Steroids

The Story of a Drug

Painkillers: History, Science, and Issues

Victor B. Stolberg

Antipsychotics: History, Science, and Issues

Jeffrey Kerner and Bridget McCoy
 Steroids

HISTORY, SCIENCE, AND ISSUES

Joan E. Standora, Alex Bogomolnik,

and Malgorzata Slugocki

The Story of a Drug

Peter L. Myers, Series Editor
Copyright © 2017 by ABC-CLIO, LLC
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, except for the inclusion of brief quotations in a review, without prior
permission in writing from the publisher.
Library of Congress Cataloging-in-Publication Data
Names: Standora, Joan E., author. | Bogomolnik, Alex, author. | Slugocki, Malgorzata, author.
Title: Steroids : history, science, and issues / Joan E. Standora, Alex Bogomolnik, and
Malgorzata Slugocki.
Description: Santa Barbara, California : Greenwood, an Imprint of ABC-CLIO, LLC,
[2017] | Series: The story of a drug | Includes bibliographical references and index.
Identifiers: LCCN 2016053073 (print) | LCCN 2017001995 (ebook) | ISBN
9781610697231 (hardcopy : alk. paper) | ISBN 9781610697248 (ebook)
Subjects: LCSH: Steroid drugs. | Steroid drugs—History. | Steroids. |
Steroid hormones—Therapeutic use.
Classification: LCC RM297.S74 S73 2017 (print) | LCC RM297.S74 (ebook) |
DDC 615.3/6—dc23
LC record available at https://lccn.loc.gov/2016053073
ISBN: 978–1–61069–723–1
EISBN: 978–1–61069–724–8
21 20 19 18 17 1 2 3 4 5
This book is also available as an eBook.

Greenwood
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This book is printed on acid-free paper
Manufactured in the United States of America
This book discusses treatments (including types of medication and mental health therapies),
diagnostic tests for various symptoms and mental health disorders, and organizations. The
authors have made every effort to present accurate and up-to-date information. However, the
information in this book is not intended to recommend or endorse particular treatments or
organizations, or substitute for the care or medical advice of a qualified health professional, or
used to alter any medical therapy without a medical doctor’s advice. Specific situations may
require specific therapeutic approaches not included in this book. For those reasons, we rec-
ommend that readers follow the advice of qualified healthcare professionals directly involved
in their care. Readers who suspect they may have specific medical problems should consult a
physician about any suggestions made in this book.
 Contents

Series Foreword ix
Preface xi
Acknowledgments xiii

Chapter 1: Case Studies, by Joan Standora 1

Case Study One: Mark 1
What Happened to Mark as a Result of Taking These Drugs? 2
Case Study Two: Angie 7
A Talk with Angie 9
Lessons Learned 12

Chapter 2: What Are Steroids? by Malgorzata Slugocki 13

Natural Steroid Synthesis and Physiological Functions 14
Major Natural Steroid Groups 15
Catabolic Steroids 15
Anabolic Steroids 18
Synthetic Steroids 20
Systemic Corticosteroids and Steroid Bases 21
Topical Corticosteroids 26
Inhaled Corticosteroids 30
Ophthalmic Corticosteroids 33
Replacement Therapy 34
Contraception 34
Anabolic-Androgenic Synthetic Steroids 37
Oral Preparations 38
vi Contents

Injectable Preparations 38
Topical Delivery Systems 38
Other Delivery Systems 39
Anabolic Steroid Supplements 39
Dietary Supplements 40
Testosterone Boosters 42
Herbal Supplements 42
Non-Hormonal Steroids 43
Cholestanes 43
Cholanes (Cholic Acids) 44
Conclusion 45

Chapter 3: The History of Steroids, by Joan Standora 47

Case Study: Ms. A 62

Chapter 4: How Steroids Work, by Tae Eun Park 65

Overview of Adrenal Glands 65
Cholesterol 66
Hormonal Steroids 67
Synthesis of Hormonal Steroids 67
Chemical Structures of Hormonal Steroids 68
How Do Glucocorticoids Work? 68
How Do Mineralocorticoids Work? 69
How Do Gonadal (Androgenic or Sex) Steroids Work? 70
Non-Hormonal Steroids 73
Bile Acids 73
Vitamin D 73
Cardioactive Steroids (CASs) 74
Conclusion 75

Chapter 5: Effects and Applications, by Malgorzata Slugocki 77

Psychological Effects of Natural Glucocorticoids 77
Permissive Action 78
The Brain 78
Cardiovascular System 80
Immune System and Anti-Inflammatory Properties 80
Carbohydrate and Protein Metabolism 82
Musculoskeletal System 82
Endocrine System 83
Gastrointestinal System 84
 Contents vii

Hematologic Effects 85
Lipid Metabolism 85
Other Effects of Glucocorticoids 85
Physiological Effects of Mineralocorticoids 86
Physiological Effects of Gonadal Sex Steroids 87
Testosterone 87
Estrogens 87
Progestogens 87
Pathophysiological Effects of Steroids 88
Adrenal Diseases 89
Therapeutic Effects of Steroids and Applications in Clinical Practice 90
Autoimmune Disorders 91
Respiratory Disorders 92
Allergic Rhinitis and Seasonal Allergies 94
Disorders of the Skin 94
Organ Transplantation 95
Ocular Diseases 96
Gastrointestinal Diseases 96
Hematologic Disorders 97
Septic Shock 97
Pneumocystis Jiroveci Pneumonia 97
Chronic Adrenal Insufficiency 98
Contraception 99
Conclusion 100

Chapter 6: Risks, Use, and Abuse, by Alex Bogomolnik 101

Medical Uses and Side Effects 101
Administration and Risks 104

Chapter 7: Production, Distribution, and Regulation,

by Joan Standora 121
Production 122
Distribution 124
Regulation 126
Legalization and Decriminalization 134

Chapter 8: The Social Impact of Steroid Use Today,

by Alex Bogomolnik 137
Prevention 139
How Steroid Abuse Begins 140
viii Contents

Motivation 144
Decreasing Steroid Use 147
Conclusion 154

Chapter 9: The Future of Steroids Management,

by Alex Bogomolnik 157
Technology and Steroids 158
Internet and Steroids 158
Manufacture of Steroids Past, Present, and Future 158
Medical Steroids and the Future of Medicine 161
Genetic Doping and Its Possibilities 164
Utilization of Catabolic Steroids with Other Medical Treatments 167
Utilization of Stem Cells in Conjunction with Steroids 168
The Future of Steroids 168
Alternatives to Steroids 169
The Glove 169
Neurofeedback 170
Steroid Use among Transgendered Individuals 174
The Impact of Technology 175

Directory of Resources 177

Glossary 183
Bibliography 191
Index 207
 Series Foreword

There have been many books written about the prevalence and perils of recrea-
tional drug use. But what about the wide variety of chemicals Americans ingest
to help them heal or to cope with mental and physical issues? These therapeu-
tic drugs—whether prescription or over-the-counter (OTC), generic or brand
name—play a critical role in both the U.S. healthcare system and American
culture. This series, The Story of a Drug, explores major classes of such drugs,
examining them from a variety of perspectives, including scientific, medical,
economic, legal, and cultural.
For the sake of clarity and consistency, each book in this series follows the
same format.
In Chapter 1, we begin with a fictional case study, bringing to life the sig-
nificance of this particular class of drug. Chapter 2 provides an overview of
the class as a whole, including discussions of different subtypes, as well as basic
information about the conditions such drugs are meant to treat. The history
and evolution of these drugs are discussed in Chapter 3. Chapter 4 explores
how the drugs work in the body at a cellular level, while Chapter 5 examines
the large-scale impacts of such substances on the body and how such effects
can be beneficial in different situations. Dangers such as side effects, drug
interactions, misuse, abuse, and overdose are highlighted in Chapter 6.
Chapter 7 focuses on how this particular class of drugs is produced, distrib-
uted, and regulated by state and federal governments. Chapter 8 addresses
professional and popular attitudes and beliefs about the drug, as well as repre-
sentations of such drugs and their users in the media. We wrap up with a con-
sideration of the drug’s possible future, including emerging controversies and
trends in research and use, in Chapter 9.
x Series Foreword

Each volume in this series also includes a glossary of terms and a collection
of print and electronic resources for additional information and further study.
It is our hope that the books in this series will not only provide valuable
information but also spur discussion and debate about these drugs and the
many issues that surround them. For instance, are antibiotics being overpre-
scribed, leading to the development of drug-resistant bacteria? Should antipsy-
chotics, usually used to treat serious mental illnesses such as schizophrenia and
bipolar disorder, be used to render inmates and elderly individuals with
dementia more docile? Do schools have the right to mandate vaccination for
their students, against the wishes of some parents?
As a final caveat, we wish to emphasize that the information we present in
these books is no substitute for consultation with a licensed healthcare profes-
sional, and we do not claim to provide medical advice or guidance.
—Peter L. Myers, PhD
Emeritus member, National Addiction Studies Accreditation Commission
Past President, International Coalition for Addiction Studies Education
Editor-in-Chief Emeritus, Journal of Ethnicity in Substance Abuse
 Preface

The word “steroids” often brings to mind the misuse and abuse of anabolic
androgenic steroids—those used by a number of professional athletes over
the past twenty-five years. Yet steroids are a natural part of the human body’s
chemistry, produced in response to stress, inflammation, and other naturally
occurring events in the life of the organism. Today, synthetic steroids—called
corticosteroids—have lifesaving properties, which can be used appropriately
and effectively when prescribed and monitored by professionals in the health
care field. Our understanding of the value of these substances, both syntheti-
cally produced and naturally present, is vital to our acceptance of medical
interventions that include the use of these substances to relieve and heal a great
number of medical problems.
There is no doubt that the abuse of anabolic androgenic steroids and the
growth hormone gHb, often used together, has resulted in serious consequen-
ces for both amateur and professional athletes. Often, the loss of professional
status and income is seen as the most dramatic outcome for those who use
these chemicals. The examples range from the suspension of a major baseball
star—Alex Rodriguez—from his team for an entire year to the banning of
Marion Johnson from competition in track and field. More seriously, the
death of a wrestler’s family, at his hands, and his subsequent suicide represent
the extreme outcome of steroid use.
The reality is that the physical, psychological, and social effects of such non-
therapeutic usage may be rooted deeply into the individual’s motivation and
mental state. These factors, leading to poor health, psychiatric problems,
criminality, violence, and even death, have resulted in more stringent controls
on both the medical prescription and the illegal manufacture and purchase of
xii Preface

various steroid synthetics. Additionally, the abuse of steroid substances found

among animal handlers, such as in the illegal doping of race horses or in
attempts to increase the growth of bulls, illustrates how commonly steroids
are relied upon for illegal activities. Recognizing the dangers of these substan-
ces, President George H. W. Bush signed the Anabolic Steroids Control Act
in November 1990, which became effective in 1991. The need for additional
controls became evident, and in October 2004, President George W. Bush
signed into law a more stringent regulation of these substances, expanding
the definition of what could be considered an anabolic steroid.
What may be surprising to many people is that steroid compounds are relied
upon in numerous medical situations to heal and stabilize health conditions.
The list is a long one, and the protocols for prescribing such interventions
are complex. Managing asthma, for example, includes the use of corticoste-
roids found in inhalers, enabling the patient to breathe more freely during an
attack. They can be used, also, in the treatment of metastatic breast cancer in
women and in the treatment of anemia associated with specific diseases—
for example, kidney failure and other types of red blood cell deficiency
(DEA 2012).
To understand just how complex the substances grouped under the name
“steroids” really are, we need to understand the body’s production and use of
natural steroid-like chemicals and the manufacture of synthetic versions to
address these needs. It is important to understand the effects on body pro-
cesses, such as the endocrine and circulatory systems, physicality and physiol-
ogy, and the brain’s response to these invasive experiences. In the contexts of
family and community, as well as social and cultural factors, the use of these
substances, legal or not, has influenced our society’s ability to manage them
appropriately and safely. The regulation of drugs is a part of the law-making
responsibility of our government. To that end, becoming familiar with which
drugs are considered “controlled substances” and with how the lists of these
drugs are updated or new drugs included in this category can increase aware-
ness and caution in their use.
In this volume, an exploration of the prevalence of use among diverse pop-
ulations and in a variety of settings is supported by a review of the most recent
research, including medical practices and illegal use, as defined by the criminal
justice system. Most importantly, perhaps, are the real-life examples of indi-
viduals who have been helped or hurt by their use. The message of this volume
is that information about any substance needs to be understood before it is
used. There are lives that have been saved and lives that have been lost because
of using “steroids.”
 Acknowledgments

My thanks to Dr. Peter Myers for opening the door to authoring this book and
to Ms. Lori Hobkirk for her very patient and supportive editing of the work.
I am grateful to my coauthors for their professionalism and expertise on steroids
and their skill in conveying that information. Many thanks to Ms. Adrienne
Markowitz for her support and assistance in gathering the glossaries for several
chapters and to my family and friends who were truly interested in the project
and its completion.
—Joan Standora

I would like to thank Tae Eun Park, Julie Kalabalik, Abdilahi Mohamed,
and Rachel Rivera for their collegial friendship, as well as my husband, mom,
and children for unfailing love and support.
—Malgorzata Slugocki

I am incredibly grateful to Joan Standora for her teaching, encouragement,

and friendship, as well as Peter Myers and Lori Hobkirk for their hard work
and dedication in making this book happen. I also thank Dorothy Rau for
her wealth of knowledge, support, and motivation. To all the following I give
my great thanks whose knowledge I learned, gained, and grew from: Denise
DeBratto, Patricia Rivers-Hamm and all the staff at South Beach Addiction
Treatment Center, all the staff from YMCA South Shore of Staten Island, all
the staff at Staten Island University Hospital South Chemical Dependency
Rehab Unit, and all the colleagues who have influenced me to continue to pur-
sue my goal and stay motivated despite life’s challenges. I would like to thank
all my dear friends who have given me additional support and motivation
xiv Acknowledgments

needed for this book. Finally, and most importantly, I would like to thank my
wife Lianne, my parents Gregory and Frida, my sister Lana and grandmother
Ida, whose constant love, support, and motivation allowed me to be part of
this book. Thank you all so much.
—Alex Bogomolnik
 Chapter 1

Case Studies
Joan Standora

Although steroids are manufactured naturally in the bodies of all human

beings, many people are not aware of their vital function in keeping people
physically healthy. Instead, knowledge of steroids for a number of people in
the United States is restricted to their belief that these are illegal drugs that ath-
letes use to increase performance in their respective sports. Others may know
that synthetic steroids are useful medications for a variety of physical disorders
and diseases. In this chapter, two case studies are presented to illustrate the
ways in which steroids are viewed and used to sustain a healthy life or to
threaten a young person’s future.
Our first case study reflects the use of performance-enhancing drugs by a
young man who wanted so desperately to be different that he jeopardized his
future.

