. Such cases are so rare however, that no conclusive link has been established. Obviously the kidneys are vital to one's heath, so the possibility of any kind of damage (although low) should not be ignored during heavy steroid treatment. If the user is notices a darkening in color of urine (in some cases a distinguishable amount of blood), or pain/difficulty when urinating, then kidney problems may be a concern. Other warning signs include pain in the lower back (particularly in the kidney areas), fever and edema (swelling). If organ damage is feared, the administered steroidal compounds should be discontinued immediately, and the doctor paid a visit to rule out any serious trouble. If steroid use is still necessitated by the individual, it may be a good idea to avoid the stronger compounds and opt for one of the milder anabolics. Primobolan, Anavar and Winstrol for example do not convert to estrogen at all, and likewise may be acceptable options. Also favorable drugs in this regard are Deca and Equipoise, which have only a low tendency to aromatize.

Liver Stress/Damage
Liver stress/damage is not a side effect of steroid use in general, but is specifically associated with the use of c17 alpha alkylated compounds. As mentioned earlier, these structures contain chemical alterations that enable them to be administered orally. In surviving a first pass by the liver, these compounds place some level of stress on the organ. In some instances this has led to severe damage, even fatal liver cancer. The disease peliosis hepatitis is one worry, which is an often life threatening condition where the liver develops blood filled cysts. Liver cancer (hepatic carcinoma) has also been noted in certain cases. While these very serious complications have occurred on certain occasions where liver-toxic compounds were prescribed for extended periods, it is important to stress however that this is not very common with steroid using athletes. Most of the documented cases of liver cancer have in fact been in clinical situations, particularly with the use of the powerful oral androgen Anadrol (oxymetholone). This may be directly related to the high dosage of this preparation (50mg per tab). The manufacturer's recommendations calls for the use of as many as 8 or 10 tablets daily for ill patients receiving this medication. This is of course a far greater amount than most athletes would ever think of consuming, with three or four tablets per day being considered the upper limit of safety. It is also important to note that the actual number of cases involving liver damage have been few, and have not been a significant enough of a problem to warrant discontinuing this compound. The average recreational steroid user who takes toxic orals at moderate dosages for relatively short periods is therefore very unlikely to face devastating liver damage.

Although severe liver damage may occur before the onset of noticeable symptoms, it is most common to notice jaundice during the early stages of such injury. Jaundice is characterized by the buildup of bilirubin in the body, which in this case will usually result from the obstruction of bile ducts in the liver. The individual will typically notice a yellowing of the skin and eye whites as this colored substance builds in the body tissues, which is a clear sign to terminate the use of any c17 alpha alkylated steroids. In most instances the immediate withdrawal of these compounds is sufficient to reverse and prevent any further damage. Of course the athlete should avoid using orals for an extended period of time, if not indefinitely, should jaundice occur repeatedly during treatment. It is also a good idea to visit your physician during oral treatment in order to monitor liver enzyme values. Since liver stress will be reflected in your enzyme counts well before jaundice is noticed, this can remove much of the worry with oral steroid treatment.

Gynecomastia
Gynecomastia is the medical term for the development of female breast tissues in the male body. This occurs when the male is presented with unusually high level of estrogen, particularly with the use of strong aromatizing androgens such as testosterone and Dianabol. The excess estrogen can act upon receptors in the breast and stimulate the growth of mammary tissues. If left unchecked this can lead to an actual obvious and unsightly tissue growth under the nipple area, in many cases taking on a very feminine appearance. To fight this side effect during steroid therapy, many find it necessary the use some form of anit-estrogen. This includes an estrogen antagonist such as Clomid or Nolvadex, which blocks estrogen from attaching to and activating receptors in the breast and other tissues, or an aromatase inhibitor such as Proviron, Cytadren, Arimidex or Aromasin which blocks the enzyme responsible for the conversion of androgens to estrogens. Aromasin is currently the most effective option, but is also the most costly.

