Introduction
Clinical laboratory tests provide information in order to evaluate and diagnose patients health . Before the onset of an Anabolic Androgenic Steroid (AAS)cycle, the steroid candidate has to undergo specific health assessment,for his overall health condition and identify possible medical conditions that may place him at risk. He may be affected by conditions that do not have overt symptoms and that can only be detected by laboratory tests. (1)
Getting into a cycle, he will stress some of his vital organs (heart,liver and kidneys). Adverse effectsand possible tissue damage is dependent on various parameters, such as age, time of steroid abuse, dosage of AAS/PEDs, type of AAS, pharmaceutical forms, number of different AAS used simultaneously or consecutively (stacking), life style, proper nutrition and supplementation, medical prevention rules, presence of underlying congenital abnormalities, family history (genetic predisposition). [2]
Dislipidemia, transaminemia , erythrocytosis and azothemia are among the commonest distortions. On the other hand, during the course of a cycle things may get even worse and perhaps the user will be forced to cease the cycle. After the end of a cycle, when post cycle therapy is through, the former user of AAS has the obligation to undergo specific laboratory evaluation (biochemical and hormonal) in order to monitorhis medical condition and possible unwanted effects. [2,3,4,5]
Laboratory evaluation before and after the end of a steroid cycle
Laboratory evaluation should be performed before, or after and not during a cycle-unless a serious medical reason exists. The assessment includes:
BLOOD/URINE TESTS
– Hematological profile:
Complete Blood Count (CBC) with Differential: Hematocrit (Hct), hemoglobin (Hgb), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), percentage and absolute differential counts, platelet count, red cell count, white blood cell count, Iron (Fe), Ferritin (Fer), Folate (folic acid) Cyanocobalamine (B12)
– Renal profile:
Urea (Bun), Creatinine (Crea), Uric acid (UA), Glomerular Filtration Rate (GFR), 24h creatinine urine clearance and urinalysis
– Lipid Profile:
Total Cholesterol (CHOL), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides (Trig), homocysteine (Hcy),Lipoprotein A (LPA), Apolipoprotein A (Apo A),Apolipoprotein B (Apo B)
– Hepatic profile:
Alanine aminotransferase(SGPT/ALT), aspartate aminotransferase(SGOT/AST), gamma-glutamyl transferase (γGT),alkaline phosphatase(ALP), Bilirubin (BIL), Lactate dehydrogenase (LDH)
– Metabolic Profile:
Glucose, HbA1c, total protein, albumin (ALB), globulin,A:G ratio, Sodium(Na), Potassium(K), Calcium(Ca), Magnesium(Mg), Phosphorus(P), Chloride (Cl)
– Creatine phosphokinase(CPK), CK-MM, CK-MB.
CPK is expressed by various tissues (skeletal, cardiac muscle). This test is not specific for the type of enzyme that is elevated. The laboratory is able to distinguish between the different components of this enzyme. For example, the fraction coming from skeletal muscle is referred to as CK-MM and the one from heart muscle is designated as CK-MB.
– Coagulation tests:
INR, activated partial thromboplastin time (aPTT),Prothrombin time (PT), thrombin time (TT), Fibrinogen (FIB)
– Hormonal profile (Evaluation of HPTA, spermatogenesis, libido and fertility):
Follicle stimulating hormone (FSH), Luteinising hormone (LH),Total Testosterone (TT), Free Testosterone (FT),Beta Estradiol (E2), Prolactin (PRL),Sex hormone-binding globulin (SHBG)
Measurements should be performed during am hours, since they are on their peak levels. [6,7]
– Thyroid Profile:
Thyroid-Stimulating Hormone (TSH), Thyroxine (T4), Free T4 (FT4), Triodothyronine (T3)
Free T3 (FT3), ANTI-TPΟ, ANTI TG, U/S of thyroid gland.
Thyroid gland’s metabolism that reflects on BMR, proper thyroidal function, size of the gland or any scenario of possible nodulation is detected.
– Tumor markers:
Carcinoembryonic antigen (CEA), CA 19/9, Alpha-fetoprotein (AFP),Prostate-specific antigen (PSA), and FREE PSA.
