Side Effects
All drugs have the potential to cause side effects and anabolic steroids are no exception to this. The cause of the side effects may be due to an individual having an unusual reaction to the drug or it may be related to using too much. It must be remembered that what one person can use safely, may be dangerous to another. As a rule of thumb the more steroids used the greater the risk of side effects and the more serious they are likely to be. However, there are also instances of people reacting adversely to low doses of steroids. There may also be evidence of taking other drugs, which can exaggerate the steroid effects. Potential effects can be reduced or avoided by being aware of the problems. Many but not all of the side effects are of a temporary nature and will resolve within some weeks of ceasing the drugs. Knowledge of the side effects will allow you to recognise early signs and thus reduce the overall risks

Skin
Acne is a common side effect of steroid use and is commonly seen on the back. The larger the amount of steroid used, the greater the likelihood that acne will develop. To help to minimize the risk, it is helpful to ensure that the skin is kept clean and oily substances avoided. The acne develops slowly and should be watched for by those who believe that they may be susceptible to the problem. Once it shows signs of developing, all steroids should be discontinued. The acne should abate over a period of 3 to 4 weeks. If this does not occur, medical advice should be sought, being sure to tell your physician that you have used steroids. Some users develop a fine follicular rash over the trunk after some 3 or 4 weeks use of the drug. This is not acne but a follicular dermatitis, which should disappear when steroids are stopped.

Breasts
Gynaecomastia is a condition in which the mammary glands, or breasts, enlarge and become sore and tender to touch. It is due to the chemical change in testosterone brought about by a process called aromatisation, when the male hormone is converted to a form of oestrogen, the female sex hormone. There is initially a sore feeling in the breast. A skin ridge appears on the outer side of the areola together with a halo appearance around the area but no swelling. As the course continues, a swelling develops and it becomes tender. Fatty tissue builds up around the area and the breast becomes prominent. At times there may be a secretion of f luid from the nipple when it is squeezed. Steroids should be stopped. If recovery does not occur by the end of 2 months, surgery should be considered. Other causes of gynaecomastia that may need to be considered are the use of medications such as Tagamet, a treatment for gastric problems, HCG and spironolactone. Some body builders use this latter drug to reduce body fluid. Occasionally boys in the post-pubertal phase develop breast enlargement due to endocrine imbalance totally unrelated to steroids.

Heart
There have been cases of people who have used anabolic steroids suffering from a heart attack and dying. This group has shown evidence of coronary artery blockage that was responsible for their deaths. It is therefore important for anyone considering the use of anabolic steroids to have a medical check up before starting to use steroids. Raised total cholesterol and low levels of High Density Lipoprotein Cholesterol (hdl) are known to predispose to heart disease and should be measured before starting steroid use. Total Cholesterol is little affected by steroids but the drug sometimes lowers hdl (good cholesterol) and increases Low Density Lipoproteins ldl (bad cholesterol). The lowering of hdl levels is due to the effect of the steroid on the liver and this applies to injectable as well as oral drugs. Cardiomyopathy, a disease of heart muscle, has been recorded in anabolic steroid users. It presents usually as a form of weakness and breathlessness and needs medical advice for its evaluation. Hypertension, or high blood pressure, has been reported with steroids but there is little evidence to support a cause and effect mechanism. Any high blood pressure might not be caused as a direct result of steroid use but may be associated with other side effects such as heart liver or kidney problems. If there are any symptoms that suggest heart disease, a medical opinion should be sought immediately. The principal complaints might be shortness of breath with or without effort, chest discomfort and feelings of faintness.

Fluid Retention
There are some people who retain excess fluid when on a course of steroids and feel bloated. This is most easily seen in the face and around the neck region. It generally disappears within a few days of stopping the drug. Should this not happen, medical advice should be sought, as there are other causes of water retention. As a consequence of the water loss, there will be a loss of weight in that period, but this does not indicate a loss of muscle mass as this f luid is in the space between muscle fibres and not inside the fibres. This is not an indication to increase the amount of steroid used in the next course, as a lack of steroid is not the cause of the condition. More steroid will accumulate more fluid and lead to a greater loss of weight and size at the end of the course. It does not occur in every user to a degree where it is obvious, but many athletes report a sudden loss of weight after the first few weeks of f inishing a course and this is almost certainly due to water loss and not loss of muscle mass.

Aggression
Aggression can take many forms:

• Physical assault
• Indirect hostility
• Irritability
• Negativism
• Resentment
• Suspicion
• Verbal hostility

It is important that all anabolic steroid users study their own reactions to the drugs. When it becomes apparent that any of the above states is becoming evident, then the user should stop. The user should take time to assess his position. Not all drugs cause the same feelings, as there are minor chemical differences between the drugs that affect their metabolism in the emotional centres of the brain. Large doses are not only wasteful but also lead to more problems with the emotional symptoms.