It is worth noting however, that a slightly elevated estrogen level may help the athlete achieve a more pronounced muscle mass gain during a cycle. But in my opinion it is safer to sacrifice a little gain for peace of mind. Puffiness or swelling under the nipple is one of the first signs of pending gynecomastia, which is often accompanied by pain or soreness in this region (an effect termed gynecodynea). This is a clear indicator that some type of antiestrogen is needed. If the swelling progresses into small, marble like lumps, action absolutely must be taken immediately to treat it. Otherwise if the steroids are continued at this point without ancillary drug use, the user will likely be stuck with unsightly tissue growth that can only be removed with a surgical procedure.

It is also important to mention that progestins seem to augment the stimulatory effect of estrogens on mammary tissue growth. There appears to be a strong synergy between these two hormones here, such that gynecomastia might even be able to occur with the help of progestins, without excessive estrogen levels being necessary. Since many anabolic steroids, particularly those derived from nandrolone (e.g. Deca), are known to have progestational activity, we must not be lulled into a false sense of security. Even a low estrogen producer like Deca can potentially cause gyno in certain cases, again fostering the need to keep anti-estrogens close at hand if you are very sensitive to this side effect.

Hair loss
The use of highly androgenic steroids can negatively impact the growth of scalp hair. In fact the most common form of male pattern hair loss is directly linked to the level of androgens in such tissues, more specifically the DHT metabolite of testosterone. The technical term for this type of hair loss is androgenetic alopecia, which refers to the interplay of both the male androgenic hormones and a genetic predisposition in bringing about this condition. Those who suffer from this disorder are shown to posses finer hair follicles and higher levels of DHT in comparison to a normal, hairy scalp. But since there is a genetic factor involved, many individuals will not ever see signs of this side-effect, even with very heavy steroid use. Clearly those individuals who are suffering from (or have a familial predisposition for) this type of hair loss should be very cautious when using the stronger drugs like testosterone, Anadrol, Halotestin and Dianabol.

In many instances the renewal of lost hair can be very difficult, so avoiding this side effect before it occurs is the best advice. For those who need to worry, the decision should probably be made to either stick with the milder substances, or to use the ancillary drug Propecia/Proscar (finasteride; 5-alpha-reductase enzyme inhibitor). Propecia offers little benefit with drugs that are highly androgenic without 5-alpha-reduction such as Anadrol and Dianabol. We must also remember also that all anabolic/androgenic steroids activate the androgen receptor, and can promote hair loss given the right dosage and conditions.

Immune System Changes
The use of anabolic/androgenic steroids has been shown to produce changes in the body that may impact an individual's immune system. These changes however can be both good and bad for the user. During steroid treatment for instance, many athletes find they are less susceptible to viral illnesses. New studies involving the use of compounds like oxandrolone and Deca with HIV+ patients seem to back up this claim, clearly showing that these drugs can have a beneficial effect on the immune system. Such therapies are in fact catching and many doctors are now less reluctant to prescribe these drugs to their ill patients. But just as a person may be less apt to notice illness during steroid treatment, the discontinuance of steroids can produce a rebound effect in which the immune system is less able to fight off pathogens. This most likely coincides with the rebound production of cortisol, a catabolic hormone in the body, which may act to suppress immune system functioning. When steroids are withdrawn, an androgen deficient state is often endured until the body is able to rebalance hormone production. Since testosterone and cortisol seem counter each other's activity in many ways, the absence of a normal androgen level may place cortisol in an unusually active state. During this period of imbalance, cortisol will not only be stripping the body of muscle mass, but it may also cause the athlete to be more susceptible to colds, flu etc. The proper use of ancillary drugs (e.g. clomid) for recovery at the end of a cycle will help to reduce this (see article #2 on recovery)