CASE STUDY ONE: MARK

Mark is an excellent athlete. As a high school junior, he was runner-up for
the school’s highest honor, “Athlete of the Year,” for his pitching and his
earned run average. He had always been serious about a career in sports, espe-
cially baseball, and worked very hard at practice and throughout the year
whenever he could. One of his favorite activities was weightlifting because he
not only liked the way it made him look, but he felt it made him stronger
and more powerful on the baseball diamond.
2 Steroids

During his sophomore year, Mark had been looking at sports and weight-
lifting magazines and spending a lot of time online reading about his favorite
athletes. During his junior year and during the winter months, he started read-
ing about performance-enhancing substances—growth hormones, anabolic-
androgenic steroids (AAS), and other medications that promise greater
strength and impressive muscle mass. Many professional athletes have been
implicated in the use of illegal steroids, but Mark did not believe that it was fair
to penalize these individuals. After all, it was “about winning,” wasn’t it?
Mark found some websites that sell these substances online. Unbeknownst
to Mark’s parents and friends, except for Jim, his best friend, Mark ordered
several bottles of the anabolic steroids and began taking them every day.
As he continued to work out at the gym, his body began to change and gain girth,
strength, and the clear definition of muscles that he had sought. Mark began to
use injectables for greater results. His performance on the baseball field demon-
strated powerful and fast pitches. He was not really surprised, either, by his
increased ability to hit the ball well and far. By his next-to-last year of high school,
he had become what some of the coaching staff thought was the best athlete that
the high school had ever had. In addition, he was being scouted by some profes-
sional baseball teams for their farm leagues.
During his senior year, however, there were other differences notable in
Mark. From the easy-going and friendly young man he had been, he became
irritable and argumentative. He appeared to be uncomfortable with his fam-
ily and began to do worse in school, academically—this, in turn, affected his
ability to stay on the team. Finally, Mark had a terrible blow-up with his
coach about his failure to attend practice regularly; as a result, he was sus-
pended from the team for two weeks. The coach decided to do a drug test
on Mark after speaking with Mark’s parents. Mark’s lab results showed him
to be positive for steroids as well as a growth hormone substance (gHb).
Mark was placed under the care of a sports physician who gradually weaned
him off of the drugs. However, Mark’s career on the team was over. When
he graduated from high school, he was no longer using these substances,
but his hopes for a professional career in baseball had been dashed as a result
of his record of use. The promise of a college sports scholarship had disap-
peared, and professional team scouts were not ready to take on a young per-
son with this type of drug history.

What Happened to Mark as a Result of Taking These Drugs?

Mark agreed to an interview with an addiction specialist while under his physi-
cian’s care to explore his perceptions of what factors influenced his behavior and
how he viewed the experience as he was leaving the drugs behind him.
 Case Studies 3

The first question posed to Mark focused on the very beginning of his use.

Addiction Let’s talk about what was on your mind when you began
Specialist (AS): reading about steroids and their effects on other athletes.
Mark (M): I felt that I understood why the pros were taking them—they
wanted to be sure they could win—be better, be the best. I
wasn’t too bad as an athlete because I’d practiced my whole
life. Even as a kid, my dad and I would go out and do
practices while I was playing in Little League. My dad got
real excited during those games; sometimes, he was even
more excited than I was when I made a good play or hit the
ball well. It was nice.
AS: So, doing well and getting that kind of attention felt good.
What about when you played in high school—did your
dad come to the games then, too?
M: Yeah, but not always. He’s dealing with some stuff right now
—lost his job for a while, but he’s working again now. He
didn’t have a lot of interest in what I was doing because he
was so worried about things. . .
AS: When you started reading about these drugs, what kinds of
thoughts did you have about taking them yourself?
M: It seemed pretty easy to get them—I just wanted to
experiment a little bit. I could stop if things got bad or I
didn’t feel good. I thought I’d give them a chance—get a
little bigger, faster maybe. Thought about how proud
everyone would be if I was really awesome.
AS: How much did you really know about steroids—all the
different kinds and the effects on the body?
M: Nothing really—except what I could see in body-
building magazines and read about on the Web.
I saw how great Alex Rodriguez was doing and knew that
he was suspected of using steroids; same with Sammy Sosa
or Roger Clemens. These guys had it all!
AS: What is “all”?
M: You know—big wins, big money—lots of attention. Lots of
beautiful girlfriends, pictures in the papers. I was scouted by
a couple of teams and thought I would have a better chance
if I could really perform like a pro.
AS: What exactly did you take? What did you decide on?
Mark: I started out with pills. Looked them up on the Internet and
picked the ones that said the athletes used them to build
4 Steroids

muscle mass quickly. I got results but not as fast as I wanted.

I started using an injectable and did a cycle every twelve
weeks at first, stacking the drugs for greater effect. I used
both pills and injectables. By then, it was what I was doing
every day. I included some growth hormone stuff, too. I’m
not short, 5 feet 9 inches, but I was curious after I got
started. I wondered if I would grow, but I didn’t. I grew the
other way—gained weight, muscle—I started to look like a
professional weightlifter . . . . The thing is, once you start,
you don’t want to stop—I was afraid I would lose everything
I had gained.
AS: How were you feeling while you were bulking up and doing
well athletically?
Mark: Actually, I wasn’t feeling great about doing this illegal stuff.
My parents didn’t know, and my friend Jim kept telling
me that I didn’t need to do it. But when I performed on
the field and knew it was the steroids that were helping me,
I didn’t want to stop. So I felt guilty, a bit, but not enough
to stop.
AS: What happened between you and your coach?
Mark: I guess I lost it one day. I wasn’t feeling very comfortable in
my skin, for some reason. I felt impatient with the way
practice was being done and didn’t really want to go and
hear the same thing from him. I missed a few practices,
and he accused me of acting like I was too good for the
team, now. I like the guy, but he was pushing me.
Finally, he said something about me being a “prima
donna,” and I got into a shouting match with him.
I broke some of the equipment in the locker room. He
made me leave and reported me to the school and my
parents.
AS: What happened then?
Mark: Next thing I know, I was called into the school with my
parents. My dad was really upset. We saw the principal, the
coach, and the team doctor. The team doctor said my
appearance had been changing and my attitude, too. He
wanted to give me a drug test. I got furious—left the room.
My parents agreed and, although I tried to find a way not
to get tested or to get over on the test—I went on the
Internet that night to see if I could fool them, I ended up
going, and the rest is history.
 Case Studies 5

AS: Did you have any withdrawal effects from stopping your use?
Mark: I was really depressed. I didn’t go to any of my friends’
graduation parties, didn’t see my girlfriend. I didn’t want
to talk to anyone. I also felt kind of sick—the little bit of
acne I had got much worse, all over my upper back. The
doctor said my cholesterol was high and so was my blood
pressure. The other problem was that I looked so heavy,
like the muscle changed into fat. I’m still dealing with that,
but I actually feel much better now.
AS: Are you seeing a therapist?
Mark: Yeah, a cool guy—he loves professional sports. We talk
about what’s happening to the pros who use steroids. He
says that I quit just in time.

Commentary
Mark’s case is not unlike that of many other adolescents in the country who
seek performance-enhancing drugs for improving appearance or feeling better
about themselves. In Mark’s case, he had supports around him who recognized
that he was getting into trouble and called on professionals to help him.
Mark obtained his drugs in the way that most people obtain illegal
steroids—on the Internet. However, there are individuals who also deal in ste-
roids directly and are, generally, the suppliers of major athletes and other “dop-
ing” circles. Mark appeared to have started out in high school after losing his
father’s attention to his athletic activities. His need to prove himself was equal
to developing a super strong body with great athletic skills. It is likely that
Mark might have excelled, anyway, by consistent practice and motivation.
He was already a dedicated ball player at school but did not appear to believe
in his own capabilities without external support—such as from his father.
In addition, Mark’s case demonstrates the progressive nature of the use of such
substances. His cycle of use became a routine upon which he depended to get
the effects he desired. This included the development of strategies of use—
cycling the weeks of use during which time he would alternate lighter steroids
in the beginning to peak with stronger AAS drugs and then decreasing back to
the lighter drugs over twelve-week periods. Although he began with oral types
of steroids, he moved further into his use by employing injectables—quicker
acting and with more dramatic results. This behavior is characteristic of some-
one who becomes involved in drug use. By the time he was discovered, Mark
did not know how to reduce his use nor did he want to lose any gains he had
made. His ambivalence created a see-sawing state of thinking that created
6 Steroids

much stress. He was aware that his personality had changed—at least as others
now perceived him. His level of irritability and moodiness, his impatience,
aggressiveness, and lack of civility, suggested the influence of drug use.
What Mark did not know was the threat of permanent damage to him
physically. His acne was a side effect, as were his higher cholesterol and blood
pressure readings. Adolescents who use steroids over a period of time may stop
growing, as AAS drugs stunt bone growth. There may be permanent damage
to the production of serotonin, a brain chemical associated with “well-
being,” so that the person suffers from chronic depression and aggressiveness.
While Mark did not appear to develop Gynecomastia, the development of
female breasts or other more serious side effects, the after-effects he did suffer
were debilitating.
Mark benefited from the care of a physician who understood the dangers of
removing the drugs from his patient suddenly; Mark was instead monitored
within a regimen of slowly decreasing the drugs until he was physically cleared
of those substances while providing short-term medication that managed his
mood swings and other aftereffects. Without that kind of protocol, he would
likely have experienced increased depression, fatigue, cravings, decreased appe-
tite, headaches, problems sleeping, and decreased libido (interest in sex).
In conclusion, Mark was quite open about his motivation to use these sub-
stances: physical prowess, future money, and lots of girlfriends. These factors
are often found among others who use illegal steroids. The need for attention
and approval is, likely, an underlying cause of this behavior, especially in teens.
However, the number of individuals using illegal steroids, growth hormones,
and other performance-enhancing substances is difficult to measure; for exam-
ple, 3.4 percent of high school seniors indicated that they have used steroids in
2013. Among adult users, the figure ranged from 1 to 6 percent in 2013, but
the use of so many combinations of substances and the frequent use of other
categories of drugs along with steroids has made concrete figures impossible
to attain (NIDA, 2013).
As long as professional athletes in every discipline are touted as cultural
heroes, however, with an acceptance that many of them use steroids, the devel-
opment of prevention programs is high priority. NIDA (2006) has developed
the Adolescents Training and Learning to Avoid Steroids (ATLAS) program
that targeted fifteen adolescent high school sports teams. The outcome dem-
onstrated a dramatic improvement in awareness levels and behavioral indica-
tors among high school students. This and other innovative programs like
them are hopeful alternatives to the continued use of steroids by high school
and college students.
 Case Studies 7

In Case Study Two, the use of a different kind of steroid illustrates the benefits
of synthetically manufactured medications for use in medical cases. The subject
of this case study discovered that the very real therapeutic effects of steroids would
impact not only her social self-confidence but also her quality of life.

