Written by Carlon Colker, MD
10 October 2006

In the Wake

What do you do when anabolic steroid abuse takes its toll?


I'm seeing an increasing number of former bodybuilders, powerlifters, and athletes with a significant history of anabolic steroid abuse coming to my office now, years later, with low testosterone, flat sex drive, low energy, fat gain with loss of muscle mass, and often, anxiety and/or depression. These people are suffering. The numbers are climbing with alarming rapidity. I speculate that this is simply because it's taken that much lead-time for these former abusers to come of age.

I mean, anabolic steroid use really did not start sweeping the nation in popularity until the mid-‘70s. After that, the abuse really started. By the late ‘80s and early ‘90s, it seemed like everyone was cranked up on the super-sauce. White, black, Hispanic, Asian, tall, short, fat, skinny, old and young; it didn't matter. You were on a hunt for the juice. Time didn't seem precious. The moment ruled. And the more everyone did the juice-abuse jig, the more invincible they felt. Under the powerful spell of the sweet sauce you looked better, you ate better, you had better sex, you felt powerful and bright days were sunnier. You were the king, pharaoh, czar, and Caesar rolled into one. Well, at least it seemed that way for a while.

But back then, there was no slave to sit behind the throne and whisper caution into Caesar's ear to curb over-confident arrogance and pompous bravado. The slave would have warned, "Glory is fleeting, glory is fleeting." This ancient caveat was instead lost in the wind, only to return in what is now a furiously growing tide. As the initial trickles of health complaints wash ashore, the sea is drawing back to reveal a fickle tsunami starting to form on the horizon. The massive proverbial wave carries with it countless bodies ravaged by steroid abuse.


            Signs and Symptoms

The symptoms manifest in an intractable and chronic way. These cases can be unbelievably difficult to manage for the average physician. If your    doctor has little or no experience in this area, he might need some help, and you may need a lot. In the most stubborn of cases, I scramble with a multitude of treatments (drugs and supplements alike). I often involve multiple practitioners and colleagues just to have the best chance of reversal and healing. Endocrinologists, urologists and psychiatrists may all play a role. For example, in one case, I successfully utilized short-term injections of human chorionic gonadotropin (HCG) combined with Viagra and saw palmetto to stimulate some natural testosterone production, support prostate health and to recover some sexual performance. I overlaid this on a backdrop of a relatively short course of antidepressants and psychotherapy. Sound drastic? Well, after almost two years of manipulating this guy's therapy and an additional six months of weaning from the interventions, he has finally recovered his normal healthy bodily functions and is no longer dependent on any of the measures.

Do not despair. It can be done, and there is hope for all. You just need a physician that is willing to invest the time to accurately diagnose and carefully establish a customized course of treatment, and you need to be a very motivated patient. It may be frustrating and a little slow-going at first. You have to be an active part of your healing and patiently willing to put in the time. For those on the fence about all this, remember that Rome was not built in a day and neither were you.

Accurate diagnosis and proper treatment is a big nut. In fact, there is as yet no standardized way to diagnose or treat this syndrome. Most physicians won't even recognize it. So, to help you navigate this conundrum in a stepwise fashion, I have broken down a general approach to the problem in an effort to take you through the ordeal.


Step #1

First, you must see your general physician and get a full physical examination to screen for any disease that has to be treated. Tell him/her to pay special attention to your liver, testicles and prostate (that's right, this includes the old digital rectal exam!). Don't be an idiot and pass this step because you're squirrelly about a test. Keep in mind that the whole diagnosis and treatment course starts with your own doctor and will always be centralized there. Also, if you have a significant disease, whether caused by the steroids or not, treating the condition with medications or surgery may take far greater precedence over your quest to recover your mojo. I mean, no matter how fast a Ferrari goes, if there's no gas in the tank, it won't beat out an old woman with a walker.


Step #2

In addition to whatever your doc wants, be sure to ask him/her to consider the following blood tests:

Serum Multiple Assay Chemistry (SMAC-20): It's a great screening test because it includes, among a bunch of other parameters, a liver and kidney function analysis, which is a must for every guy with a history of chronic abuse. Glucose, sodium, potassium, chloride, carbon dioxide, glucose, blood urea nitrogen, creatinine, calcium, magnesium, phosphorus, ASL/ALT, albumin, uric acid, iron, cholesterol and triglycerides are all part of the blood test. This test is fairly standard and I would expect that your doctor would automatically order it.