Prostate Enlargement
Prostate cancer is one of the most common forms of cancer in males. Benign prostate enlargement (a swelling of prostate tissues often interfering with urine flow) can precede/coincide with this cancer, and is clearly an important medical concern for men who are aging. Prostate complications are believed to be primarily dependent on androgenic hormones, particularly DHT, much in the same way estrogen is linked to breast cancer in women. Although the connection between prostate enlargement/cancer and steroid use is not fully established, the use of steroids may theoretically aggravate such conditions by raising the level of androgens in the body. It is therefore a good idea for older athletes to limit/avoid the intake of strong 5-alpha reducible androgens like testosterone, methyltestosterone and Halotestin, or otherwise use Proscar (finasteride), which was specifically designed to inhibit the 5-alpha-reductase enzyme in scalp and prostate tissues. This may be an effective preventative measure for older athletes who insist on using these compounds. Drugs like Dianabol and Anadrol, which do not convert to DHT yet are still potent androgens, are not effected by its use however. It is also important to mention that not only androgens but also estrogens are necessary for the advancement of this condition. It appears that the two work synergistically to stimulate benign prostatic growth, such that one without the other would not be enough to cause it. It has therefore been suggested that non-aromatizable compounds may be better options for older men looking for androgen replacement than lowering androgenic activity in the prostate. It is easier to accomplish, and should be accompanied with less side effects. It would also be very sound advice, regardless of steroid use, for individuals over 40 to have a physician check the prostate on a regular basis.

Sexual Dysfunction
The functioning of the male reproductive system depends greatly on the level of androgenic hormones in the body. The use of synthetic male hormones may therefore have a dramatic impact on an individual's sexual wellness. On one extreme we may see a man's libido and erection frequency become extremely heightened. This is most commonly seen with the use of strongly androgenic steroids, which seem to have the most dramatic stimulating impact on this system.

On the other extreme we may also see a lack of sexual interest, possibly to the point of impotency. This occurs mainly when androgenic hormones are at a very low. This will often happen after a steroid cycle is discontinued, as the endogenous production of testosterone is commonly suppressed during the cycle. Removing the androgen (from an outside source) leaves the body with little natural testosterone until this imbalance is corrected. The loss of its' metabolite DHT is particularly troubling, as this hormone may have a strong affect on the reproductive system that may not be apparent with other less androgenic hormones. It is therefore a very good idea to use testosterone-stimulating drugs like HCG and Clomid/Nolvadex when coming off of a strong cycle (see article #2 on recovery), so as to reduce the impact of steroid withdrawal. Impotency/sexual apathy may also occur during the course of a steroid cycle, particularly when it is based strictly on anabolic compounds. Since all "anabolics" can suppress the manufacture of testosterone in the body, the administered drugs may not be androgenic enough to properly compensate for the testosterone loss. In such a case the user might opt to include a small androgen dosage (perhaps a weekly testosterone injection).
It is also interesting to note that it is not always simply an androgen vs. anabolic issue. People will often respond very differently to an equal dose of the same drug. While one individual may notice sexual disinterest or impotency, another may become extremely rampant!. It is therefore difficult to predict how someone will react to a particular drug before having used it.

Stunted Growth –age!
Many anabolic/androgenic steroids have the potential to impact on an individual's stature if taken during adolescence. Specifically, steroids can stunt growth by stimulating the epiphyseal plates in a person's long bones to prematurely fuse. Once these plates are fused, future liner growth is not possible. Even if the individual avoids steroid use subsequently, the damage is irreversible and he/she can be stuck at the same height forever. Not even the use of growth hormone can reverse this, as this powerful hormone can only thicken bones when used during adulthood. Interestingly enough it is not the steroids themselves, but the buildup of estrogen that causes the epiphyseal plates to fuse. Women are shorter than men on average because of this effect of estrogen, and likewise the use of steroids that readily convert to estrogen can prematurely suppress/halt a person's growth. In fact, the use of steroids like Anavar, Winstrol and Primobolan (which do not convert to estrogen) can actually increase one's height if taken during adolescence, as their anabolic effects will promote the retention of calcium in the bones. This would also hold true for non-aromatizing androgens such as trenbolone, and Halotestin. Thus maybe the youngsters on the board can see my argument about waiting a few years!