CASE STUDY TWO: ANGIE

Angie is a bright, nineteen-year-old sophomore at a community college.
She plans to complete a nursing program once she graduates with her biology
degree. Lately, she has been thinking about doing a pre-med course after get-
ting her nursing credentials. Angie has a long history of dealing with the medi-
cal profession on a very personal level. She has psoriasis, a condition of the skin
that can be treated but that is often difficult to manage and often distressing,
emotionally, to the individual who is suffering from it.
When she was in the seventh grade, Angie had a bout with strep throat.
It was a severe infection, and Angie was out of school for a couple of weeks.
After her recovery and her return to school, she began to experience episodes
of itching all over her body, especially her arms and legs. Small red spots
emerged that were uncomfortable and demanding of some kind of relief.
When she saw her doctor, he diagnosed her with Guttate Psoriasis, a form of
skin condition that occurs in young people. The doctor explained that psoria-
sis was a disorder of the immune system, sometimes genetic, for which there
was no known cure. The body overreacts, basically, to the need for protection
against illness and produces antibodies in the form of white blood cells. These
white blood cells begin to attack the healthy cells, mistaking them for viruses
or bacteria-carrying cells. When the white blood cells attack healthy skin, the
immune system responds and makes more white blood cells, sending more
blood to the skin. The skin, in turn, cannot shed the additional white blood
cells and dead skin so they begin to build up on the skin, taking the form of
patches or spots. They form silvery scales that flake off over a period of time,
but cause itching, bleeding, and pain.
Angie was given a skin cream, and it appeared to work to lower the itching
sensations and the obvious red marks. Angie was very self-conscious of these
marks, however, and continued to feel the stress of trying to hide them when
she was at school. She cut back on her social activities, especially in the
summer, and often wore long-sleeved blouses despite the weather temperature.
After some time, however, the creams seemed to make the spots disappear, and
Angie began to resume her usual school and sports interests.
When she entered high school at age fourteen, Angie had become more
sociable again, joined the swim team, and was enjoying a busy schedule of
8 Steroids

extracurricular activities. In the middle of that first high school year, the pso-
riasis returned. This time the spots had become more like large, red patches,
scaly, and sometimes bleeding. Angie questioned the doctor about why this
was happening and why it could not be cured. He reminded her that psoriasis
was not a curable disorder but noted that she had been free of symptoms for
two years. Now the condition had returned, and they would, once more, uti-
lize the topical, steroid creams that seemed to help her before. Angie com-
plied and faithfully applied the prescribed creams. Once again, the scales
were reduced in number and size; however, this time they did not disappear.
Angie became depressed and anxious about her appearance. She began
covering her body again, stopped attending the swim team practices, and,
ultimately, dropped the team entirely. Her close friends knew about her pso-
riasis and tried to convince her to stay on the team (psoriasis is not conta-
gious). But Angie felt that people certainly would talk about her or point at
her when she competed against other high schools. She sought various cos-
metic cover-ups but her doctor did not want her to use anything on the
patches except medicine. She began to feel hopeless about her appearance
and thought about dropping out of school. She saw the school counselor
both on her own and with her parents. Because she was such a good student
and had many strengths in her history of athletics and community work, she
and her counselor began to work on a plan to help others with the same
disorder.
As the patches lessened, once again, in redness and size, Angie decided to
do some research of her own. She questioned family members about psoria-
sis and discovered that her grandmother and a cousin had suffered from the
same condition. Further, her grandmother’s arthritis was, in fact, called pso-
riatic arthritis, which occurs when the white blood cells attack the joints as
well as the skin. When Angie understood more clearly that psoriasis was a
chronic (long-lasting) condition and, in her case, might be genetic, she pur-
sued all of the avenues she could discover to deal with the likelihood that it
might reoccur, even if the patches disappeared again. She studied recom-
mended diet and exercise regimens and stress-reduction techniques. She
read about all of the recommended treatments and the effectiveness of ste-
roid creams when used appropriately. She also sought out emotional sup-
port from her family and her counselor. Her counselor put her in touch
with a group of other high school students who met every month to talk
about their own experiences with psoriasis. These support systems enabled
Angie to stabilize and make decisions about taking control of her health
and well-being.
 Case Studies 9

Her desire, now, as a community college student to enter medicine is based

on her personal journey with psoriasis, the new combination of treatments that
she is following (light therapy and corticosteroid creams with vitamin D), and
her understanding of the emotional effects such a condition can have on a per-
son. She is particularly interested in the development of new treatments for
young people and the role of diet and exercise in relieving the stress response
that can also cause flare-ups of the condition. Lastly, Angie’s goal is to work
with adolescents and young adults who suffer from psoriasis—as she still does.

A Talk with Angie

Angie was very forthcoming about her psoriasis and what she thought and
felt about the fact that this was an incurable, ongoing condition with which
she would deal the rest of her life. Her own study of the illness and her desire
to help others came through on her discussion with the interviewer.

Interviewer Thanks for spending some time to discuss your personal journey
(IN): dealing with psoriasis.
Angie (A): You’re welcome. I think it’s important to let people, especially
kids, know about this condition and how it can affect their lives.
IN: Can you talk a little bit about what it was like for you in the
seventh grade to experience this problem?
A: It was pretty frightening. I couldn’t seem to stop itching and, the
more I scratched, the worse my skin looked. It was like being in
some kind of horror movie—you know—some kind of alien has
entered your body and is causing this. Made me think of that
movie, Alien!
IN: Do you remember talking to anyone about it?
A: At first, I didn’t. I was embarrassed by those red spots. They
made me look as though I had a disease—I covered up a lot
when I was out of the house, at school. I actually stayed home
a lot, but I was always worried. Then, my mom and I talked
about it. I could see that she was concerned, too. She took me
to the doctor, and that’s when I first heard about psoriasis.
IN: Did his explanation help you and your mom?
A: I think so. At least I didn’t have an alien inside me! He explained
that it was a condition created within my body, and that it wasn’t
contagious, but it also wasn’t curable. He also told me that lots of
other kids have this condition, and there was treatment for it.
10 Steroids

IN: How did you feel about that?

A: I wasn’t happy that it was incurable, but I had never seen other
kids with it. That made me think that they were covering up,
too, just as I was. I wanted to try the treatment right away.
IN: What was that treatment?
A: Only a cream that I applied to the spots on my body. It was a
steroid cream, and it helped me get rid of the itching and the
redness. Eventually, the spots seemed to disappear. I thought
the doctor must be wrong—that, in fact, I was cured!
IN: It came back?
A: Yes, when I went to high school. I love to swim and am pretty
good at it. I also like to do community volunteering, and
I joined a club of other students who helped out in pantries,
childcare centers, and other places like that. But then, the
psoriasis came back again. This time it seemed worse—lots of
red, scaly patches on my arms and elbows, my knees. This time
I would bleed from the dryness of those patches. This time
I guess it got the better of me. I felt really hopeless that I could
ever get past this problem.
IN: And, what happened?
A: I started withdrawing again—big time! I dropped out of the
swim team because I couldn’t bear people looking at me, as
though I had leprosy or something. I didn’t feel comfortable
around people at school, didn’t want to go to the dances because
I didn’t think anyone would want to touch me, much less dance
with me. I tried those scar-covering cosmetics but the doctor had
a fit when I told him that. He said it could infect me, and then I
would really be in trouble. Finally, I saw the counselor at school
—she was great. She called my parents in for meetings, too,
which was OK with me. At least, I trusted them to try to under-
stand what I was going through.
IN: How did the counseling change things for you?
A: We talked about psoriasis and how it was taking control of my
life. We talked about how the new steroid cream was
beginning to work, and that this was a signal to me to do some
studying about my condition to prepare for any future
outbreaks. I think the counseling helped me to find my own
strength—after all, I had been helping other people in the
community, so now it was time to help myself.
IN: What did you do?
 Case Studies 11

A: I started reading and researching—found out that genetics were

a factor, most likely, for me, and that I could be more attentive
to the ways I was living. It helps to ward off any more severe
attacks by my white blood cells—you know, diet, exercise,
practicing stress-reduction techniques, focusing on staying
healthy. I also found out that my strep throat infection when I
was in the seventh grade might have triggered the psoriasis,
which I didn’t know I had until then.
IN: How are you feeling about the psoriasis now?
A: Well, of course, I wish I didn’t have it, but, because I do, I’m
making it work for me, rather than against me.
IN: How so?
A: I am in charge again. I like myself and know how to take care of
myself. I’m using the steroid cream and light therapy in
combination, which have helped tremendously. Also, the
experience of this condition has pointed me in the direction of
a career that I think will be awesome—being a doctor and
helping young people or kids deal with this. I want to look for
more ways to treat psoriasis, too, other than what is done
today. Wouldn’t it be great to find a “cure” for an incurable
disease? You never know . . . .

Commentary
Angie’s case is typical of other children or teens who find themselves afflicted
with childhood psoriasis. Research indicates that about 40 percent of individuals
with psoriasis have other family members with the disease. Psoriasis is a reoccur-
ring condition, and, while there appears to be no precursor to outbreaks, there are
some risks that are associated with its reappearance. As in Angie’s case, a person
who carries the disease but who has been asymptomatic (without symptoms)
may experience an outbreak as a result of strep throat or other infectious illnesses,
high stress levels, skin irritations, obesity (folds of skin can encourage psoriasis),
and cold weather because of the lack of sun.
The first course of treatment for psoriasis is generally a corticosteroid cream
that can be applied to the surface of the infected skin. As will be further dis-
cussed in this book, this type of cream represents the powerful anti-
inflammatory action of steroids. By reducing the inflammation, the cream
reduces the immune system’s activity. In psoriasis, because the white blood
cells are reproducing to attack healthy skin and the immune system is working
overtime to produce more blood, the cells continue to pile up on the skin,
12 Steroids

creating the patches and spots experienced by Angie. The corticosteroid cream
can slow this process and help the immune system return to its normal levels of
activity.
While it is also true that corticosteroids may have side effects, depending on
how they are administered and how often they are used, their effectiveness has
been documented in the research. The side effects are generally those associ-
ated with the ingestion of steroids rather than the topical application of the
creams. If these creams become less effective, there are other options for treat-
ment. Angie uses a combination of phototherapy (ultraviolet light on those
affected areas) and topical steroid cream. She will be able to gage the effects
and cease this type of combination when her symptoms subside or improve.
According to the National Psoriasis Foundation (NPF), psoriasis is the most
prevalent autoimmune disease in the United States, affecting as many as
7.5 million Americans. For those young people dealing with psoriasis, seeing
a physician at first notice of a skin abnormality is a key step. From there, test-
ing and examination by the physician will result fairly quickly in an accurate
diagnosis. As in Angie’s case, the support of family and other professionals as
well as medication specific to the condition (in this case, steroids for psoriasis)
are crucial components in the healing and management of illness.
Angie’s decision to help others to consider seriously a career path as a der-
matologist and to address the source of her transient depression with
problem-solving rather than medication proved to be the right direction for
her. For others, all of these components might not work in the same way.
The importance of utilizing the best medical advice and understanding how
emotional responses can be managed through the course of psoriatic outbreaks
will help a person regain control of what might appear to be an uncontrollable
and, at times, overwhelming situation.

LESSONS LEARNED
Both of these case studies reflect a reality that many young people are dealing
with in their everyday lives. It is clear that knowledge and the willingness to take
responsibility for one’s well-being are key elements when making decisions about
steroid use. There can be a critical balance between natural steroids and their syn-
thetic counterparts as both enhance the body’s physical, chemical, and emotional
states when used correctly. The consequences of misuse are reported regularly in
the media. This book seeks to educate the reader not only on the biochemical
characteristics of steroids and what they do in the human body but also on the
historical discoveries, social aspects, and future uses of such synthetics as we move
further into the twenty-first century.
 Chapter 2

What Are Steroids?

Malgorzata Slugocki

Steroids are natural compounds that are physiologically produced by the body
and exert a number of significant effects. They also occur in other animal and
plant forms. The most important role of steroids in humans is to function as
hormones. Hormones are substances that act as messengers secreted directly
into the bloodstream, whose role is to stimulate a cell or a specific tissue into
action. The biological effects of steroid hormones include regulating carbohy-
drate metabolism, maintaining fluid and electrolyte balance, and maintaining
reproductive functions. Steroid hormones are also involved in producing
inflammatory and stress responses and modulating cardiovascular, bone, and
cognitive functions. Each of these effects will be described in more detail in
the coming chapters.
Synthetic steroids are substances that resemble natural steroids. They are
meant to mimic the effects of natural steroids. Some synthetic steroids are used
to replace natural steroids in case of any deficiency or medical condition that
impairs their production. Another group of synthetic steroids is used to sup-
press inflammation in a variety of inflammatory or autoimmune diseases (dis-
eases that attack the body itself ). You will discover as you study that, along
with beneficial actions of synthetic steroids, there are also many dangerous
effects that can occur due to inappropriate use of these agents.
The effects of steroids were discovered by the work of Reichstein and Kendall,
who isolated and identified cortisone, which was the first pharmacologically effec-
tive glucocorticoid. Tait and colleagues subsequently isolated and identified
aldosterone. It is the study of the function of these two compounds that
14 Steroids

delineated the role of major organs involved in the synthesis of steroids, as well as
helped recognize the overall function of steroid hormones.
Chapter 4 discusses how the chemical nature of natural steroids renders
them not only vital to human life but also extremely influential in how we per-
ceive pain, experience emotions, and sustain healthy (or unhealthy!) lifestyles.
This chapter, however, will look at a somewhat simpler description of steroids
and their many varieties.
In order to understand the biological effects of steroids, there is, first, a brief
review of the basis behind the natural steroids’ physiological functions and
their synthesis. A more detailed discussion of this will occur in Chapter 4.