Many different tumor markers have been characterized and are in clinical use. Some are associated with only one type of cancer, whereas others are associated with two or more cancer types. They reflect on specific tissues, such as lungs, testicles, large intestine, prostatic gland, visceral organs. Tumor markers (CEA, AFP, PSA, CA 19-9) are reliable in case of particular inflammations, but also for the evaluation of the specific disease. However they are valuable for those who wish to use growth factors (HGH,IGF1,FST, MGF peptides), since somatropin, somatomedin C, Mechanic Growth Factor ,Follistatin and GHRH peptides are responsible for cellular growth, that leads to proliferation, tissues growth and eventually to oncogenesis of a cancer.
There are some limitations to the use of tumor markers. Sometimes, noncancerous conditions can cause the levels of certain tumor markers to increase. In addition, not everyone with a particular type of cancer will have a higher level of a tumor marker associated with that cancer. Moreover, tumor markers have not been identified for every type of cancer. Tumor markers are used to help detect, diagnose, and manage some types of cancer,pr inflammatory disease (cancer is the result of chronic inflammation).Although an elevated level of a tumor marker may suggest the presence of cancer, this alone is not enough to diagnose cancer. Therefore, measurements of tumor markers are usually combined with other tests, such as biopsies, CT. [8]
All these laboratory tests should be counted after 12 hours of fasting, with proper hydration. Cholesterols fragments and triglycerides monitoring require clean diet the day before, in order the results to be properly measured.
CARDIOVASCULAR ASSESSMENT
A typical cardiovascular check up includes:
– Evaluation of blood pressure
– Frontal X-ray of the thoracic cavity, that reveals the shape of the heart (front image) and assessment of the cardiothoracic index.
– Electrocardiogram (ECG), that reveals any recent or former AMI (acute myocardial infarction), arrhythmias (ventricular or atrial), LVH (left ventricular hypertrophy).
– Echocardiography (Triplex U/S), which illustrates the size and functionality (estimated ejection fraction) of all cardiac chambers, valves, the presence of structural abnormalities in the myocardium. Furthermore the ascending aorta and aortic arch is illustrated and tested for their morphology and functionality.
It should be noted that cardiovascular abnormalities, such as hypertrophic cardiomyopathy, right ventricular cardiomyopathy (cor pulmonare),or congenital coronary arteries anomalies are typically silent until a potentially fatal arrhythmia occurs, but may in some cases be detected through a careful cardiovascular examination. [9]
– If necessary, 24 hrs Holter monitoring(rate, rhythm, blood pressure), stress test/echo (U/S) or even coronary magnetic resonance imaging (CMR), known as cardiac MRI, could be performed.
Coronary MRI is superior to other imaging techniques. The technique has a key role in evidence-based diagnostic and therapeutic pathways in cardiovascular disease. Its applications include assessment of myocardial ischemia and , cardiomyopathies, myocarditis, vascular diseases (endothelial dissfunction),conditions that are adverse effects of AAS abuse. It is the reference standard for the assessment of cardiac structure and function and is valuable for diagnosis and surgical planning in heart disease. [10]
IMAGING STUDIES
Ultrasound(U/S), computed tomography scan (C/T) of the abdominal cavity could reveal fatty liver (NAFLD),hepatic peliosis, hepatic/bile tumors, either adenoma or hepatocellular carcinoma (hepatoma). A pelvis MRI could be performed, complementary to other imaging techniques, if the presence of a prostate cancer should be excluded.
This check up has to be performed once a year.