Testicular Atrophy
When the administration of androgens from an outside source causes a surplus of hormone, it will cause the body to stop manufacturing its own testosterone. Specifically this happens via a feedback mechanism, where the hypothalamus detects a high level of sex steroids (androgens, progestins and estrogens) and shuts off the release of GnRH (Gonadotropin Releasing Hormone). This in turn causes the pituitary to stop releasing LH and FSH the two hormones (primarily LH) that stimulate the Leydig's cells in the testes to release testosterone (negative feedback inhibition has been demonstrated at the pituitary level as well). Without stimulation by LH and FSH the testes will be in a state of production limbo, and may shrink from inactivity. In extreme cases the steroid user can notice testicles that are unusually and frighteningly small. This effect is temporary however, and once the drugs are removed (and hormone levels rebalance) the testicles should return to their original size. Many regular steroid users find this side effect quite troubling, and use ancillary drugs like HCG (see article #2) during a steroid cycle in order to try to maintain testicular size during treatment.

Virilization
Since anabolic/androgenic steroids are synthetic male hormones, they can produce a number of undesirable changes when introduced into the female body. This includes the possibility of virilization, which is the tendency for women to develop masculine characteristics when taking these drugs. Virilization symptoms include a deepening or hoarseness of the voice, changes in skin texture, acne, menstrual irregularities, increased libido, hair loss (scalp), body/facial/pubic hair growth and an enlargement of the clitoris. In extreme cases the female genitalia can become very disfigured, and may actually take on a penis-like appearance. Women must clearly be very careful when considering the use of steroids, especially since most virilization symptoms are irreversible. The stronger androgenic compounds should obviously be off-limits, with cautious female athletes restricting themselves to the use of only mild anabolics such as Winstrol, Primobolan and Anavar. Since even these milder anabolics have the potential to cause problems, users should additionally remember to be conservative with drug dosages and duration of intake. After each cycle of course a notable break from treatment would be a good idea as well, so that the body has sufficient time to reestablish a hormonal balance.

Regardless of your age, it’s important to always bear in mind that the use of AAS for the purposes of gaining an edge in sport can be an inherently unhealthy endeavor. There is a distinct difference between the doses of hormones or drugs that are used in slowing the aging process through hormone replacement therapy (hereafter referred to as HRT, please see the chapter on HRT by Dr. Ramon Scruggs for further clarification) and those that are used to enhance performance. If one is to properly use performance enhancing drugs, it is vital that they know the potential side effects of drugs they are using, know how to combat these side effects, and most importantly, actually implement the knowledge they have. Time and time again I’ve seen a bodybuilder develop gynecomastia (commonly referred to as “bitch tits” in the bodybuilding vernacular) despite the fact that the individual in question knew this was a possibility and also knew the preventative measures to take. One should not engage in the use of AAS or any other performance enhancing drug if the maintenance of proper health is not of primary concern.

Compounding the problem of treating the side effects of AAS is the hysteria surrounding their use in the first place. Many bodybuilders that use steroids find themselves to be social pariahs, muscular misfits if you will, and end up finding comfort in the company of others that engage in steroid use as well. Because a bodybuilder wears his sport, he’s branded a steroid user by many regardless of whether that’s the case or not. Often times, the shame one feels regarding their steroid use will cause them to suffer through the side effects associated with their use, rather than seeking competent medical help. Truth be told, it’s very difficult to find competent medical help to treat the side effects of steroids, as most doctors simply have no idea how to properly do so. More often than not, the physicians I worked with for most of my years on steroids were completely clueless as to how one might ameliorate the negative side effects of these drugs, and would simply tell me to “get off the steroids”. I say this not to dissuade those of you reading this from seeking out the advice of a doctor regarding the side effects of steroid use, just to prepare you for a probable response.