NATURAL STEROID SYNTHESIS AND

PHYSIOLOGICAL FUNCTIONS
The main site for the production of steroids is the adrenal glands. These
glands are small organs, approximately one-half inch by three inches long,
and they are perched on top of each kidney. There are two parts to the adrenal
gland: the adrenal medulla within the gland that secretes hormones that affect
blood pressure, heart rate, and perspiration. The external or outer part, called
the adrenal cortex, secretes a diverse group of hormones that control metabo-
lism. This outer part also secretes male sex hormones that influence the devel-
opment of sexual characteristics and reproduction in both men and women.
Other organs that also produce steroid hormones are the ovaries, testes, and,
during pregnancy, the placenta.
All natural steroids are derivatives of cholesterol. Cholesterol structure con-
tains twenty-seven carbon atoms. Synthesis of all hormones involves a conver-
sion of cholesterol to eighteen, nineteen, or twenty-one carbon structures,
which subsequently become steroid hormones.
Adrenal glands produce all major groups of steroids: glucocorticoids, miner-
alocorticoids, and small amount of androgens. Other organs involved in hor-
mone production and release are the testes, ovaries, and placenta.
Glucocorticoids are released in response to another hormone called adreno-
corticotropic hormone (ACTH), secreted by the pituitary gland whenever
there is an inflammatory process or during stress.
Release of all steroid hormones occurs via a negative feedback mechanism
where the production of the hormones is regulated by their levels in the body;
higher levels of the hormones will inhibit their synthesis. Substances involved
in this process include angiotensin II, which regulates the release of mineral-
ocorticoids (aldosterone), as well as the luteinizing hormone (LH) and the
follicle-stimulating hormone (FSH), which controls the release of reproductive
hormones (progesterone and estrogen).
 What Are Steroids? 15

There are two main processes that occur in any living organism: anabolism
and catabolism. The linking of these two processes is known as metabolism.
Anabolism is the process of building—a series of chemical reactions that lead
to a formation of molecules or compounds from smaller components.
Catabolism, on the other hand, is the process of breaking down—or a chain
of chemical reactions that lead to disintegration of a molecule or compound.
The functions of steroid hormones involve both of these processes. Examples
of anabolic functions of steroid hormones include muscle growth or maintain-
ing bone strength. There are a number of undesirable effects that anabolic ste-
roids exhibit due to inappropriate use, which will be discussed later. Catabolic
steroids are employed in the treatment of various medical conditions, and it is
due to those destructive (catabolic) effects that they exhibit a number of seri-
ous adverse effects.
Now that we understand the biochemical processes of steroids, we can
talk about different types of natural steroids that are released due to ACTH
stimulation.

MAJOR NATURAL STEROID GROUPS

As mentioned earlier, steroids contain eighteen, nineteen, or twenty-one
carbon atoms in their ring structures. The adrenal cortex synthetizes two
classes of corticosteroids: glucocorticoids and mineralocorticoids (which have
twenty-one carbon atoms), and the androgens (which have nineteen carbon
atoms). An example of a hormone that contains eighteen carbon atoms is
estrogen, which is mainly produced by the ovaries. Each class of steroids will
be discussed separately and will be grouped according to the catabolic or ana-
bolic function they exhibit.

Catabolic Steroids
Glucocorticoids
The main function of glucocorticoids is to protect the tissues that highly
depend on glucose (brain and heart) from starvation. Hence, the term
gluco-corticoids. Glucocorticoids significantly affect carbohydrate (glucose)
and protein metabolism. Depending on the glucose needs of those tissues, they
either increase or decrease blood glucose levels. Whenever there is an increased
need for glucose by any organ or tissue (e.g., under any stress, psychological, or
physical), glucocorticoids stimulate the liver to form glucose from amino acids
and glycogen. It is then stored in the form of glycogen. In the peripheral tis-
sues, glucocorticoids reduce glucose usage and increase the breakdown of
16 Steroids

protein and production of glutamine. All these actions result in the availability
of alternative sources for glucose production with the net result to increase
blood glucose level.
Similarly, whenever the need for glucose decreases, glucocorticoids will
reduce production of glucose, and the negative feedback mechanism that
reduces the release of corticosteroids will take place. At this point, it is not fully
understood exactly how glucose utilization is decreased by glucocorticoids in
the peripheral tissues, but it is thought to result from a shift of glucose recep-
tors to the inside of the cells. In general, glucocorticoids decrease the uptake
of glucose in the fat tissue, skin, lymphoid tissue, and other cells.
Because of this effect on glucose metabolism, glucocorticoids have to be
used with extreme caution in patients with diabetes, because they may have a
negative impact on their glucose control. Also certain patients are more predis-
posed to hyperglycemia (increased blood glucose) when taking glucocorti-
coids. Likewise, the effects of glucocorticoids on the peripheral tissues (skin,
fat, and lymphoid tissue) may result in a number of catabolic adverse effects
such as skin thinning and decreased muscle mass. A more thorough discussion
of undesirable effects associated with steroids, both pathophysiological and
due to inappropriate use, will take place in Chapter 6.
Another important role of glucocorticoids is their ability to suppress inflam-
mation. The process of inflammation is normally mediated by many different
immune cells. The actions of these cells result in the classic signs of inflamma-
tion, such as redness, pain, and swelling. Glucocorticoids have the ability to
act on these immune cells and either prevent or reduce the inflammatory
response. Because of this, glucocorticoids have been used as powerful anti-
inflammatory agents in many disease states. Additionally, glucocorticoids are
extremely valuable in treating diseases that result from abnormal immune
responses, such as urticaria (hives) or transplantation rejection.
Many steroids have been isolated from the adrenal tissue, but there are only
two glucocorticoids that are secreted physiologically in significant amounts:
cortisol and corticosterone. Cortisol is released from the adrenal gland, and
it circulates in the bloodstream bound to a plasma protein called cortisol-
binding globulin (CBG or transcortin) or albumin. There is also a small
amount of cortisol that is not bound to a protein but flows around freely and
is able to directly enter a cell if needed. Cortisol also occurs in an inactive form
of cortisone. Cortisone can be found mainly in peripheral tissues such as fat tis-
sue, liver, muscle tissue, and the brain. Cortisone is converted to active cortisol
via an enzymatic reaction. A synthetic formulation of cortisone, hydrocortisone,
is widely used in practice to manage allergic disorders, skin conditions, ulcera-
tive colitis, arthritis, lupus, psoriasis, or breathing disorders.
 What Are Steroids? 17

Corticosterone is released in a much smaller amount in humans, but it is a

major glucocorticoid produced in amphibians, reptiles, birds, rats, mice, and
rabbits.

Mineralocorticoids
Another class of steroids released by the adrenal glands are mineralocorti-
coids. The main function of these hormones is to maintain an adequate
electrolyte and water balance. Water constitutes about 60 percent of total body
mass. Most of this water is concentrated in the intracellular compartment, or
inside of the cells. The balance of water between the inside of the cell and
the outside environment is determined by the amount of different particles
present in both of these compartments. Depending on the concentration of
those particles (osmolality), the fluid shifts either to inside of the cells or to
the outside of them, in order to maintain stability. This movement of water
is controlled by mineralocorticoids. The most potent mineralocorticoid pro-
duced by the body is aldosterone. It acts on the distal tubules and collecting
ducts of the kidney. Aldosterone also acts to a lesser extent on the colon,
salivary gland, and sweat glands. The release of aldosterone is regulated by
another non-steroid hormone that is synthesized in the kidney, called renin.
Physiologically, whenever there is a decrease in overall body fluid or blood
pressure, renin counteracts that by increasing aldosterone concentration.
In individuals with an increased salt intake, the levels of aldosterone will be
reduced in an effort to reduce sodium concentration in the cells. Similarly,
low sodium will enhance the release of aldosterone, and so will increased potas-
sium level. Only about 50 to 70 percent of aldosterone is bound to plasma
proteins.
The net result of aldosterone action is that sodium cations are absorbed back
into the body, in exchange for potassium and hydrogen cations, which are
excreted. This results in conserving water and stabilizing blood pressure.
Despite its stabilizing effect on fluid and blood pressure, several studies have
shown that aldosterone also has a negative effect on cardiovascular system,
especially in excess amount. The mechanisms through which aldosterone
exerts this negative effect include increased water retention and direct action
on the heart and blood vessels, which causes thickening of the cardiac muscle.
Deoxycorticosterone is another mineralocorticoid released in about the
same amount as aldosterone; however, it only contains about 3 percent of
the mineralocorticoid activity of aldosterone. Its effect on electrolyte–water
balance is normally negligible, although it can be appreciated in diseases in
which its secretion is increased, such as adrenal cancer.
18 Steroids

Anabolic Steroids
Androgens
Another group of steroid hormones are androgens, also known as sex
steroids. The term “androgens” is rather broad, and it encompasses three groups
of natural anabolic steroids, according to the number of carbon atoms found in
their structures. Any nineteen-carbon atom steroid hormone, such as testoster-
one or androsterone, belongs to a group of hormone called androstanes. These
hormones are responsible for development and maintenance of male secon-
dary characteristics. Any eighteen-carbon steroid hormone, such as estradiol
or estrone, belongs to estranes group of hormones. Those substances control
the development and maintenance of female secondary characteristics and
are produced mainly by the ovaries. A third type of steroid hormone, called
pregnanes, contains twenty-one carbon atoms and is responsible for menstrual
cycle regularity as well as serving as differentiation factor for mammary glands.
As mentioned earlier, the androgens are released as a result of stimulation by
two hormones: the luteinizing hormone (LH) and the follicle-stimulating hor-
mone (FSH). The luteinizing hormone (LH) activates the release of progester-
one and testosterone, while the follicle-stimulating hormone (FSH) stimulates
the synthesis of estradiol.
The sites for androgen production include the adrenal cortex, testes, and
ovaries. In males, the major androgenic hormone is testosterone, which is pro-
duced in the testes, specifically by the Leydig cells. Testosterone may exist,
also, in the form of dihydrotestosterone. The primary activity of testosterone
is to develop masculinization and secondary male sex characteristics: the
enlargement of the larynx, which causes the deepening of the voice, growth
of body hair (pubic, facial, or auxiliary), enhanced activity of sweat glands,
and CNS effects (libido and increased aggression). While the ovaries and adre-
nal glands produce very little testosterone, they release weaker androgens, such
as dehydroepiandrosterone (DHEA) and androstenedione, which can be con-
verted to more potent androgens.
The anabolic effects of androgens include the growth of skeletal muscle
and bone, stimulation of growth, as well as sustaining reproductive functions,
cognitive functions, and a sense of well-being.

Estrogens and Gestagens

In females, the production of primary sex hormones occurs in the ovary.
Those include estrogens such as estradiol and progestins such as progesterone.
They are involved in development and maintenance of secondary enlargement
 What Are Steroids? 19

of breasts, wider hips, and body hair distribution mainly in the underarm and
pubic areas. Both estrogen and progesterone play a role in controlling ovula-
tion, optimizing the reproductive tract for fertilization, and contributing to
mineral, carbohydrate, protein, and lipid metabolism. Estrogens also contrib-
ute to sperm production, behavior, and bone integrity in males. The major
female androgen produced by the ovary is estradiol.
Testosterone is also synthesized in females, mainly through the conversion
of androstenedione. Testosterone is also produced by the placenta during
pregnancy. At physiological levels in women, testosterone exhibits mainly ana-
bolic functions and contributes to maintaining the reproductive and cognitive
functions. However, at increased concentrations testosterone may lead to
development of unwanted hair, increase in body weight, and menstrual cycle
abnormalities. The increase in testosterone concentrations can be caused by
factors such as smoking, alcohol consumption, and medications. The implica-
tions of these factors will be discussed in later chapters.
As mentioned earlier, the body also produces another weaker androgen
called dehydroepiandrosterone (DHEA). The physiological role for DHEA is
not clearly defined. It is known that it’s used to produce other androgens and
female sex hormones. It also plays a role in the development of auxiliary and
pubic hair and is involved in maintaining immunity. A decline in DHEA levels
with age is associated with some of the physical changes that occur during the
aging process. Some studies have also shown that this hormone may improve
chronic conditions such as diabetes and obesity. For this reason, DHEA has
been dubbed as the “fountain of youth hormone” and is available on the mar-
ket as a dietary supplement.
Androstenedione is structurally similar to DHEA and has almost iden-
tical physiological roles and actions. It is available as a dietary supplement
as well.

Placental Hormones
Another important organ that manufactures steroid hormones is placenta.
Placental hormones include progesterone, estrogens, human chorionic
gonadotropic (HCG), lactogen, prolactin, growth hormone, leptin, and other
substances that support the development of the fetus and maintenance of preg-
nancy. The HCG is one of the most important pregnancy-related hormones.
It belongs to the same biochemical group as luteinizing hormone (LH) and
follicle-stimulating hormone (FSH). It regulates the immune response in the
mother and acts on the corpus luteum, which is the structure in the ovary that
produces progesterone. In pregnancy, progesterone is crucial to the proper
20 Steroids

development of the lining of the uterus, which in turn is critical for adequate
attachment of the embryo to the uterine wall.
The most abundant estrogen hormone in pregnancy is estradiol. Placental
estrogens stimulate the growth of duct cells, preparing the mother for lacta-
tion. Estrogens are also extremely important during labor and delivery because
they act on the uterine smooth muscle and aid in achieving forceful contrac-
tions needed for delivery.
Lactogen, prolactin, and placental growth hormone share structural similar-
ities and all are structurally related to HCG. Lactogen regulates the metabolic
state of the mother by increasing the resistance to insulin, thereby enabling the
delivery of maternal nutrients to the fetus. Prolactin, like estradiol, aids in enlarge-
ment of mammary glands and prepares for the production of milk. Leptin is
responsible for causing a sensation of increased hunger and weight gain. These
actions are necessary for adequate nutrient supply to the developing fetus.