Laboratory Values Interpretation
Possible causes of elevated laboratory values along AAS abuse are:
– Htc: Erythrocytosis from AAS abuse, smoking, dehydration (falsely elevated due to increase in plasma concentration), living at high altitude (>2000 m)
– Urea: Positive nitrogen balance-azothemia, dehydration, renal failure
– Creatinine: rhabdomyolysis (CPK>1000), increased creatine intake (>10gr/day), high consumption of red meat, increased muscle mass (BMI>30), non-steroidal anti-inflammatory drugs (NSAID’s) abuse, renal failure, glomerulosclerosis, tubular necrosis,aminoglycosides antibiotics
– Uric acid: increased intake of animal proteins, involved in purine’s metabolism,Gout
– SGOT (AST), SGPT (ALT): Abuse of 17 alkylated AAS per os (pharmaceutical hepatitis), acetaminophen abuse, rhabdomyolysis, over-training,alcohol consumption
– γGT, ALP: cholestasis-jaundince, alcoholism, liver cirrhosis
– Total/ conjugated bilirubin: Jaundice, Cirrhosis, pharmaceuticalhepatitis,hemolysis
– LDL, Total cholesterol: dyslipidemia, atherogenesis, SFA’s consumption, absence of EFAs (Ω-3,6,9),
– Τriglycerides: absence of DHA, EPA (omega 3 PUFA’s)
– Homocysteine:AAS abuse and high risk of cardiovascular/cerebrovascular events ,low B12,Folate
– Ammonia: Cirrhosis, Severe hepatitis, Kidney failure,high protein consumption
– Glucose, HbA1c: diabetes mellitus type 2, metabolic syndrome,insulin resistance
– INR: AAS abuse
– CPK: rhabdomyolysis, overtraining,cocaine use
– B12: DECREASE equals to megaloblastic anemia (cyanocobalamine deficiency), as a result of either malnutrition, or alcoholism
– TSH: hypothyroidism
– T3, T4: hyperthyroidism
– CEA, AFP, Ca 19-9: Tumors of lungs, testicles (seminoma), large intestine (bowel), visceral organs (liver, bile, pancreas, stomach)
– PSA/free PSA: Benign prostate hypertrophy, prostatitis
Laboratory testing is critical to the athlete who abuses AAS and physicians should be accurately informed and provide such monitoring. Each doctor is obligated to inform his patients how to preserve well being. Assessment is crucial firstly to determine the user’s current health and risks before any cycle is initiated, then to assess the direct impact of the AAS/PEDsuse and finally to evaluate the distortion or restoration of original state of good health.However,laboratory data is never a substitute for a good physical exam and patient history and clinicians should treat the patient, not only the laboratory results.
References:
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Fallon KE. Br J Sports Med. 2008 May; 42(5):334-7
2. Outpatient clinic for users of anabolic androgenic steroids: an overview.
Smit DL, de Ronde W. Neth J Med. 2018 May; 76(4):167
- Heavy testosterone use among bodybuilders: an uncommon cohort of illicit substance users. Westerman ME, Charchenko CM, Ziegelmann MJ, Bailey GC, Nippoldt TB, Trost L. Mayo Clin Proc. 2016;91:175-82
4. Hepatotoxicity associated with illicit use of anabolic androgenic steroids in doping.R. Solimini,
M. C. Rotolo,et al. Eur Rev Med Pharmacol Sci 2017; 21 (1 Suppl): 7-16
5.Cardiac and metabolic effects of anabolic-androgenic steroid abuse on lipids, blood pressure, left ventricular dimensions, and rhythm. Achar S, Rostamian A, Narayan SM. Am J Cardiol. 2010 Sep 15; 106 (6): 893-901.
- Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Pope HG Jr., Wood RI, Rogol A, Nyberg F, Bowers L, Bhasin S.Endocr Rev. 2014;35:341-75.
7. Combined effects of androgen anabolic steroids and physical activity on the hypothalamic-pituitary-gonadal axis. Hengevoss J, et al. J Steroid Biochem Mol Biol. 2015 Jun; 150:86-96.
8. https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis/tumor-markers-fact-sheet<
- Cardiovascular manifestations of anabolic steroids in association with demographic variables in body building athletes. FarzadGheshlaghi, et al. J Res Med Sci. 2015 Feb; 20 (2): 165–168.
- Representation of cardiovascularmagnetic resonance in the AHA / ACC guidelines. von Knobelsdorff-Brenkenhoff F, Pilz G, Schulz-Menger J. J Cardiovasc Magn Reson.2017 Sep 25;19(1):70.