Complete Blood Count (CBC):  This test looks at blood cells to see if they are abnormal in count or morphology (shape). White blood cells and red blood cells are the main parameters. Anabolic steroids can unnaturally and temporarily boost hemoglobin and hematocrit, but other then that, they should not permanently mess up these blood cells. Just the same, it's nice to know that they're okay. Coupled with the SMAC-20, the CBC is a fairly standard screening test for a multitude of purposes.

Prostate Specific Antigen (PSA): This test is of critical importance because the prostate tends to take a beating in long-term steroid abusers. Many prostate cancers are testosterone dependent and actually grow and proliferate in the presence of testosterone. The simple PSA is a fairly good indicator of prostate cancer. Just keep in mind that a normal PSA does not mean that you don't have an enlarged prostate (also called benign prostatic hypertrophy, or BPH). Your doctor can only tell that by examination and by symptoms of urination problems.

Free and Total Testosterone: Knowing both free and total numbers provides the clinician with a great deal of information with regard to this male sex hormone. In my practice, I need both these levels to make a proper interpretation. The fact is, 98 percent of circulating testosterone is bound to other molecules and thus, unavailable. The remaining two percent is the free, biologically active form available to the cells in your body. This free form of testosterone is more directly reflective of the immediate clinically manifested response at the time the blood test is done, whereas the total (which includes the portion of testosterone bound to other sites) provides an estimate of the total amount of testosterone in your body. The normal adult male should have between 260-1,000ng/dL of total testosterone and 50-210ng/dL of free testosterone.

Free Estradiol and Total Estrogens: Many problems in males can be linked to an excess of these female sex hormones. Yet, in the face of the ever-popularly requested testosterone levels, the estrogens are often the overlooked culprit responsible for untoward symptoms. Like testosterone, estradiol is mostly bound and inactive, with about 95 percent unavailable. Long-term steroid abuse can mess up this delicately balanced ratio between the active (unbound) and inactive (bound) forms. In addition to the symptoms of chronic abuse, formation of gynecomastia (bitch tits) can occur. Total estrogens tell you about all three forms of estrogen (estradiol[E1], estrone[E2], and Estriol[E3]). They are all the principle estrogens in the body and should occur in very low amounts in the normal male body. The normal adult male should have no more then 0.3-0.9pg/mL of free estradiol and no more than 130pg/mL of total estrogens.   

Dehydrepiandrosterone (DHEA, DHEA-S): As a testosterone and estrogen precursor, derangement in DHEA and DHEA-S levels is often indicative of sex hormone production problems. Though the sulfated version (DHEA-S) is more common throughout the body, the unsulfated version (DHEA) is really the active form. They are weak androgens and their levels can be influenced by long-term anabolic steroid abuse. Though not always very telling, and with a ridiculously wide reference range, a very elevated or very depressed level can still help guide a physician in terms of treatment. The normal adult male should have between 130-1,250ng/dL of DHEA.

Luteinizing Hormone (LH, 3rd Generation): LH is a hormone produced by the anterior pituitary gland and is a great indicator to test the axis of testosterone production at this level since it is responsible for stimulating the testicles to produce testosterone. I've always found that LH levels are extremely useful in helping me assess gonadal (testicular) function, especially in cases where symptoms are related to steroid abuse. Yet, despite the great utility of this test, LH levels are one of the most often overlooked tests. The normal adult male should have between 0.95-5.60IU/L.

Prolactin: Prolactin is a pituitary hormone that serves a far greater function in the female physiology. Nevertheless, if elevated in the male, it can lower LH, which in turn will lower testosterone. It's rarely a cause of residual symptoms of chronic steroid abuse. But I've seen it missed, so you should be aware of the presence of this hormone, its activity and the possible need to screen for it.

Thyroid Function Testing (TSH, T3, T4): Long-term steroid abusers can indirectly mess up thyroid gland function. In some cases, symptoms that have been initially attributed to low testosterone end up being caused by a poorly functioning thyroid. In fact, the symptoms can be so identical that in many cases where I have a high level of suspicion, I am always sure to rule out sluggish thyroid function.


Step #3

Based on your clinical presentation combined with the results of those tests, your personal physician should treat you appropriately. With an eye toward giving you and your doctor some help, I've listed 10 tips. I've personally utilized these in a variety of different men, all with a significant history of anabolic steroid abuse, notable test findings and significant related symptoms.


