On May 7, 2009, L.A. Dodger outfielder Manny Ramirez was suspended for 50 games, losing $7.7 million in salary after he admitted to having used a substance called human chorionic gonadotropin, or HCG. A few ill-informed reporters noted that this meant the baseball star was caught using anabolic steroids, but HCG is not a steroid. It’s a protein-based hormone most associated with pregnancy and fertility. Many pregnancy tests work by detecting higher counts of HCG, since the substance rises early in pregnancy. At one point, HCG—along with an extreme diet only of 500 total daily calories—was touted as promoting bodyfat loss. The HCG diet plan is resurrected every few years, despite the absence of scientific evidence for its effectiveness.
The question: Why would a professional male athlete use the stuff? The answer: HCG is very similar to luteinizing hormone, which is secreted by the anterior pituitary gland. LH is involved in female fertility but also controls testosterone synthesis in the Leydig cells of the testes. Bodybuilders have injected HCG—it’s a protein, so it must be injected—to kick-start their own testosterone production after extended anabolic steroid regimens. Doctors also use it to treat men who have used steroids and have depressed testosterone levels after getting off the drugs.
The implication is that Ramirez used HCG following an anabolic steroid regimen. Somehow, admitting to the use of HCG rather than steroids seems less severe, although there is little other reason for a healthy athlete to use it. The whole matter is moot, as the Los Angeles Times reported that Ramirez was suspended because his testostosterone-to-epitestosterone ratio was 4-to-1, 1-to-1 being the normal ratio. That means that he likely did use testosterone injections.
The steroids-in-sports issue is subject to heated controversy. In one corner you have a group that sees nothing wrong with using performance aids, noting that there are rarely any medical complications from their use among healthy athletes. That, of course, avoids the ethical issue: that using steroids and other so-called performance drugs is a blatant form of cheating and detracts from the nobility of being an athletic champion. On the other hand, no drug alone can produce a champion. Training, skill and genetic makeup all play prominent roles in determining who rules the athletic roost.
Indeed, if we were to literally follow the rule of no unfair advantage, we’d ban athletes born with certain genetic mutations from all sports competitions: those born minus genes that code for myostatin; those born with ACTN3 mutations; those with mutations in the ACE enzyme and so on. Although athletes with those mutations are without a doubt “natural,” they possess advantages over athletes not as genetically gifted.
Rare as they are, complications arising from steroid use do occur. Perhaps the primary problem in that regard is that some people may have occult medical problems that become evident following their use of steroids. Complications can range from cardiovascular disease to more benign conditions, such as hair loss and acne.
The medical literature often reports on case studies showing adverse effects of anabolic steroids, but no scientist in his or her right mind would think that a case study proves a cause-and-effect relationship between steroid use and medical complications. Rather, the studies are meant to alert physicians to potential problems. So what follow are a few recently reported case studies involving anabolic steroid use.
The connection between anabolic steroids and blood clotting is controversial. The majority of serious adverse effects, including a few deaths, have involved cardiovascular complications. Most heart attacks and strokes are initiated by a clot that occludes an artery in a heart with blood vessels already narrowed by atherosclerosis. A few bodybuilders have had minor heart attacks and strokes, although a direct cause and effect has never been established between those symptoms and anabolics. One study showed that high-dose testosterone injections increase hematocrit, or concentration of red blood cells.1 Thicker blood increases the risk of internal clot formation and boosts the risk of stroke. The higher the dose of testosterone, the greater the effect on hematocrit. High doses can also raise blood pressure, lower protective high-density lipoprotein and adversely affect heart muscle structure. Those effects, however, are offset by the good nutrition and exercise practices of most bodybuilders and athletes, which explains why you rarely see them dropping dead from heart attacks or strokes.
But there can be exceptions. A 19-year-old bodybuilder showed up at a medical clinic with a significant swelling of his left leg.2 He was otherwise healthy and had no family history of abnormal clotting. Tests revealed that the swelling resulted from a clot, which was treated with anticoagulants. The same man returned to the clinic two years later, this time complaining of shortness of breath, chest pain and fever and spitting up blood. Those are signs of a pulmonary embolism, or a blood clot in the lung, which can rapidly prove fatal. He was again given anticoagulants but woke up in the morning with nausea and headache. That proved to be caused by a subdural hematoma, or blood clot on the brain. Further tests showed that he had a genetic deficiency of protein C, which protects against excess clotting.
It turned out that the bodybuilder used high doses of Dianabol. When asked how much he took, he replied, “Usually a handful”; it came in five-milligram tablets. That reminds me of the time I witnessed a well-known bodybuilder casually gulp down an entire bottle of Anavar following dinner by just pouring the pills into his mouth like candy. The point is, this guy wasn’t aware of his clotting problem, which was likely accentuated by his use of Dianabol. Fortunately, he received treatment in time and survived with no complications. Would he have had the pulmonary embolism without using steroids? Difficult to say, but the fact that he had no clotting problems prior to using the steroid does suggest some involvement.
Another case ended more tragically. An autopsy on a 29-year-old man found dead in his house discovered that he had used large doses of the anabolic steroids nandrolone, a.k.a. Durabolin, and testosterone.3 You recall the normal ratio of testosterone to epitestosterone is 1-to-1. This guy showed a 35-to-1 ratio. The cause of death proved to be rare: pulmonary peliosis, characterized by blood-filled cysts in his lungs, which resulted in massive internal hemorrhage and lung collapse.
An earlier case of pulmonary peliosis in a steroid user involved a hospitalized man given Anadrol long-term to treat anemia. (Anabolic steroids are no longer used to treat that particular condition, which is a complication of kidney failure.) Most cases of peliosis in steroid users occur in long-term users, such as hospitalized patients, and happen in the liver. Steroids have, however, been implicated in a few deaths of unhospitalized people, such as the Austrian professional bodybuilder who died several years ago of massive internal bleeding. While liver enzyme abnormalities are common in those on high-dose oral regimens, peliosis hepatitis, as the liver version of the disease is called, is rare.