Most of the side effects related to steroids are cosmetic and will disappear when one discontinues their use. But those that aren’t are the most important to understand and treat as necessary. Most of these cannot be seen or felt, and all are related to issues of cardiovascular health. Steroids can adversely affect cholesterol levels, triglyceride levels, and hypertension, which over time can and will lead to an increase in heart disease. Always monitor your resting hear rate and blood pressure on a weekly basis when taking steroids and have your cholesterol and triglycerides checked every six months if you are using steroid consistently. These are not problems you can live with, ignore them and you may very well die much earlier than you would have otherwise. Ask yourself this question: “How much is every year of my life worth to me?” If you ignore the potential for an increased risk of heart disease when using anabolic steroids, you are essentially answering the question with, “Very little indeed.”

Before we begin a look at the actual side effects themselves and how to treat them, it’s important to note that not all AAS are created equal!! At times, for the sake of brevity, I will lump all AAS together, but the fact remains that some steroids will cause more negative side effects than others. One of the points of this book is to allow you to make that distinction, and walk away with the knowledge of how to use them as safely as possible. Below is a list of steroids most commonly associated with the side effects listed in this chapter:

Anadrol-50 (Oxymetholone)
Dianabol (Methandrostenolone)
Halotestin (Fluoxymesterone)
Testosterone and its various esters

Unfortunately for us, these also happen to be most of THE most effective AAS (with the exception of Halotestin) for building LBM. Generally, the maxim that the more effective a steroid is the more side effects it has holds true.

Finally, before we begin, readers will notice that I do not advocate the use of estrogen blockers such as nolvadex, clomid (I do post cycle, but not for the purposes of estrogen suppression), or Proviron. With anti-aromatases like Arimidex (anastrazole), Femara (letrozole), and to a lesser extent Cytadren (aminoglutethiamide) becoming cheaper and more readily available, use of estrogen blockers should be relegated to the bodybuilding archives. For a complete explanation as to why, read the chapter Proper Use of Ancillary Medications Both On and Off Cycle.

AAS Side Effects

Acne: One of the primary indicators of steroid use is acne, and I’m sure many of you reading this have either experienced acne caused by steroids or have seen someone who has. Like all steroid side effects, the degree to which someone will suffer from acne varies from individual to individual. The more androgenic a compound is, the more profound effect it will have on increasing oil production in the skin via stimulation of the sebaceous glands. Having said that, I’ve seen individuals use incredibly androgenic stacks and never have a hint or a pimple or blemish, and I’ve seen athletes (especially women) use very mild anabolics and suffer from horrible acne.

Treating acne is very important, both for physical and psychological reasons. Untreated acne can cause permanent scarring of the skin if it becomes severe enough, resulting in a pockmarked area that can only be smoothed through expensive plastic surgery. And acne can have a very powerful negative psychological effect on someone suffering from it, branding someone a steroid user and further isolating them from “normal” society. Severe acne can and will detract from the most aesthetic of physiques, and take away from ones overall presentation.

Depending on the severity, there are several options for the treatment of acne. Since acne is generally caused by the more androgenic steroids, there is always the option of switching to steroids that have few androgenic properties, such as nandrolone, oxandrolone, or primobolan. Light cases can commonly be controlled through frequent washings of the effected area (to remove excess dirt and oil before pores become clogged and infected) and the use of over the counter topical treatments. Moderate cases will generally respond to the use of Retin-A coupled with use of an antibiotic (such as tetracycline) which kills the bacteria which feeds off the oil created by the sebaceous gland. Severe cases of acne should be treated with Accutane, a prescription drug manufactured by Roche that is very effective at permanently eliminating acne. Accutane has a host of unpleasant side effects itself, and treatments are both lengthy and costly (health insurance is a must), but its use is much better than the possibility of permanent scarring from cystic acne. Fortunately, while acne is one of the most commonly seen side effects, it’s also the easiest to treat, as competent Dermatologists can easily be found.

It should also be noted that acne commonly become an issue for bodybuilders that do not cycle off steroids correctly, which will often cause a severe imbalance between levels of androgens and estrogens. Preparation for your off cycle period is equally important as the time spent on steroids, so use of an anti-aromatase both on and immediately following a cycle containing AAS that can convert to estrogen is a must.