SYNTHETIC STEROIDS
Most synthetic steroids are used for therapeutic purposes. The two major
uses of this group of drugs are anti-inflammatory and immunosuppressive.
The effects of administered corticosteroids have been traditionally considered
as either physiological or pharmacological. Physiological actions were thought
to occur at normal daily production levels, while the pharmacologic actions
were viewed as occurring at levels higher than normal. More recent assump-
tions suggest that, in fact, the pharmacologic use of synthetic corticosteroids
can have a therapeutic effect at levels corresponding to the physiological levels
of steroids. Therefore, the adverse effects that are associated with corticoste-
roids will closely match their therapeutic effectiveness. In other words, the
adverse effects will occur even at normal (or physiological) daily doses of
administered steroids.
Traditionally, modifications to the cortisol molecule have created synthetic
steroid derivatives, with selective activities: mainly glucocorticoid or mineralo-
corticoid activity. Furthermore, these modifications allowed the production of
preparations with greater potency, selective activity, and a longer duration of
action. For example, creating a double bond and adding a keto group (a group
containing a carbon–oxygen double bond), on ring A of the steroid structure,
are essential for both glucocorticoid and mineralocorticoid activities. A hydroxyl
group on ring C of the structure is essential for glucocorticoid but not mineralo-
corticoid activity.
An extensive list of steroids in various dosage forms is available on the mar-
ket as a result of these structural modifications. The choice of a specific dosage
 What Are Steroids? 21

form is based on the severity of the condition being treated, the need for local-
ized versus systemic effect, the anatomic site at which the effect in needed, and
ease of administration. Steroid medications can also be classified according to
their potency. As mentioned previously, the two main steroid groups are
anti-inflammatory and immunosuppressive. Another therapeutic application
of steroids is “replacement therapy,” where synthetic steroids are used to
“replace” the physiological substances in various states of insufficiency.
Finally, the third group of synthetic hormones is used as contraceptive agents.

Systemic Corticosteroids and Steroid Bases

Therapeutic glucocorticoids are generally classified according to their
potency (strength), duration of action, and the ability to retain sodium.
The exact mechanism responsible for the anti-inflammatory effects of glu-
cocorticoids will be discussed in detail in Chapter 4. Generally, this effect is
due to their action on gene transcription (they increase the transcription of
anti-inflammatory genes and decrease the transcription of inflammatory
genes), increased synthesis of several anti-inflammatory proteins, and interfer-
ence with the inflammation process due to action on molecules that mediate
this process (e.g., cytokines, interleukins, and inflammatory enzymes). These
actions have led to a widespread use of steroids in a variety of inflammatory
conditions. This includes autoimmune diseases, such as Crohn’s disease,
inflammatory bowel disease, or rheumatoid arthritis—all of which are associ-
ated with increased onset of inflammatory genes. Other conditions, whose
clinical manifestations result mainly from the release of inflammatory media-
tors, include asthma, chronic obstructive pulmonary disease (COPD), infec-
tious diseases, as well as inflammatory skin conditions.
The main goal of steroid administration is to relieve treated symptoms and
minimize the associated adverse effects. A single dose of a glucocorticoid, even
a high one, is very unlikely to cause any side effects, as is a short-course
therapy. Most adverse effects are associated with long-term (less than one
week) therapy as well as a rapid discontinuation of therapy. The latter circum-
stance stems from the suppression of the hypothalamic-pituitary-adrenal axis,
which is a complex system of interactions and feedback mechanism between
three main endocrine glands, involved in releasing steroid hormones.
In response to these concerns, multiple routes of administration have been
developed. Generally, the intravenous formulation is preferred when a quick
effect is needed. Topical preparations, available in numerous dosage forms,
are used whenever appropriate to minimize systemic adverse effects, because
absorption through the skin delivers less drug to the systemic circulation.
22 Steroids

There are hundreds of glucocorticoid molecules that have been synthesized

since the advent of therapeutic use of steroids. Some of those molecules are no
longer available. As mentioned previously, the available synthetic steroids are
generally used systemically in a variety of inflammatory and autoimmune con-
ditions. Furthermore, vast groups of glucocorticoids are used in dermatology
and in pulmonary and ophthalmic conditions. These categories of agents are
delivered locally to the site of their action. This approach minimizes the sys-
temic adverse effects.
Generally corticosteroids are available as attached to a salt molecule.
The salt changes the characteristics of the steroid in terms of its water solubil-
ity, duration of action, and rate of absorption. These characteristics in turn
determine whether the agent is suitable for oral, parenteral, or topical
administration.
The following is a discussion of various groups of corticosteroids and available
synthetic agents within each group. Details regarding the effects and applications
of glucocorticoids in clinical practice will be discussed in Chapter 5.
A summary of the synthetic corticosteroids is included in Table 2.1.

Hydrocortisone and Cortisone

As mentioned previously, all synthetic glucocorticoids are derived from a
molecule of cortisol. Cortisone and hydrocortisone are both synthetically

Table 2.1 Available Synthetic Corticosteroids and Their Characteristics

Anti-
inflammatory
Route of Duration of (glucocorticoid) Mineralocorticoid
Drug administration action (t1/2)2 potency3 potency
Hydrocortisone, IM, IV, PO1 12 hours 1 1
cortisone
Prednisone, PO 12–24 hours 4 1
prednisolone
Triamcinolone PO, IM 24 hours 5 0
Dexamethasone PO, IV 36 hours 25 0
Methylprednisolone IV 18–36 hours 5 0
Betamethasone IM 36 hours 25 0
1
PO refers to oral route of administration.
2
t1/2 refers to half-life, which is the amount of time needed for the compound to decrease to half or its origi-
nal concentration, which in turn determines duration of action.
3
All potencies are expressed in reference to hydrocortisone.
 What Are Steroids? 23

made. They are both classified as short-acting glucocorticoids and have a rapid
onset of action. Physiologically, cortisone is an inactive form of cortisol, which
is stored in liver and fat, serving as a protective mechanism from the high cir-
culating levels of cortisol. Synthetic cortisone contains an 11-ketol group and
needs to be enzymatically converted to a hydroxy derivative before it is biologi-
cally active. Most of the enzymes that facilitate this conversion are located in
the liver, fat tissues, bone, eyes, and skin. Hydrocortisone does not require this
conversion. Therefore, it is prudent to use hydrocortisone in any condition
that results in an impaired enzymatic activity (e.g., hepatic failure), and hydro-
cortisone is generally considered as a preferred agent.
Hydrocortisone is the least potent corticosteroid, both in terms of glucocor-
ticoid and mineralocorticoid potencies. It is available as a systemic [oral, intra-
venous, intramuscular (IM)] and topical preparation. Systemic preparations
are used as anti-inflammatory or immunosuppressive agent in conditions such
as acute asthmatic attack (status asthmaticus), septic shock, as well as for
replacement in adrenal insufficiency (Cortef, Solu-Cortef ).
Topical preparations are indicated for local symptom relief in a variety of
dermatologic and rectal disorders: psoriasis, atopic dermatitis, eczema, hemor-
rhoids, and ulcerative colitis (Anucort, Locoid, Proctozone, Westcort). They
come in a multitude of formulations, including creams, lotions, ointments,
foams, and rectal suppositories or suspensions. They are also branded with
multiple names. Hydrocortisone can be prepared by a pharmacist as a suspen-
sion for patients unable to swallow the tablet.
Depending on the strength, topical hydrocortisone is available either over
the counter or with a prescription. Preparations of 0.5 to 1 percent can be pur-
chased as over-the-counter products. Prescription-strength hydrocortisone is
available as 2.5 percent preparation. You may notice that certain rectal prepa-
rations of hydrocortisone that require a prescription actually have lower
strength than 2.5 percent. This is because the absorption from the rectal
area is much more extensive than from the skin and has a potential for more
systemic adverse effects.

Prednisone and Prednisolone

These compounds, similarly to cortisone and hydrocortisone, differ in their
need for an enzymatic activation. Prednisone needs to be enzymatically con-
verted to the hydroxy derivative, whereas prednisolone does not. Thanks to a
chemical modification, prednisone and prednisolone have a much higher glu-
cocorticoid activity relative to their mineralocorticoid activity. They both have
an intermediate duration of action because of that enhanced glucocorticoid
activity.
24 Steroids

Prednisone is used as an immunosuppressive and anti-inflammatory agent

in a plethora of inflammatory and autoimmune conditions, organ rejection,
and hypersensitivity. Due to its longtime market presence, prednisone is
mainly manufactured in its generic form, although it is still available under a
brand name of Deltasone. Additionally, prednisolone (Omnipred ) is com-
monly used in various ophthalmic inflammatory conditions. Both agents are
available in many systemic preparations both as a tablet and as liquid oral formu-
lations (solutions, suspensions, and syrups): Prelone, Pediapred, and Orapred.
The intermediate duration of action of these compounds allows for less
frequent daily dosing and is therefore suitable for patients who have diffi-
culty with adhering to their medication regimens. On the other hand, due to
the longer duration, prednisone and prednisolone are only available via
prescription.

Fludrocortisone
Another chemical modification on the cortisone molecule allowed for avail-
ability of fludrocortisones, which generally has no glucocorticoid activity but
exhibits a significant mineralocorticoid activity. Fludrocortisone is available
in its generic form in a tablet formulation and is primarily used as a replace-
ment therapy in adrenal insufficiency (Addison’s disease).

Methylprednisolone
Methylprednisolone is available as both oral and injectable formulation
(Solu-Medrol ). It is the most commonly used intravenous steroid. It has a greater
potency than prednisolone and a lower tendency to induce sodium and water
retention. The injectable formulation contains a water-soluble salt molecule (suc-
cinate), which allows for a rapid onset of action. Another type of methylpredniso-
lone is an acetate formulation, which is much less soluble in water.
Methylprednisolone acetate (Depo-Medrol ) is accessible as a depot formu-
lation. It is injected intramuscularly and forms a depository at the injection site
and releases the medication slowly overtime. This type of formulation is most
suitable whenever oral or intravenous routes are not feasible, as well as for use
as injections administered directly into joints or lesions. Methylprednisolone
as a base (without the addition of any type of salt) is also available as an oral
tablet for use in various inflammatory and autoimmune conditions. Due to
concerns with abrupt discontinuation of glucocorticoid therapy, current
guidelines recommend as short as possible duration of therapy and an imple-
mentation of a tapered-dosage schedule, in order to avoid the adverse effects.
In light of that, the oral formulation of methylprednisolone is available as a
 What Are Steroids? 25

convenient twenty-one-tablet packet that can be easily tailored to a required

tapering schedule (Medrol Dose-Pak).

Triamcinolone
Triamcinolone, dexamethasone, and betamethasone are all called the
9-fluoro derivatives because they have a fluoride molecule attached to one of
the rings. This manipulation gives them a marked glucocorticoid activity and
virtually eliminates the mineralocorticoid activity.
Triamcinolone is nearly five times more potent than cortisol in its glucocor-
ticoid activity, with minimal mineralocorticoid activity. Like methylpredniso-
lone acetate, it is used as an injectable formulation, but it has a slow absorption
and is therefore suitable for intralesional, intra-articular, and slow IM injec-
tions. The salt that causes triamcinolone to exhibit these properties is acetonide
(Kenalog). Triamcinolone acetonide is also accessible as a topical dosage form:
lotion, cream, and ointment. It is indicated for the treatment of various derma-
toses and inflammatory conditions (Triderm, Dermasorb). It may also be used
in cases of oral inflammatory lesions (Oralone 0.1 percent). Another important
formulation of triamcinolone acetonide is the nasal spray (Nasacort AQ), as it is
commonly used to relieve symptoms of allergic rhinitis. Triamcinolone may
also be used as an intra-ocular agent in ophthalmic inflammatory conditions
and procedures (Triesence). It is used as an intra-ocular injection in this case.

Dexamethasone
Dexamethasone also has a more pronounced glucocorticoid activity com-
pared to the mineralocorticoid. The addition of a sodium phosphate salt to dex-
amethasone molecule makes it highly water-soluble and therefore suitable for
intravenous administration (Double Dex and generic forms). In addition, dex-
amethasone can also be used for a slow IM injection in its base form (available
as a generic version). Like methylprednisolone, dexamethasone is also available
in dose packs, which facilitate dose-tapering schedules (DexPak 10 Day,
DexPak 13 Day, DexPak 6 Day). Baycadron is an oral elixir used for relief of
various oral inflammatory symptoms. Ophthalmic solution (Ozurdex) is also
available.

Betamethasone
One of the most potent and long-acting corticosteroids, Betamethasone
is available as a systemic preparation, attached to a sodium phosphate salt,
making it suitable for an intramuscular (IM) of intra-arterial preparation.
26 Steroids

Oral formulation, in its base form, is rarely used but available as a solution
(Celestone Soluspan). Due to its potency, the IM dosage form of betamethasone
is most commonly used as an anti-inflammatory agent.
Betamethasone is also available in a multitude of topical formulations:
cream, ointment, lotion, foam, and gel. These are used for local relief of symp-
toms of various inflammatory dermatologic conditions.

Topical Corticosteroids
Topical corticosteroids are used in a variety of dermatologic conditions and
are available in many different dosage forms. They have been grouped into
seven classes in order of decreasing potency, which is defined by the degree
of local blood vessel constriction that each class causes. The potency of these
agents is also determined by the salt to which the molecule is attached.
Thus, dipropionate and butyrate salts are stronger than valerate salts. Some
preparations are also attached to other molecules (e.g., salicylic acid or urea),
which also affect their potency.
In addition to the appropriateness of the specific steroid, the ingredients
with which those agents are manufactured are extremely important. These
ingredients are called vehicles. There are three basic ingredients used for
vehicles: powders, oils, and liquids (e.g., water). Vehicles contain varying pro-
portions of these three ingredients and are formulated in dosage forms most
suitable for specific skin lesions or conditions. Depending on the type of the
dermatologic condition (lesions that are dry, itchy, or oozing), the vehicle
may either aid or delay in healing.
For example, powders absorb moisture, oils act as moisturizers, and liquids
provide a cooling sensation while helping oozing lesions to dry. Similarly, alco-
hol in vehicles may increase stinging and pain. Some additional factors that
will increase the absorption and potency of steroids include the use of occlusive
dressings as well as the size of the area of the body on which it is applied.
In summary, depending on the severity and location of the lesion, a steroid
of a parallel potency will be selected for treatment.