Another case study links steroid use to multiorgan damage in a 24-year-old man who worked out regularly and didn’t drink alcohol.4 He did, however, inject himself three times a week with testosterone for two months prior to his reported symptoms. His diagnosis was acute pancreatitis, or inflammation of the pancreas, acute kidney failure and elevated blood calcium. Doctors attributed his problems to his very high blood calcium and his steroid use, although the precise amount of testosterone he injected wasn’t disclosed. Curiously, abnormal elevation of blood calcium is almost never observed in athletes who use anabolic steroids.
A recent report involving two young men, aged 21 and 30, attributed their acute kidney injury to their use of steroids and vitamins.5 While liver and blood lipid abnormalities are common in those on high-dose steroid regimens, kidney problems are rare. A 1994 case study described a 26-year-old man who developed severe cholestasis—failure of bile circulation due to liver inflammation—and acute kidney injury after using a veterinary form of stanozol, or Winstrol. The swelling was thought to have caused his kidney problem. A 1999 report documented similar problems in another young man who used Dianabol. He recovered rapidly after being treated with a drug used to promote bile flow in his liver.
In the more recent cases the two men were also taking a veterinary supplement containing massive amounts of vitamins A, D and E. The extreme dose of vitamin D resulted in high blood calcium, which produces volume depletion and constriction of the blood vessels in the kidney and, often, kidney damage. Calcium deposits in the kidneys can lead to renal failure. While vitamin D is more often in short supply in most people’s diets, these guys were taking 17,500,000 units once a week. The suggested dose for vitamin D is between 2,000 and 4,000 units daily, and exposure to sun for 30 minutes can produce 10,000 units of D in the skin. No wonder they had kidney problems.
Despite the obvious cause of the men’s problems, the doctors writing the case study attributed their kidney problems to the excessive vitamin intake and anabolic steroids, though the steroids weren’t named. They appear to have based that conclusion on the few reports of kidney problems related to steroid use. Trouble is, most of the prior studies also involved liver problems, and none involved massive, possibly toxic, intake of fat-soluble vitamins. Anabolic steroids here were more than likely innocent bystanders.
While recent headlines about steroid use in sports have focused on baseball, football has been linked to steroid use for years. When you compare the size of today’s pro football players with those of years past, you have to wonder what’s going on. I was asked to give a talk to pro players at a meeting of the National Football League Players Association 22 years ago. My talk was on the topic of how to build muscle without using drugs. After my presentation, though, the players gathered around to ask me about “the best steroid cycles.” They all claimed not to want to use drugs, but since most were linemen, they felt the drugs were a necessary evil for the size they needed to successfully compete.
A recent study surveyed 2,552 retired football players about their competitive use of anabolic steroids.6 Of the responding players, 9.1 percent reported having used steroids. As I found, most were line players, with 16.3 percent of offensive-line and 14.8 percent of defensive-line players using. The retired pros reported a variety of musculoskeletal injuries that they linked to drugs, including disk herniations, knee injuries, elbow injuries, neck injuries, spine injuries and foot, toe and ankle injuries. Interestingly, none reported any connection between steroid use and tendon injuries. Prior studies involving animals had shown that steroids may adversely affect tendon function.
Perhaps the most famous case of a pro football player and steroids was that of Lyle Alzado. Alzado was a ferocious lineman—his famous line was, “If King Kong and me went into an alley, only one of us would come out, and it wouldn’t be the f—in’ monkey.” Years ago he wasted away from the effects of a brain tumor. Alzado attributed his disease to his 26 years of using anabolic steroids without a break. Privately, however, he felt that the tumor got legs from his use of growth hormone, which he added to his regimen when he returned to football at age 40. While some studies do implicate growth hormone in brain tumors, the effect is more theoretical than actual. Children with GH deficiency are treated with GH for years and have no increased incidence of brain tumors.
I suspect that most football injuries stem from the violence inherent in the sport itself rather than from any particular drug use. Few pro football players retire without some kind of chronic injury. On the other hand, a good case can be made for the notorious “’roid rage” shown by some players, such as one guy with the same initials as a popular fruit juice.
Editor’s note: Jerry Brainum has been an exercise and nutrition researcher and journalist for more than 25 years. He’s worked with pro bodybuilders as well as many Olympic and professional athletes. To get his new e-book, Natural Anabolics—Nutrients, Compounds and Supplements That Can Accelerate Muscle Growth Without Drugs, visit www.JerryBrainum.com. IM
1 Coviello, A.D., et al. (2008). Effects of graded doses of testosterone on erythropoiesis in healthy young and older men. J Clin Endocrin Metab. 93:914-919.
2 Alhadad, A., et al. (2008). Pulmonary embolism associated with protein C deficiency and abuse of anabolic-androgen steroids. Clin Appl Thromb Hemost. In press.
3 Vougiouklakis, T., et al. (2009). First case of fatal pulmonary peliosis without any other organ involvement in a young testosterone-abusing male. Foren Sci Int. 186(1-3):e13-6.
4 Samaha, A., et al. (2008). Multi-organ damage induced by anabolic steroid supplements: A case report and literature review. J Med Care Reports. 2:340.
5 Daher, E.F., et al. (2009). Acute kidney injury due to anabolic steroid and vitamin supplement abuse: Report of two cases and a literature review. Int Urol Nephrol. 41(3):717-23.
6 Horn, S., et al. (2009). Self-reported anabolic-androgenic steroid use and musculoskeletal injuries. Am J Phys Rehabil. 88:192-200.