1. Human Chorionic Gonadotropin (HCG). HCG is a hormone produced by the placenta and does not serve a regular function in the adult male physiology. Nevertheless, this hormone acts much like LH when introduced into the adult male, thereby stimulating the production of testosterone. A physician can utilize these injections in the short term to "wake up" testosterone production. I've used this hormone in practice for males suffering from hypogonadotropic hypogonadism in doses of 500-1,000 USP Units three times per week for three weeks, followed by the same dose two times per week for another three weeks. Another popular course is to give 4,000 USP Units three times per week for up to nine months, followed by 2,000 USP Units three times per week for an additional three months. If that doesn't wake things up to help you function on your own, using HCG much longer won't be very fruitful. In fact, I think if used in excess it can cause gynecomastia while actually making you quite dependent. At that point, you are just trading one form of physiologic addiction for another.

2. Sex/Masturbation. Ejaculating through sex and/or masturbation is one of the most highly effective, but least talked about, ways to stimulate testicular function. Isn't it just like me to talk about what everyone else wants to shy away from? Use it or lose it! I speculate that stimulation and ejaculation promote the production of testosterone and may also positively affect the ratio of free testosterone to total testosterone. I can't prove exactly how, but I suspect it's through some kind of negative feedback. If your sexual function is so poor that you cannot maintain a sexual relationship, as is the case for too many patients, you may opt for masturbation. You'd actually be amazed at some of the former juiced-up massive hard bodies that now don't have functioning wedding tackle. They still look great out and about socially and on the bodybuilding scene. Yet, you'd be astounded to know that these former big-shot skirt chasers are doing nothing more exciting then pulling toffee at day's end. And even that is no small task for some. They really have to focus on getting excited for a date with Madame Palm and her five sisters. In terms of frequency of sex/masturbation, it's tough to say and really depends on the individual, but at least a few times per week should suffice.

3. Viagra.TM This little blue pill has revolutionized sexual activity and health in the middle-age to older set. In fact, an increasing number of younger males are flocking to their physicians for the magic. Though it won't directly affect your sex drive or testosterone levels, I feel quite strongly that ViagraTM can indirectly boost them. In my clinical experience, ViagraTM helps support normal sexual function (erection). In so doing, it can help a male suffering from the ravages of significant steroid abuse to obtain an erection in order to ejaculate. Because testosterone is needed for the production of sperm (the key component in semen), it seems logical to me that the act of ejaculating would stimulate testosterone production. ViagraTM comes in doses of 50-100 milligrams, and is no longer dispensed in the 25-milligram tablets. (Most men simply needed the higher doses).

L-Arginine. This amino acid is a critical precursor in the production of nitric- oxide which, in turn, is responsible for obtaining male erection. Thus, in terms of the utility of L-arginine, it's related to ViagraTM and in this way, I think it actually supports the activity of the drug. Though a number of people respond to lower doses, taking much less then 2,800 milligrams may not do much for you, at least according to the research.

Essential Fatty Acids (EFAs). I have yet to figure out why, but when I increase the concentrations of healthy fats either in the diet, through supplementation, or both, I seem to get good results in patients suffering from residual symptoms of chronic steroid abuse. I suspect it may have something to do with supporting healthy steroid metabolism in the liver and providing a backdrop of anti-catabolism and healing. Also, the brain does a great deal with essential fats on the molecular level. So, it may be that essential fats have some central effect in the brain by providing precursor backbones for the formation of neurotransmitters and steroid complexes. Perhaps in this way libido can be positively influenced.

Increase Sleep. Sleep is way too overlooked. Suffering from residual symptoms of chronic steroid abuse can stress you out and keep you up at night. Restlessness and sleepless nights leave you exhausted and unhealed. This is a vicious cycle that sometimes even requires intervention with AmbienTM (a pretty serious drug in its own right), but I hate to give it since this drug has proven to be so damn addictive in many patients. Sleep deprivation also robs your body of testosterone, which is exactly what you are trying to avoid. So getting at least seven hours of sleep a night is critical for healthy hormonal recovery.

