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Anabolic steroids and male reproductive health

October 11, 2019

Anabolic-androgenic steroids (AAS) are the most used substances for improving muscle strength, mass and performance. Most users are not competitive athletes and a portion of the users are adolescents. This phenomenon has become increasing common among ordinary exercisers and amateur gym goers.

When using steroids, users try to maximize the anabolic (i.e. tissue growth-stimulating) effect and minimize the androgenic (i.e. male type) effect. The anabolic/androgenic ratio of testosterone is 1:1. In actual anabolic steroids, this ratio varies and can be even over 30. Steroids can be processed in many different ways to achieve a certain kind of effect and not all preparations are used to pursue great muscle mass.

The impact of androgyny is dependent on the dosage and how long steroids are used [1]. To maximize the desired effects while avoiding the undesired ones, other hormone preparations are often used simultaneously as well. Because the balance between androgen and estrogen in the tissues changes, users try to prevent the adverse effects with other preparations. Accordingly, the websites selling anabolic steroids often offer packages that include androgenic preparations, but also pharmaceutical substances to treat the adverse effects. These substances are associated with health hazards of their own.

Anabolic androgens have a significant effect on gonadal function, causing one’s own testicular androgen and sperm production to fail. The effects are individual-specific and they cannot be predicted.

Testicular function and its disruption

The function of the testes is to produce sperm and secrete testosterone (i.e. the sex hormone). Normal testosterone production generates masculine sexual characteristics and ensures high testosterone concentration in the testes (several dozen times higher than the levels found in the blood circulation) that is indispensable for normal sperm production.

Testicular function is controlled by the pituitary gland, or hypophysis. Anabolic androgens administered from outside the body prevent the regulation of normal hypophysis function.  In the absence of pituitary regulation, the testosterone production of the testes and its concentration decrease and, as a consequence, sperm production decreases and may cease totally. Anabolic steroids induce a dose-dependent dysfunction in the pituitary-testicular axis, preventing the secretion of gonadotropin hormones, which are born in the pituitary gland and accelerate testosterone production. This leads to decreased body testosterone production, diminished testicular size, and disrupted sperm production. Infertility may then be the consequence. Exogenously administered testosterone cannot bring about a high concentration of testicular testosterone; in fact, it will decrease it because the concentrations of the gonadotropins, which are secreted by the pituitary gland, and which accelerate testosterone production, will fall.

The effect of anabolic androgens on sperm production is all too known among physicians who treat childlessness. According to some studies, about 25% of anabolic steroid users had no sperm production while in about 50% of them the sperm production was lower than normal. Only 25% of the users had normal semen [2, 3]. Anabolic steroids also have an effect on the structure of the sperm. Especially in teenagers, anabolic steroids may cause permanent damage to sperm production.

Effect of anabolic androgens on sexual desire

Sexual desire, or libido, is mostly controlled by testosterone. Anabolic steroids can increase the libido. The heightened libido may be a problem because high androgen doses may also increase violence.

A highly common problem following use is that the body’s testosterone production goes into hibernation, as it were. This is a problem faced by almost all users. In that case, the testosterone concentration in the blood circulation is insufficient for normal libido and the hormone imbalance causes sexual apathy. In addition to this, testosterone deficiency is associated with many other kinds of symptoms and health hazards.

Very low testosterone concentrations may also cause erection problems and psychological symptoms. When, for example, one’s weightlifting results fall drastically at the same time, the risk of a new round of the androgen cure tends to grow.

Other health hazards of anabolic androgens

Recently, people have become aware of other wide-ranging adverse effects of anabolic steroid doping, some of which also affect reproductive health at least indirectly. Some users exhibit psychiatric symptoms and severe mood disorders, such as hyperactivity, irritability, aggression, attention disturbances, reckless behaviour, as well as psychotic symptoms and suicidal thoughts and actions. Only some users have these and no one knows precisely what the mental state of these users was before they became users.  There is strong evidence of harm to the heart: people who have used anabolic steroids have cardiac muscle changes involving the weakening of the cardiac pump function. The cardiac muscle changes may be partly reversible if steroid use is discontinued, but if the use of anabolic steroids has led to cellular destruction in the cardiac muscle, the changes are irreversible. Harm to the liver may lead to a liver transfer or the loss of life.

Examination of the effects and their treatment

Anabolic steroid users are somewhat aware of the problems caused by anabolic steroids, but they do not bring up their use, for example, at a doctor’s appointment. Thus the harm caused by these may be left undiagnosed and treatment cannot be carried out in an optimal way. At the same time, general practitioners may have extremely superficial knowledge about the significance of using anabolics.

Some of the clues of long-term use, which can be observed during a medical examination, include the typical habitus, but also the side effects of androgen treatment: for example, acne, breast growth, stretch marks, and possible needle marks. In addition, laboratory tests may show high hemoglobin and low high-density lipoprotein (HDL) cholesterol (i.e. “good” cholesterol), as well as abnormal liver values. As a result of prolonged androgen use, testicle size may have diminished considerably.

The effect of anabolic androgens on the reproductive functions depends considerably on the preparations used, the doses, and the period of use. The hormone tests that depict testicular function show typical anomalies.  In a substantial number of users, semen examinations show a total absence of sperm. It should also be remembered that the use of anabolic androgens does not preclude other reasons for male infertility.

The changes caused by anabolic androgens were previously thought to be reversible, but for some of the harm this is evidently not the case. Serious harm of the kind affecting the heart or the liver may leave damage to the rest of one’s life: damage, such as heart failure, sudden death or the need for a liver transplant when liver function becomes badly damaged.  The recovery of testosterone and sperm production may take a long time and many people find it difficult to wait patiently.  Even then, these functions will recover in all cases. As a rule, the most efficient and effective treatment is easy to see: discontinuing the use of anabolics. A precondition for treatment success is that the individual understands the factual connections and the duration of recovery.

Maintaining the physiological testosterone concentrations through testosterone replacement therapy may be necessary in the recovery phase if the hypofunction has been severe and prolonged. However, there is a possibility for the risk of abuse. Replacement therapy entails a confidential therapeutic relationship. This must take into account the fact that even physiological replacement therapy delays the recovery of sperm production and therefore the therapy has to try to keep a balance between unpleasant testosterone deficiency symptoms and one’s future health.

Antti Perheentupa
M.D. h.c., Docent
Reproductive Medicine and Andrology
Specialist Doctor of Gynecopathies, the Department of Obstetrics and Gynecology in Turku University Hospital
Biomedical department/Physiology, University of Turku

Updated by

Leo Niskanen
Doctor of Medicine (MD), Docent,
Specialist in Endocrinology and Internal Medicine
Helsinki University Hospital


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