Liver Changes
Many steroids cause changes in liver function as shown by alterations in the liver function tests. This is most frequently seen with the oral preparations that are alkylated at the C-17 position. There have been cases of jaundice reported when steroids have been used but these have often been in patients who used unusually large doses or who were suffering from medical diseases. Peliosis hepatica, a condition in which there are blood filled sacs in the liver has been found in people using steroids. Liver tumours have been noted in people who used anabolic steroids. It is difficult to prove cause and effect, but in some people the tumours have decreased in size after withdrawal of the steroid, suggesting that the drug may stimulate tumour growth rather than cause it

Sexual Disturbance
Anabolic steroids may cause a disturbance in sexual function. The use of anabolic steroids depresses the formation of the pituitary hormones that affect the function of the testis. Follicle Stimulating Hormone (fsh) is responsible for the formation of sperm and Luteinising Hormone (lh) stimulates the formation of testosterone. Both of these functions are suppressed, at least in part, by anabolic steroids and it is inevitable that the size of the testis will be effected to some degree with their use. This decrease may not be noticed by the individual but is present nevertheless. The degree of decrease in size of the testes varies among users and at times can be quite obvious. The prolonged use of anabolic steroids will cause a greater loss of size than a short course and the higher the dose, the more likely it is that the testes will decrease in size to a notable degree. Following the cessation of the drug, the testes usually return to their normal size, but in those who have used long or high dose courses it is not uncommon for the changes to persist for many months even up to a year or two. If the reduction of the testes persists, medical advice is needed to restore the bulk of the testes and even then, the recovery may be prolonged. The reduction in Follicule Stimulating Hormone decreases the amount of sperm and decreases the likelihood of pregnancy but this is not a guarantee of contraception. Extended courses may lead to a temporary sterility lasting several years possibly even permanently. Steroids have an effect on libido. This varies widely from over stimulation to a total loss of libido. When the latter occurs, the athlete should cease the course and wait for the expected return of the sex drive. This does not always happen as the sexual act is a very complex act and there are many causes of impotence. The cause of the loss of libido is not a lack of testosterone. It is due in most cases to outside influences and a few shots of steroids will not fix it but make it worse. In women there is sometimes an increase in libido when using the drug but this will return to normal on cessation.

Bleeding
Anabolic steroids cause a lengthening of the bleeding time and this can lead to bleeding from the nose, mouth or other orifice. If this occurs and does not settle quickly, or is recurrent, a doctor should be consulted to ensure that there is no serious clotting deficiency that could put a user in a precarious position as a result of a sudden bleed after little trauma such as forcibly blowing one’s nose. It goes without saying that the doctor should be told of the history of steroid use. There is evidence of some athletes suffering a stroke when using steroids due to clot formation, the opposite of bleeding. The clotting mechanisms are very complex and these events are usually associated with large doses. To date the research into this area has not fully explained the different results of steroids on the clotting mechanisms. Similar events have been described in women using the contraceptive pill.

Hair Loss
Balding is part of the genetic make up of many males. In any male who has a predisposition to it the use of steroids may speed up the process. It should be noted that a hair loss might occur in men who have never used a steroid.

Insomnia
If it is difficult to sleep when using steroids the best approach is to cease the drug. Using sleeping tablets will not cure the problem and may have a hangover like effect.

Tendon Damage
Anabolic steroids strengthen muscle and not tendon and there is an increased likelihood of tendon rupture in the users. The event is sudden and demands immediate attention. The most common tendon affected is the biceps tendon and the tear may be partial or complete. It is important that there be no further use of the arm until the problem has been fully evaluated by a doctor. The other frequent site for muscle rupture is in the quadriceps group.

Young People
Anabolic steroids have been reported to be associated with stunting of growth in adolescents. The steroids may lead to premature closure of the epiphyses of the bone. This is the growing part of the bone and once union at that site has occurred, no further increase in height is possible. This will decrease the future benefits of steroids for those interested in appearance or body building competitions. Once this has happened there is no method by which it can be reversed interest to the older male who uses these substances as this age group in particular is susceptible to urinary blockage due to swelling of the gland. If there is a difficulty in passing urine in the form of trouble in starting the flow, anabolic steroids should be ceased and medical attention is needed. It is important to establish the correct diagnosis early to enable simple curative measures to be undertaken. Even the young person needs to consider this side effect when faced by urinary problems

Infections
The commonest infection during the course of steroid use is the one due to lack of sterility in the technique. It can be avoided by using a new syringe and needle for each injection and making sure that the hands are washed before any preparation is done. The infection will show up as an abscess at the site of injection. This may be superficial or deep – the latter may take several days to develop. Once there is a suspicion of an abscess formation medical help is needed immediately Anabolic steroids have also been known to have an effect on the immune system and some users have been known to complain of having more colds when using steroids. The other source of infection comes from sharing injecting equipment. This is one way HIV and Hepatitis are spread.

Women and Side
Effects Anabolic steroids can produce unwelcome side effects in a female user and it is very important that the initial signs be recognized early. The development of deepening of the voice is a sign of virilisation. Once this has been detected, the drug must be stopped to allow some degree of recovery. The recovery may not be complete in all cases. Any hoarseness that remains after 3 months is likely to be permanent. Clitoral enlargement is not an obvious disability in the early stages and is often ignored for that reason. Skin changes are obvious in many women. Change in texture of the skin is the first abnormality seen. The development of facial hair is of two types, namely, a fine downy hair over the face that will disappear on stopping the drug, and a darker hair in the beard area. This latter hair is likely to remain. Irregularity of periods or, at times, a total cessation of them, may be due to steroids. As courses should only be of 6 weeks duration at the most, it is often hard to be sure that the absence of a period is due to steroid use. Courses of longer duration are more likely to cause longer periods of amenorrhoea and so require a longer spell of steriod abstinence. It is important that if another course is contemplated, a resumption of periods must be awaited before starting the next course. Pregnancy is the commonest reason for missed periods and needs to be eliminated before any other treatment is considered. Once this has been done, any glandular abnormality should be investigated