Aggression: Men, due to their higher natural production of testosterone, are generally more aggressive than women. AAS, especially those that are extremely androgenic, will further increase aggression in both males and females. This can be beneficial as long as the individual in question can focus the aggression appropriately, such as the lifting of heavier weights during training. There often seems to be a direct correlation between ones ability to control aggression and ones intelligence.

There is nothing worse than an out of control steroid user who is unable or unwilling to control their aggression. Before beginning a cycle of AAS, especially one containing strong androgens, you must prepare yourself mentally for the fact that you are in all likelihood going to be more aggressive than normal, and consequently take the time to assess the nature of your reactions while using them.

Controlling yourself during a cycle is simply a matter of maturity, intelligence, and discipline. If you find that you are becoming easily irritated, constantly arguing with others, or becoming extremely upset over minor things, the use of androgenic compounds should be reduced or eliminated altogether. Might does not make right, and any bodybuilder who allows steroids to control their demeanor is simply affirming the stereotypes people have about overly muscular people.

Benign Prostatic Hyperplasia: BPH is simply an enlargement of the prostate, a walnut-sized gland that surrounds the urethra whose function is to squeeze fluid into the urethra as sperm move through during sexual climax. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic. This condition is now considered a normal part of aging for men, with more than half of men in their 60’s and upwards of 90% of men in their 70’s-80’s will show some symptoms. As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself. Urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.

Although no conclusive medical evidence exists that long term use of testosterone will lead to an increase in BPH or an acceleration in its development, such a conclusion can readily be made by understanding the mechanisms through which BPH develops. DHT is a primary culprit in the development of BPH, and it is theorized that estrogen may play a role as well. Men who cannot produce DHT do not develop BPH, and the primary treatment for BPH is Proscar (Finasteride), which inhibits the 5a-reductase enzyme. It is this enzyme which is responsible for converting testosterone (along with Halotestin) into DHT. Studies done with animals have suggested that BPH may occur because the higher amount of estrogen within the gland increases the activity of substances that promote cell growth.

Knowing that use of testosterone will increase both levels of DHT and estrogen if the appropriate accessory medications are not used, you can see where I draw my conclusions. It is highly likely that long term use of testosterone, whether it be for performance enhancement of hormone replacement therapy purposes, will accelerate the onset of BPH. Thusly, one should use both an anti-aromatase and 5a-reducatase inhibitor when using testosterone.

Birth Defects: This applies only to female steroid users, as steroid use by males cannot induce birth defects. Any female using steroids should have a pregnancy test before doing so and use an effective form of birth control while on them. When used by a female who is pregnant, AAS can cause Adreno-genital syndrome, which will result in the inappropriate growth of the genitals in a developing fetus.

Cancer: Steroids are commonly believed to cause cancer, even by many who use them. This is primarily for one reason, the hysteria surrounding the death on former football great Lyle Alzado, who died of a brain tumor in 1992. Prior to his death, Lyle went on a very public campaign divulging his many years of steroid abuse, and pointing the figure at AAS as the causative factor behind his cancer. The media latched on to this and exploited it for all it was worth, despite the fact that Lyle’s own physician readily admitted that AAS could in no way caused the cancer the killed his patient.
The fact is that the number of cases that have directly linked steroids to cancer is statistically insignificant, and all are related to the use of C17 alpha alkylated compounds. Again, C 17 alpha aklylation is a chemical modification that allows steroids to be used orally. This makes them mildly hepatotoxic, and continued use over long periods of time can place serious stress on the liver. The few cases of liver damage and subsequent cancer that have been confirmed to be related to the use of AAS have occurred in primarily in sick patients whose liver function had already been compromised in some fashion, not athletes. Furthermore, the steroid involved in these cases was almost always Anadrol-50. This makes complete sense, as Anadrol comes in a very high dose per pill (50 mg) when compared to other oral steroids. Furthermore, the amount of Anadrol that was often to prescribed to patients was astronomical, the Physician’s Desk Reference (known as the PDR, the reference guide physicians use when prescribing drugs) recommended 1-5 mg/kg of body weight per day. To put this into perspective, a 200 lb individual would be given anywhere between 100-500 mg of Anadrol per day. This is between 2-10 tabs of Anadrol daily. Anyone having used real Anadrol (and there’s very few that have, almost ALL of the oxymetholone available today is severely underdosed) knows that even 100 mg is an incredibly effective dose that will always be accompanied by a host of negative side effects.