Ointments
Ointments primarily contain water suspended in oil, which makes this
vehicle an excellent lubricant. It also promotes the retention of the medication
at the site of application. This characteristic makes them the most potent
vehicle. Their effects may be enhanced by use of occlusive dressings, which
also increases the systemic absorption and the risk for adverse effects.
 What Are Steroids? 27

Creams
Creams are mixtures of oil in 20 to 50 percent of water and can be easily
washed off with water. They are more cosmetically appealing because of the
ease of application. Creams are also less potent vehicles than ointments.

Lotions
Lotions are formulated in a similar fashion to aerosols and solutions.
They are the least potent topical therapies, which consist of powder-in-water.
Due to this, lotions should be shaken before each application in order to
ensure consistency in concentration. The tendency of lotions to evaporate
allows them to have a cooling and a drying effect, which makes them a useful
vehicle for treating itchy and oozing lesions.

Solutions
Solutions are mixtures of water and non-aqueous liquids such as alcohol or
propylene glycol. Similar to lotions, this type of vehicle aids in drying oozing
lesions by means of evaporation. They also cause constriction of local blood
vessels, which decreases local swelling.

Gels
Gels are mixtures containing oil, water, and alcohol. They form a thin,
greaseless, non-staining film when applied. Gels combine the lubricant advan-
tage of ointments with the ease of administration of creams. They may still
cause irritation due their alcohol content.

Foams
Foams are pressurized mixtures of gaseous bubbles suspended in a matrix of
liquid film. They are usually easier to apply and spread, which makes them
suitable for applications to inflamed scalp lesions. Due to complexity of the
delivery systems required for the manufacture of foams, they are usually more
expensive than other dosage forms.

Wet Dressings
Wet dressings permit the cleansing of oozing lesions (e.g., ulcers), simulta-
neously allowing for their drainage. Closed, wet dressings are covered by a
28 Steroids

waterproof substance that cause heat retention and results in maceration of the
lesion.
Synthetic topical steroids, their potencies, and dosage forms are summarized
in Table 2.2.
As described before, the type of vehicle and the salt molecule may determine
the potency of a specific preparation. This is the reason for certain agents being
listed in two different categories.

Table 2.2 Synthetic Topical Corticosteroids and Their Potencies

Potency class Generic name Strength Dosage form Brand name

1 Ultra High Betamethasone 0.05% Cream, Diprolene

dipropionate2 ointment
Clobetasol 0.05% Cream, Temovate
ointment, foam, Olux (foam)
shampoo
Diflorasone 0.05% Ointment Psorcon
Halobetasol 0.05% Ointment Ultravate
2 High Amcinonide 0.1% Ointment Cyclocort
Betamethasone 0.05% Ointment Diprosone
Desoximethasone 0.25% Cream, Topicort
ointment, gel
(0.05%)
Diflorasone 0.05% Ointment Florone
Flucinonide 0.05% Cream, Lidex
ointment, gel
Halcinonide 0.1% Cream, Halog
ointment,
solution
3 Medium to high Betamethasone 0.05% Cream Diprosone
dipropionate
Betamethasone 0.05% Ointment Betatrex
valerate
Diflorasone 0.05% Cream Florone
Triamcinolone 0.1% Ointment, Kenalog
cream (0.5%)
4 Medium Amcinonide 0.1% Cream Cyclocort
Desoximethasone 0.05% Cream Topicort

(continued )
 What Are Steroids? 29

Table 2.2 (Continued)

Potency class Generic name Strength Dosage form Brand name

Fluocinolone 0.2% Cream, Synalar
ointment
(0.025%)
Flurandrenolide 0.05% Cream Cordran
Hydrocortisone 0.2% Cream Westcort
valerate
Triamcinolone 0.1% Ointment Kenalog
acetonide
Mometasone 0.1% Cream, Elocon
ointment
5 Medium Betamethasone 0.05% Lotion Diprosone
dipropionate
Betamethasone 0.2% Cream, foam Betatrex
valerate
Fluocinolone 0.025% Cream Synalar
Flurandrenolide 0.05% Cream Cordran
Hydrocortisone 0.1% Cream Locoid
butyrate
Hydrocortisone 0.2% Cream Westcort
valerate
Triamcinolone 0.1% Cream (also Kenalog
0.025%),
lotion
6 Low Alclometasone 0.05% Cream, Aclovate
ointment
Desonide 0.05% Cream, foam Tridesilon
Fluocinolone 0.01% Cream, Synalar
solution
7 Very low Dexamethasone 0.1% Cream Decadron
sodium phosphate
Hydrocortisone 0.5%, Cream, Multiple
0.1%, ointment, manufacturers
2.5% lotion

In addition to the vehicle type, the specific application site may either
increase or decrease the absorption of topical steroids. The optimal vehicles
for different body locations are shown in Table 2.3.
30 Steroids

Table 2.3 Vehicle Preference Based on the Characteristics of Body Site

Vehicle Ointment Cream Lotion Solution Gel Foam

Smooth hairless Preferred Acceptable Rarely used
skin; callous
raised lesions
Hairy skin Rarely used Acceptable Preferred Acceptable Preferred
surfaces
Palms, soles Preferred Acceptable Acceptable
Infected areas Rarely used Acceptable Preferred Rarely used Acceptable
Between skin Acceptable Acceptable Acceptable Rarely used Acceptable
folds; moist
lesions

Inhaled Corticosteroids
The introduction of inhaled corticosteroids has transformed the treatment
of conditions such as asthma, because they have been shown to improve the
lung function as well as death rate associated with asthmatic attacks. This is
mainly due to the fact that the principal pathophysiological problem in asthma
is inflammation. The administration of glucocorticoids via inhalation allows
for minimizing the systemic adverse effects by concentrating the medication
at the specific site. Thus, glucocorticoids have become a mainstay therapy as
the “controller” medication in asthma: they control the daily symptoms associ-
ated with the inflammatory process. Inhaled steroids have also been used in
obstructive pulmonary conditions (e.g., COPD); however, they have not been
associated with improving overall lung function or decreasing death rate.
Like topical corticosteroids, inhaled steroids are classified according to their
potency (expressed as daily dose) and are available in a variety of delivery devi-
ces. Providing details regarding advantages and disadvantages of each device is
beyond the scope of this text. We will review basic characteristics of each type
of delivery system. Some inhaled corticosteroids are also available in combina-
tion with another agent, usually a bronchodilator, which helps with the pas-
sage of air through inflamed airway.
Table 2.4 summarizes the available inhaled corticosteroids and their
characteristics.

Metered Dose Inhalers (MDIs)

This device has been a mainstay of treatment of respiratory diseases and is the
most commonly prescribed system for inhaled corticosteroids. Key components
Table 2.4 Inhaled Corticosteroids and Combination Corticosteroids, Their Potencies and Delivery Systems

Low potency Medium potency Delivery

Steroid name Available strength (dose)1 (dose) High potency (dose) system Brand name

Beclomethasone 40 mcg per puff 80–160 mcg per >160–320 mcg per day >320 mcg per day (max MDI Qvar
80 mcg per puff day 320 mcg twice daily)
Budesonide 90 mcg per inhalation 180–360 mcg >360–720 mcg per day >720 mcg per day (max DPI, solution Pulmicort
180 mcg per inhalation per day 720 mcg twice daily) for nebulizer2 Flexhaler
Ciclesonide 80 mcg per puff 80–160 mcg per >160–320 mcg per day >320 mcg per day (max MDI Alvesco
160 mcg per puff day 320 mcg/day)
Fluticasone 44 mcg per puff 88–220 mcg >220–440 mcg X2 per >440 mcg X2 per day MDI Flovent HFA4
propionate 110 mcg per puff X23 per day day (max 440 mcg twice
220 mcg per puff daily)
50 mcg per inhalation 100–250 mcg >250–500 mcg X2 per >500 mcg X2 per day DPI Flovent Diskus
100 mcg per inhalation X2 per day day
250 mcg per inhalation
Fluticasone 100 mcg per actuation N/A 100 mcg per day 100 mcg twice a day or DPI Arnuity
furoate5 200 mcg per actuation 200 mcg once a day Ellipta
Mometasone 100 mcg per inhalation 110–220 mcg >220–440 mcg per day >440 mcg DPI Asmanex DPI
200 mcg per inhalation per day
100 mcg per actuation 100–200 mcg >200–400 mcg >400 mcg HFA6 Asmanex HFA
200 mcg per actuation
Flunisolide 80 mcg per actuation 320 mcg daily >320–640 mcg daily >640 mcg daily MDI Aerospan

(continued )
Table 2.4 (Continued)

Low potency Medium potency Delivery

Steroid name Available strength (dose)1 (dose) High potency (dose) system Brand name
COMBINATION “CONTROLLER” STEROID AND BRONCHODILATOR
Name Available strength Low potency Medium potency (dose) High potency (dose) Delivery Brand name
(dose) system
Budesonide- 80 mcg–4.5 mcg per 80 mcg–4.5 mcg 160 mcg–4.5 mcg X2 N/A MDI Symbicort
Formoterol actuation X2 twice a day twice a day
160 mcg–4.5 mcg per
actuation
Fluticasone 100 mcg–50 mcg per 100 mcg– 250 mcg–50 mcg twice 500 mcg–50 mcg twice DPI Advair Diskus
propionate- inhalation 50 mcg twice a a day a day
Salmeterol 250 mcg–50 mcg per day
inhalation
500 mcg–50 mcg per
inhalation
45 mcg–21 mcg per puff 45 mcg–21 115 mcg–21 mcg X2 230 mcg–21 mcg X2 MDI Advair HFA
115 mcg–21 mcg per puff X2 mcg twice a twice a day twice a day
230 mcg–21 mcg per puff day
Fluticasone 100 mcg–25 mcg per N/A 100 mcg–25 mcg once 200 mcg–25 mcg once DPI Breo Ellipta
furoate-Vilanterol inhalation daily a day
200 mcg–25 mcg per
inhalation
Mometasone- 100 mcg–5 mcg per puff N/A 100 mcg–5 mcg X2 200 mcg–5 mcg X2 MDI Dulera
Formoterol 200 mcg–5 mcg per puff twice a day twice a day
Notes: 1Dose is expressed as usual adult dose. 2Budesonide is the only inhaled steroid available as a solution for nebulizer. 3X2 refers to two puffs or inhalations. 4HFA refers to
the type of propellant used in metered dose inhaler. 5Fluticasone furoate has a greater anti-inflammatory potency than fluticasone propionate and is therefore used at a lower
daily dose and administered once daily.
 What Are Steroids? 33

of the device are the propellants, formulation, metering valve, and actuator.
These components all play a role in the formation of the spray and determine
the drug delivery to lungs. By modifying this device, the spray characteristics
and fine particle dose can be adjusted. The most important aspect of the spray
delivery to lungs is the proper coordination of the dose actuator with the inhala-
tion. This has been recognized as one of the shortcomings of this drug delivery
system, as the accuracy of the dose is highly dependent on the patient’s technique.
The use of a spacer markedly improves the delivery of the drug to the lungs and
reduces the need for the above-mentioned coordination between the actuation
of the dose and the inhalation.

Dry Powder Inhalers (DPIs)

The DPIs are similar to MDIs but do not require the synchronization
between the actuation and inhalation. However, the delivery of the drug to
the lungs involves a forceful inspiration of the powder contained in the device.
In fact, there is a minimum inspiratory rate requirement (at least 28 L/min),
which limits the use of these devices in young children.

Nebulizers
Nebulizer is a device that changes the medication from a liquid form to a mist.
It is relatively easy to use and requires virtually no actions from the patient, other
than ability to breathe in and out through a mouthpiece. There are different types
of nebulizing machines, and they are sometimes specific to a particular medica-
tion. Nebulizers are also used to deliver other medications such as antibiotics.
In addition to the above delivery systems, inhaled corticosteroids are also
available as nasal sprays, which are delivered to the nasal cavity to treat symptoms
of rhinitis such as runny nose and congestion. The following preparations are
available as nasal sprays: beclomethasone (Qnasl ), budesonide (Rhinocort
Aqua), ciclesonide (Omnaris), flunisolide (generic manufacturers), fluticasone
(Flonase Allergy), mometasone (Nasonex), and triamcinolone (Nasacort AQ).

Ophthalmic Corticosteroids
The most common reason for use of corticosteroids in ophthalmology is to
control the inflammation caused by various surgical interventions. They are
also used to manage inflammation associated with certain autoimmune condi-
tions, such as uveitis, allergic disorders, and infections. They are available as
solutions, suspensions, ointments, and implants. Ophthalmic steroids can lead
to many ocular adverse effects, such as cataracts, glaucoma, and elevated
34 Steroids

Table 2.5 Ocular Steroids and Their Characteristics

Dosage form Side effect

Drug (ophthalmic) Brand name profile
Loteprednol Gel, ointment, Lotemax 0.2%, 0.5% Favorable
suspension
Rimexolone Suspension Vexol 1% Favorable
Difluprednate 0.05% Durezol Favorable
Fluorometholone Ointment, suspension FML 0.1%, 0.25% Less favorable
Prednisolone Suspension 0.12%, generic Less favorable
Prednisolone Solution Omnipred 1% Least favorable
Dexamethasone Solution, suspension, Maxidex 0.1% Least favorable
implant
Triamcinolone Suspension Triesence 40mg/ml Least favorable
Fluocinolone Implant Iluvien Least favorable

intraocular pressure. Some of these preparations are formulated to minimize

these adverse effects by being quickly inactivated.
Table 2.5 summarizes the available agents in this category and their
characteristics.

