Health effects of anabolic androgenic steroid use in male amateur athletes

An estimated 20.000 amateur athletes use anabolic androgenic steroids (AAS) in the Netherlands. These drugs are illicitly obtained and usually of very low quality. The harmfulness of AAS has hitherto not been studied systematically. Therefore knowledge of the unwanted somatic and psychological effects of AAS is based on rather low-level evidence, such as expert opinion, case reports and cross-sectional studies. The outpatient AAS clinic in Haarlem was founded to gain more insight into health risks associated with AAS use. Patients interviewed in this clinic helped to envisage the typical AAS user and what side effects and health issues are mostly encountered. To generate more reliable data less susceptible to bias, the HAARLEM study was initiated, which prospectively analyzed a cohort of 100 amateur athletes during and after an AAS cycle. The cohort was assembled of strength athletes mostly in their 20s and 30s, and one-fifth was competitor in a bodybuilding competition. The majority used AAS to gain muscle mass and to improve their level of strength. The cycle performed during the first year of the study had a median duration of 13 weeks, average weekly androgen dose of 901 mg and consisted of 5 different AAS types. All of the subjects reported positive effects as well as a wide range of transient and mild negative side effects, such as acne, gynecomastia and erectile dysfunction. Four subjects encountered a serious adverse event, among others congestive heart failure, but all recovered with treatment. Liver and kidney function were only slightly affected by AAS use. Psychological questionnaires revealed no major changes during and after the cycle. A body dysmorphic disorder was present in one-fourth of participants. During the cycle testicular dysfunction was observed with suppression of endogenous testosterone production as well as spermatogenesis. Both recovered in most subjects after the cycle, although a long history of AAS use was associated with a limited rate and extent of recovery. The performance of PCT did not affect recovery in any positive way. Changes of cardiovascular parameters observed during AAS use were an elevated blood pressure, rise in hematocrit and platelet count, and a mostly inimical change of lipid profile. The extent of these changes was not associated with cycle dose or duration, but oral AAS had a worse impact on lipid profile than injectables alone. Electrocardiography revealed a shortened corrected QT interval, increased rate of early repolarization, and higher indices for left ventricular hypertrophy. The latter was confirmed with echocardiography, which not only showed an increased left ventricular mass but also a reduced ejection fraction, an increased ventricular stiffness and larger left atrial volume. After discontinuation of AAS use, all of the mentioned changes reversed back to baseline levels. The cohort was followed-up for an additional year after the first. Two-thirds of subjects used AAS again this year, and one-quarter of them used AAS all year long, mainly in a blast and cruise fashion. Continuous use was determined in some degree by taking part in bodybuilding competitions and training time. Future research should particularly focus on how to effectively reduce harm in this group of avid users. A trial assessing a harm reduction strategy with face-to-face counseling by health professionals in the outpatient AAS clinic will soon be under way.