Decrease Training Frequency/Duration/Intensity. Another often-overlooked factor in driving testosterone through the cellar is overtraining. Strangely, I often find that the more one suffers from residual symptoms of chronic steroid abuse, the more one becomes addicted to working out! I guess the gym just ends up being one of the only places of comfort. (After all, it sure isn't the bedroom for most sufferers!). I suppose guys tend to think that since the gym is the place where they improved themselves in the past, somehow it will still do the same. So, they end up increasing the frequency, duration and/or intensity of their workouts. But by placing more stress on the body and increasing the need for recovery, the result is more energy drainage. Too much training does the exact opposite of what is intended. My advice during times of hormonal recovery is to back off substantially on training. Take a couple of weeks away from the gym and then come back with no more than three one-hour sessions per week until you feel substantially better. Also, no forced reps, negatives, or gut-busting reps, either. The idea is to refocus your body energies on healing from the residual symptoms of chronic steroid abuse, and not squander what little powers you have on recovering from the workout.

Antidepressants/Anxiolytics. Sometimes, the depression and/or anxiety can be so overwhelming in guys with residual symptoms of chronic steroid abuse that I get a psychologist or psychiatrist involved. Being anxious and/or depressed when dealing with residual symptoms of chronic steroid abuse is only natural, but that doesn't mean you're obligated to suffer! Remember that battling excess feelings of insecurity and sadness usher in yet another cycle of futility that robs you of valuable healing energy. Turning to the help of a psychologist for evaluation and counseling, or a psychiatrist for the same with possible pharmaceutical intervention, has proven enormously effective in may cases I've handled.    

Drop Fat. When battling residual symptoms of chronic steroid abuse, too many guys turn to food for comfort, especially as they see muscle loss. The result is excess body fat and the nightmare begins. Peripheral fat stores are the site for aromatization of testosterone to estrogen. Thus, what little free testosterone you have may be getting sucked up in this reaction and converted to the female sex hormone. This robs you of valuable testosterone mojo while replacing it with a feminine side. Worse yet, an increase in estrogen will not only predispose you to gynecomastia, but will make you even fatter! The best thing you can do is to not compensate for the suffering by turning to food as a vice. Remember that you have to eat to heal, but dropping a few pounds worth of can-cakes keeps the estrogen surge at bay.

Fluid. Finally, for whatever reason, hydration seems to end up being a critical issue in those suffering residual symptoms of chronic steroid abuse. Of those I've tested, total body water (TBW) always seems to be on the low side. Pumping in good old H2O seems to be one of the best ways to put out the catabolic fire while supporting a normal, healthy hormonal milieu.


Step #4

If all else fails, your doctor may be left with no other choice than to provide your body with supplemental testosterone injections. Though we don't always have a choice, it's something you want to try to avoid because continued treatment can be littered with perils, including possible liver problems, prostate issues and cancer. This does not mean it will happen, but the possibility exists. So, if this method is in the cards, you need to be very carefully monitored by your doctor. I tend to do general screening blood draws on these patients on a monthly basis (SMAC-20, CBC) with more specific prostate screening and examinations a couple of times each year. I also work in free and total testosterone, as well as levels of total estrogens, throughout the year. If you want to avoid needles, you've got another big problem because your doctor won't likely use oral agents. Using oral agents for this long-term purpose would just be bad medicine. Orals go through what is called "first-pass metabolism" and thus must travel from the gut directly to the liver for metabolism. So orals may beat on this organ over time. A doctor who knows you're a candidate for long-term testosterone replacement would be hard-pressed to find the logic in letting you get away with orals. With that in mind, testosterone injections are also a bit of a mental burden. Staying with the long-acting forms, I try to restrict using them in such patients to every week or two for just this reason.


A Question of Irony

All this begets a rhetorical question: Isn't it ironic that the abuse of anabolic steroids and the way they ravage your body and rob you of so much, can still leave some with a dependency on its use? It kind of reminds me of that old man "Red" in the movie "The Shawshank Redemption" who, after a near lifetime in prison, was finally released only to find that he had become incurably dependent on the very prison that confined him all those years because it defined his existence. Red couldn't deal with life outside the prison and hung himself. Unfortunately, I know former bodybuilders like that. Far too many tragic cases come to mind.

The saddest thing is seeing the next generation of pumped up egomaniacs screaming their way through workouts, oblivious to their own human frailty and in love with someone they think is themselves. Cats in the cradle. The take-home message in all this is that glory days do fade. After that, what you are left with is you.

So, in summary, as increasing numbers of those with a significant history of anabolic steroid abuse check in with Father Time, I suspect many more casualties will float to the surface in the wake of the steroid express as it speeds indiscriminately from port to port. Has it visited your port yet? At least now you now know what to look for and what to do when it does!