Replacement Therapy
Corticosteroids are also used in adrenocortical diseases that result in the adre-
nal glands’ inability to regulate the hormone secretion. Such conditions include
adrenal crisis, Addison’s disease, and chronic adrenal insufficiency. Various
replacement regimens have been devised and they include all deficient hormones:
glucocorticoids, mineralocorticoids, and androgens. A more detailed discussion
of these principles will occur in Chapter 5.

Contraception
Exogenous hormones are also administered to prevent unwanted pregnancy.
There are two main classes of hormones that can be used as contraceptives: com-
bined estrogen and progesterone (progestin) preparations or progesterone-only
dosage forms. There are many different forms of hormonal contraception avail-
able: tablets, patches, injections, implants, and intra-vaginal and intrauterine
devices. Contraceptive steroids have several mechanisms of actions but their most
important effect is to inhibit ovulation by interfering with the hypothalamus-
pituitary feedback mechanism, which results in suppression of the release of the
follicle-stimulating hormone (FSH). This action is the effect of the estrogen
 What Are Steroids? 35

component. Progestins work by thickening the cervical mucus, thinning the

endometrium, and suppressing ovulation.
Patient selection criteria and principles of therapy for each group of contra-
ceptives will be discussed in Chapter 5.
Two synthetic estrogens are available in all oral contraceptives: ethinyl estra-
diol and mestranol. Mestranol must be converted to ethinyl estradiol by the
liver to attain pharmacologic activity, and it also about 50 percent less potent
than mestranol. There is also a new formulation containing estradiol valerate
with a progestin dienogest (Natazia). Estradiol valerate is a more naturally
occurring form of estradiol, which is associated with fewer adverse effects.
Progesterone components of oral contraceptives include etonogestrel, levo-
norgestrel, medroxyprogesterone, norethindrone, norgestrel, norgestimate,
and desogestrel. Progestin-only contraceptive options are usually available as
injections, implants, and intrauterine devices, and they provide a long-term
type of contraception.
Combination oral contraceptives are available in twenty-one- or twenty-
eight-day cycles, with some preparations containing supplemental agents such
as iron. They may also contain varying doses (phases) of estrogen in an attempt
to minimize the total monthly steroid dose.
Table 2.6 summarizes selected available contraceptive steroids

Table 2.6 Selected Contraceptive Preparations

Contraceptive Combination Additional

agent products Brand names comments

Monophasic Some products are

available as 21-day
regimens with a 7-day
supplement regimen
Progestin Estrogen
Drospirenone Ethinyl estradiol Beyaz 28, Gianvi 28,
Loryn 28, Nikki 28, Yaz
Levonorgestrel Ethinyl estradiol Aviane 28, Falmina 28,
Lessina 28, Lutera 28,
Orsythia 28, Sronyx 28
Norethindrone Ethinyl estradiol Gildess Fe1/20, Junel Fe
1/20 28, Larin Fe 1/20,
Loestrin Fe 1/20 28,
Loestrin 24 Fe,
Microgestin Fe 1/2 28,
Tarina Fe 1/20
(continued )
36 Steroids

Table 2.6 (Continued)

Contraceptive Combination Additional

agent products Brand names comments

Desodestrel Ethinyl estradiol Apri 28, Desogen 28,

Emoquette 28, Juleber
28, Ortho-Cept 28,
Reclipsen 28, Solia 28
Drospirenone Ethinyl estradiol Ocella 28, Syeda 28,
Yasmin 28, Zarah 28
Levonorgestrel Ethinyl estradiol Altavera 28, Chateal 28,
Kurvelo 28, Levora 28,
Marlissa 28, Portia 28
Norgestrel Ethinyl estradiol Cryselle 28, Elinest 28,
Low-Ogestrel 28
Ethynodiol diacetate Ethinyl estradiol Kelnor 28, Zovia
1/35E 28
Norgestimate Ethinyl estradiol Estarylla, Mono-Linyah,
MonoNessa, Orhto-
Cyclen 28, Previfem 28,
Sprintec 28
Multiphasic
Dienogest Estradiol valerate Natazia
Norethindrone Ethinyl estradiol Lo Loestrin Fe,
Ortho-Novum
Desogestrel Ethinyl estradiol Azurette 28, Kariva 28,
Kimidess 28, Mircette 28,
Pimtrea 28, Viorelle 28
Levonogestrel Ethinyl estradiol Trivora 28, Myzilra 28,
Cesia 28
Norgestimate Ethinyl estradiol Orth-Tri-Cyclen, TriNessa
Extended
combinations
Levonorgestrel Ethinyl estradiol Amethia Lo 91, Camrese These products are
Lo 91, LoSeasonique 91, taken continuously
Quartette 91, Jolessa 9 for 84 days followed
by either 7 inactive
tablets or 7 low-dose
estrogen tablets,
during which men-
struation will occur

(continued )
 What Are Steroids? 37

Table 2.6 (Continued)

Contraceptive Combination Additional

agent products Brand names comments

Progestin-only products
Norethindrone None Camilla 28, Debiltane,
Errin 28, Heather,
Jencycla, Jolivette 28,
Lyza 28, Nora-BE 28,
Norlyroc
Medroxyprogesterone None Depo-Provera IM or SQ injection
acetate given every
3 months. Drug
forms a depository
and slowly releases
active hormone
Etonogestrel None Nexplanon An implant rod
placed under skin
layer in inner arm for
a 3-year period of
contraception
Levonorgestrel None Mirena, Skyla Intrauterine device
Other products
Norelgestromin Ethinyl Estradiol OrthoEvra, Xulane Transdermal patch
Etonogestrel Ethinyl Estradiol NuvaRing Vaginal ring

ANABOLIC-ANDROGENIC SYNTHETIC STEROIDS

Various disease states that result in the deficiency of androgens require the
supplementation of synthetic androgens. This is mainly achieved by adminis-
tering testosterone. Replacing testosterone is therapeutically appropriate in
cases of testosterone deficiency in males (a condition called hypogonadism).
These deficiency states result in symptoms that represent the lack of the male
sex characteristics described before: loss of facial hair, breast growth, small
testes, and low libido.
In addition to hormone replacement, testosterone also exhibits a number of
anabolic effects such as skeletal muscle growth and improved bone density.
This anabolic action of steroids has led to increase in inappropriate use of
androgens and contributed to the development of a multimillion dollar market
for steroid-based dietary supplements or “designer steroids.” The purpose for
using these agents is usually to enhance athletic performance.
38 Steroids

Most of the available preparations have originated from structural modifica-

tions to a molecule of testosterone. The common goal of these modifications is
to separate the androgenic and anabolic activities as much as possible.
However, despite these modifications the anabolic and androgenic actions
cannot be fully separated.
Therapeutic testosterone preparations are available in three dosage forms:
oral, injectable, and transdermal. These agents are available only via valid
prescription and are all classified as controlled substances in Schedule III,
which means they have a significant potential for abuse and dependence.
These preparations are also used in women to treat testosterone deficiency,
although this practice remains controversial and lacking in supporting clini-
cal data.

Oral Preparations
Methyltestosterone (Android ), available as tablets and capsules, is also pre-
scribed to treat delayed puberty and metastatic breast cancer. The chemical
structure of this agent interferes with its activation and makes it the least effec-
tive in the treatment of testosterone deficiency.

Injectable Preparations
Testosterone cypionate (Depo-Testosterone) and testosterone enanthate
(Delatestryl ), intramuscular (IM) solutions, chemically administered every
two to four weeks, form a depository in the muscle and release the medication
over time. These preparations have been shown to be more effective than oral
dosage forms and also offer the benefit of freedom from daily administrations.
Testosterone undecanoate (Aveed ), an extra-long-acting intramuscular
(IM) preparation, can be administered every ten to fourteen weeks. Its admin-
istration is restricted to an office or hospital setting by a trained professional
due to rare reports of severe allergic reactions.

Topical Delivery Systems

Owing to its excellent absorption through the skin, testosterone is available
in a multitude of transdermal delivery systems: patches, pumps, and gels.
The advantage of this type of administration is maintenance of a relatively
steady concentration of the hormone throughout the day. Androderm is a
transdermal patch applied daily. Testim, AndroGel, and Fortesta are all gels,
available in different strengths (1 percent, 1.62 percent, and 2 percent, respec-
tively) and supplied in metered-dose pumps.
 What Are Steroids? 39

Other Delivery Systems

Testosterone is also available as a buccal system (Striant), which is adminis-
tered via application to the cheek within the mouth.
Another dosage form is testosterone subcutaneous implants (Testopel ),
which are small pellets implanted under the skin every three to six months.
Other synthetic androgens, like danazol, are used to treat endometriosis.
Danazol is a progestin-like oral hormone preparation. Oxandrolone (Oxandrin)
is used to promote weight gain in patients who are recovering from extensive
surgery or severe trauma.

ANABOLIC STEROID SUPPLEMENTS

As mentioned earlier the anabolic activity of androgens contributed to the
widespread abuse of these agents among athletes as well as the general population,
including school-aged children. According to Drug Enforcement Agency,
0.5 percent of the U.S. adult population had used anabolic steroids. The use of
anabolic steroids is prohibited by the World Anti-Doping Agency (WADA),
and its list of banned substances includes almost one hundred agents.
Dietary supplements are available in natural food grocery stores, and a lot of
people do not believe the risks associated with the use of these products.
Meanwhile using anabolic steroids has been shown to have a high potential
for abuse and physical dependence. Some of the dangers of steroid abuse
include aggression, depression, extreme irritability, infertility, high blood pres-
sure, liver disorders, and impaired fetal development during pregnancy.
Details regarding the anabolic steroid abuse, strategies employed by the
abusers, and regulatory aspects will be discussed in the forthcoming chapters.
Perhaps one of the most famous anabolic androgenic steroids is Primobolan,
which is the trade name for methenolone enanthate. This steroid was used by
Alex Rodriguez, star of the New York Yankees, and was called his “drug of
choice” in articles written for both Sports Illustrated and Popular Mechanics.
This drug is considered a long-acting steroid but actually has a half-life of
twenty-four hours and needs to be used in combination with intense physical
workouts to build muscle.
Another common practice among steroid abusers is to take other drugs
along with the anabolic steroids, for the purpose of masking the abuse, allevi-
ating the short-term side effects of anabolic steroids, or serving as steroid alter-
natives. Drugs used to mask the steroid abuse include the following:
erythropoietin, human chorionic gonadotropin (HCG), probenecid and diu-
retics (spironolactone, furosemide), clomiphene (Clomid ), and tamoxifen
(Nolvadex).
40 Steroids

The latter two are supposed to combat the side effect of gynecomastia,
which is growth in breast tissue and nipple size in males using designer ste-
roids. Clomid was requested by Alex Rodriguez as an exemption to the rules
of the Major League Baseball organization and was granted that exemption
in 2008. It was to address weight loss and low testosterone levels. Because
the use of anabolic steroids can reduce the production of testosterone,
selective estrogen receptor modulators (SERMs) are utilized to increase tes-
tosterone production while balancing too much estrogen—the reason for
gynecomastia—while the body returns to its healthy, pre-anabolic steroid
state.
The “stacking” and “cycling” process is the rationale for the use of SERMs.
This appears to be the case for the famous ballplayer, as well.
Examples of steroid alternatives that increase the concentration of testoster-
one include insulin, human growth hormone, erythropoietin, gamma-
hydroxybutarate (GHB), and drugs that block the conversion of androgens
to estrogens in the body (letrozole and anastrozole).

Dietary Supplements
A significant number of testosterone precursors have been marketed as
dietary supplements. Examples of these substances include androstenedione,
DHEA, and hydroxymethylbutyrate.
Compounds containing androstenedione can be identified with many names,
such as androstene-3beta, 17beta-diol, 4-androstenediol, and 5-androstenediol,
among others. However, the names given to website supplements can be differ-
ent; this is what presents a problem for the buyer. Not knowing the true dangers
and risks of such a substance increases the danger to the person who believes the
website’s claims.
Androstenetrione is called an alternative to those anabolic steroids banned
by the government; it blocks the conversion of testosterone to the female hor-
mone estrogen, a natural process in the body. The manufacturers claim the
body will make more testosterone as a result of this blockage. There is no
research to support that claim, but the supplement will be legally sold until it
can be evaluated by the FDA.

Hydroxymethylbutyrate (HMB)
This chemical is produced in the body when an amino acid (lucine) breaks
down. This substance can be used to treat high cholesterol, heart disease,
 What Are Steroids? 41

and/or high blood pressure when combined with other amino acid supple-
ments. It promotes weight gain in patients with AIDS or terminal cancers
who are experiencing “wasting”—a debilitating process of excessive muscle
and fat loss. It is also said to increase benefits from weight training and exer-
cise, especially for those who need this as a therapeutic intervention.
Bodybuilding websites advertise it as a muscle builder that promotes fat loss.
However, evidence from clinical trials provides conflicting conclusions
regarding these claims.