My point is not to minimize the dangers of long term use of 17-AA AAS, but the truth is that short term use of them (4-8 weeks) is a relatively safe proposition.

Depression: Use of AAS can have a profound affect on an individual’s disposition. Depression is most commonly exhibited in male bodybuilders post cycle, when estrogen levels can be incredibly high and endogenous production of testosterone has been suppressed. This can leave a male bodybuilder with a hormone profile more resembling that of a woman, and this can play a profound role in their attitude and outlook on life. More than once I’ve seen incredibly muscular and normally stoic males reduced to tears over sappy television commercials and lamenting their deteriorating condition as the imbalance of estrogen/testosterone wreaks havoc on them physically and mentally. Once again, this can be avoided through use of proper ancillary medications both on and off cycle. Estrogen levels must be kept in check at all times to ensure both maximum gains and minimum side effects. Please refer to the chapter, Proper Use of Ancillary Medications Both On and Off Cycle for more information.

Edema: Many AAS will affect the amount of will affect the amount of water that is stores in the various tissues of the body. To some degree this can be beneficial, the strength that one will gain through the retention of water in muscle and connective tissues will certainly help add additional LBM over time. However, the moon face of a bodybuilder on a bulking cycle suffering from extreme edema is both physically repugnant and inherently unhealthy. One should not ignore the fact that water retention can have a negative impact on both blood pressure and renal function.
Edema is associated with increased levels of estrogen, and thus the culprit for it is once again the aromatizing androgens. An athlete should always prepare for this when using these steroids, through proper application of anti-aromatases like Arimidex, Femara, or Cytadren.

Gynecomastia: Primarily referred to as “bitch tits” or gyno, gynecomastia refers to enlargement of the male breasts. Male breast tissue is ripe with estrogen receptors, just as in that of a female. Consequently, elevated estrogen levels can cause swelling and eventual growth of this tissue, leaving a man with unsightly lumps beneath both nipples. The effect is exactly that experienced by a male pre-op transsexual receiving female hormones to induce the growth of the breasts, albeit on a lesser scale. Untreated, the swollen breast tissue will harden, becoming permanent fixtures underneath your nipples until removed by surgery.

Because elevated levels of estrogen are the primary culprit behind the development of gyno, one should always use an anti-aromatase when using steroids that aromatize. This would normally be during a bulking cycle, when the use of strong, aromatizing androgens becomes a necessity. Unlike many others that have commented on the subject of gynecomastia and estrogen suppression, I would not wait until the effects of estrogen can be seen or felt before incorporating the proper ancillary drugs into my regime, they should be in place from Day 1!

It should be noted that I do recommend use of an estrogen antagonist when using Anadrol-50 (oxymetholone), as this drug exhibits estrogen-like activity despite the fact that it does not aromatize. Because of this, the estrogenic effects of Anadrol cannot be combated using an anti-aromatase, and one would need use an estrogen receptor antagonist such as Nolvadex or Clomid.

There are several AAS that exhibit progestational activity, such as many of the nandrolones or trenbolone (which is derived from nandrolone). It is possible that these steroids could produce or exacerbate gyno in a very small percentage of extremely sensitive individuals, even without elevated estrogen levels. Male bodybuilders that are extremely sensitive to the effects of progestins will have a very hard time avoiding the development of gyno, since the majority of effective steroids either aromatize, exhibit estrogenic qualities on their own (Anadrol), or have progestenic activity. These individuals would need to totally suppress estrogen production while on cycle (using both an anti-aromatase and an estrogen antagonist) or find someway to acquire the drug RU-486, the so-called abortion pill. Use of RU-486 would be the ideal situation for these individuals, as it is a progesterone antagonist. Unfortunately, this drug is nearly impossible to obtain.