Dehydroepiandrosterone
This hormone is produced by adrenal glands and functions as a precursor
(a chemical that is converted by the body) to male and female sex hormones.
The production of DHEA is said to peak for a person sometime in their
mid-twenties and declines with age. Because the sex hormones, testosterone,
and estrogen also decline with age, DHEA can increase their levels.
Some studies have shown beneficial, anti-aging results from DHEA supple-
mentation, but others have not resulted in the same outcomes. Other claims
about DHEA include strengthening the immune system, building muscle
strength, improving mood and memory, increasing energy, and slowing down
the aging process.
Health food stores and muscle-building companies push the positive effects
of the DHEA supplement; however, there is no evidence yet that DHEA slows
the aging process and enhances a more youthful outlook or physical condition.
In fact, long-term use of the supplement may be dangerous over time. Perhaps
most interesting to those who look for increased muscle strength and growth,
DHEA is on the list of banned substances for school athletes, although it is not
banned by the federal government.
In a New York Times article (2009) about the discovery of steroids in
dietary supplements, two pills favored by high school students were identi-
fied: Tren Xtreme and Mass Xtreme. These supplements are made with ille-
gal synthetic steroids, one of which is called Madol. Because the supplements
are compounded with these particular synthetic steroids, they are illegal for
purchase. Currently available, a YouTube video, produced by CBS News,
reports on this discovery and the impact of these hidden designer steroids
on a group of young athletes: “Store Bought Steroid Scandal” by CBS. In this
video, Tren is the supplement about which these athletes’ families are suing
the manufacturer.
42 Steroids

Testosterone Boosters
There are, of course, supplements that promise similar results to those of
steroids but which, in reality, are combinations of vitamins and minerals or
herbs and other plant products (sterols). Often touted as “testosterone boost-
ers,” the belief in their effectiveness seems to be more in the minds of their
users than in any proven research. For example, creatine ethyl ester (CEE)
has been sold as a muscle builder by many body-building outlets and in popu-
lar pharmacies, such as CVS. According to a research study by Spillane et al.
(2009), a rigorous experiment comparing CEE to other supplements demon-
strated no significant influence on body mass; rather a regular weight lifting
regimen appeared to be a key factor in the growth of muscle among the young
men in the study. Nevertheless, CEE continues to be sold with claims of its
power reinforced on various websites and advertisements.
Another popular supplement for increasing testosterone is ZMA. This is
a blend of magnesium, zinc, and vitamin B6, which will supposedly
increase “free” testosterone, that is, the natural testosterone that circulates
throughout the body and is not attached to any particular protein cells.
This type of testosterone is involved in building muscles and influencing
mood. Sold in reputable health food outlets and online, an online ad from
the Vitacost company states that ZMA provides “quality zinc, magnesium
and B6 to supplement dietary intake, ARO ZMA may have the effect of
helping to improve the hormone profile of those engaging in intense physi-
cal activity.” The company follows that sentence with the following:
“These statements have not been evaluated by the Food and Drug
Administration. This product is not intended to diagnose, treat, cure, or
prevent any disease.” Other outlets, however, are not as direct in noting
the lack of FDA approval.

Herbal Supplements
Stinging Nettle (Urtica dioica)
Stinging nettle is a perennial, flowering, stalk-like plant that has been
used throughout history to treat muscle and joint pain, anemia, arthritis, and
eczema.
Experimental studies suggest, among other effects, a decrease in proteins
that bind circulating androgens and inhibition of enzymes that convert testos-
terone to estrogens. This increases the concentration of testosterone. However,
lack of quality clinical trials limits any substantial recommendations regarding
these products.
 What Are Steroids? 43

Tribulus terrestris
This perennial, creeping herbal product has been used in traditional cul-
tures, traditional Chinese medicine, and Indian Ayurvedic medicine as both
a diuretic and an aphrodisiac (a drug or food that arouses sexual desire).
It has been supported for many years as a booster of free testosterone.
However, the clinical use of this product remains controversial, and little is
known about the mechanism of action and effects of this herb.

NON-HORMONAL STEROIDS
Because so many steroids exist, scientists have classified five main categories
based on their chemical compositions. These five categories are the following:
cholestanes, cholanes, pregnanes, androstanes, and estranes. Within each of
these groups, thousands of variations of steroids can be identified. Pregnanes,
androstanes, and estranges include the hormonal steroids that have already
been discussed. The non-hormonal steroids belong to the categories of choles-
tanes and cholanes.

Cholestanes
These chemicals are known as “precursors” to hormones and serve as basis
for synthesis of many other hormones. There are some important types of cho-
lestanes: glycosides, saponins, benzoic acids, secosteroids (vitamin D), and ste-
rols. These substances are usually plant-derived and are used to synthesize
designer steroids.

Glycosides
These are naturally occurring compounds that contain a sugar molecule
(glycone) and a non-sugar molecule (aglycone). These steroids produce sugars
and non-sugars and are found in many plants. With the help of certain labora-
tory processes, the non-sugar portion contains the chemicals that can be used
in medicines for both humans and animals. For example, digoxin is a type of
heart medicine classified as a cardiac glycoside and is used in the treatment of
congestive heart failure. This particular steroid is found in the leaf of the fox-
glove plant, called digitalis.
There are several sub-types of glycosides, one of which is called a flavonoid.
This particular type is interesting because it is sold in health food stores as anti-
oxidant supplements. Quercitrin, rutin, and others are used to preserve capil-
laries (tiny blood vessels) in addition to minimizing cell damage.
44 Steroids

Saponins
Steroid saponins are called saraponins and structurally resemble glycosides.
They produce a soapy foam when dissolved in water. Saponins have shown
anti-cancer and anti-cholesterol activity and may also stimulate human
immune system. Saponins are present in many foods such as soybeans, chick-
peas, and kidney beans.

Benzoic Acid
This substance is a precursor to the supplement Tryptophan, which is a
pharmaceutical equivalent of the naturally occurring amino acid, tryptophan.
This is a supplement used by body builders in conjunction with their anabolic
androgenic steroid use. In addition, however, this substance is also a precursor
to a drug called methaqualone or Quaalude. This drug is a Schedule I
Controlled Substance and it is illegal to buy, sell, or possess.

Secosteroids
These compounds are derived from vitamin D. They include calcitriol
(1,25-dihydroxyvitamin D), which is a calcium-regulating hormone, released
as a result of calcium deficiency. The second compound is 25-hydroxy-
vitamin D, which is a precursor of the active hormone, whose primary func-
tion is to maintain the balance between calcium and phosphorus.

Sterols
Sterols are found in virtually all animals and plants. To date, more than forty
plant sterols have been identified in humans, with cholesterol being the most
widespread sterol. In plants, sterols have a similar function to cholesterol that is
normally present in animal cells. It has been postulated that plant sterols reduce
intestinal absorption of cholesterol in humans, thereby reducing its level, and
many fat-containing foods were enriched with plant sterols for this effect.

Cholanes (Cholic Acids)

These acids are instrumental in breaking down foods so they can be reab-
sorbed into the lower intestines. Additionally, they can be useful as digestive
aids and laxatives. Cholbam (cholic acid) is a recently FDA-approved agent that
is indicated for the treatment of patients with a rare bile acid synthesis disorder
due to enzyme deficiency.
 What Are Steroids? 45

CONCLUSION
In this chapter, we have covered some of the basic categories of steroids,
both catabolic and anabolic. The importance of these drugs, natural and syn-
thetic, is clearly established in the lives of present day society. How many of
these drugs do you recognize in your neighborhood drugstore? Do we really
know what they are doing to our minds and bodies and do we trust their
applications to our physical and mental needs?
Our next chapter focuses on the history of discovery of natural steroids and
the ability of scientists and biochemists to find methods to synthesize and cre-
ate new, more powerful steroid medications and products from those that are
natural to all humans and plants.
 Chapter 3

The History of Steroids

Joan Standora

Curiosity about how the human body functions is evident in all cultures from
the beginning of our oldest, documented history. Very early, scientists did not
have the benefit of the Internet to research the work of others nor the modern
day equipment and resources to move easily into the realms of the unexplored
and mysterious qualities of human life. In ancient civilizations, such as Egypt,
there was a distinct effort to explain and treat how the body responded to vari-
ous illnesses and ailments. The same efforts are found in the records of ancient
medicine from India, China, Greece, and Italy.
Perhaps the clearest indication that the discovery of steroids would occur
over time was the early belief in the power of male testosterone, namely in
the form of testes. There are many examples in history that suggest the associ-
ation between strength, stamina, and power with the male sex hormone.
Observations that males were likely to be more aggressive and, certainly, physi-
cally stronger than females were the basis for the focus on testicles. Castration
was a not uncommon practice in the ancient civilization of Assyria, where
competition for leadership roles was dealt with by removing the testicles of
the potential threat. These castrated individuals, called “eunuchs,” never
developed male characteristics and were physically weaker, lacked the usual
appearance of body hair, and had high voices. Another example of the belief
in the power of male sex organs is found in early Greece, where Olympic ath-
letes were said to ingest animal testicles before competitions to gain greater
prowess in the field. In Ancient East India as well as Central America, animal
testicles were believed to combat sexual impotence. From native Mexicans to
48 Steroids

Southeast Asians, examples abound with the preparation and ingestion of ani-
mal testicles and penises to enhance virility. South African witch doctors might
use the body parts of a person (cut from a living person) to create magical
potions for strength and courage. All of this leads to the fact that the observa-
tions of people regarding male characteristics were linked to the physiological
presence of male sexual organs.
Spiritual beliefs, also, were instrumental in the development of early
approaches to treating illnesses and mental disturbances. For the Egyptians,
every part of the body had a special spiritual overseer, or godlike entity, respon-
sible for the body’s well-being. “Egyptians assumed that the body was divided
into 36 parts, each of which was under the sway of a certain god. ‘There is no
limb of his without a god’ (Leyden Papyrus, a.k.a. Leiden Papyrus), and so
invoking these, they heal the diseases of the limbs.” The Egyptians developed
medicines to address pain, burns, and other physical problems based on their
observations of how certain herbs and food substances seemed to relieve or
cure these ailments. For the people of this civilization, it was to the priests they
turned for help when troubled with illness. The priests would provide magical
and spiritual treatments with the herbal medicines they had created. According
to historians, the list of remedies was extensive, supported by documents that
explained and evaluated the application of the medicines and their impact on
the body.
Various mixtures of foods, seeds, and plants made up the cornucopia of
remedies to ingest or apply. Today, we continue to use some of those similar
herbal applications, recognizing that their effects are attributable to chemical
reactions, rather than magic or spiritual interventions. A good deal of what
we know about this kind of treatment, however, comes from these ancient sci-
entists who must have spent many years observing cause-and-effect examples
between the use of treatments and the outcomes on the body. These practices
may be seen as the forerunners of the preoccupation of modern science with
the communication between body organs and body function. In particular,
the examination of male characteristics and sexual function was a focus for a
German scientist in 1849. Arnold Adolph Berthold, who is often called the
father of modern endocrinology, experimented with birds called cockerels by
removing their testes. The experiment resulted in losing their male character-
istics. In a following experiment, Berthold removed the testicles of the cocker-
els and transferred them to the abdomens of the birds. The sexual functions
were not affected in this case, but a greater understanding of how the testicles
connect to circulation and work to maintain the body’s healthful process was
achieved. The result of the experiments was a greater understanding of the
 The History of Steroids 49

relationship of maleness to the testicles and the latter’s influence on healthy

functioning in the male animal.
From the late 1880s to the early 1890s, researchers in Germany and France
became interested in the possibility that there was a system of coordination
between organs that maintained the body’s ability to function and support life.
It is important to remember that the early scientific work was done primarily
for therapeutic reasons to address human ailments and not for the enhance-
ment of power and physique in the human body.
In the late 1880s, however, a highly respected physician, Dr. Charles-
Edouard Brown-Séquard, experimented with developing a solution to old
age and its potentially debilitating consequences. Before these experiments,
Dr. Brown-Séquard had been recognized professionally for his contributions
to the knowledge of neurology in the United States as well as in England and
France. He was elected to many prestigious academic associations, including
the Royal Society, the National Academy of Sciences (United States), and
the Academie des Sciences in France. He was the founder and editor of three
medical journals, published a number of books, and was prolific in his writing
of scientific papers, which totaled more than 500.
His life prior to experimenting with an anti-aging remedy was complicated.
Dr. Brown-Séquard was born in 1818 in Mauritius, a British colony, to an
American sea captain father and a French mother. He never knew his father,
who had died prior to his birth. Dr. Brown-Séquard was raised by his mother
and, at the age of 21, moved to Paris as a hopeful writer. Unfortunately, for
him, he was not successful. Instead, he decided to go to medical school and
become a doctor. He completed his studies in 1846 and wrote his thesis on
the physiology of the spinal cord. He focused his early work on experimental
and clinical neurology and developed ideas relative to the central nervous sys-
tem (CNS) and its connection to areas of the brain. He is considered, also,
to be a pioneer in the treatment of epilepsy. In 1849, he published his most
famous work in neurology with the result that his discovery would become
known as the Brown-Séquard effect.
He became interested in the functioning of the adrenal glands in 1855, after
reading about the work of another scientist, Thomas Addison. Brown-
Séquard’s interest culminated in his major contribution to the field of endocrinol-
ogy when he reported that the removal of both adrenal glands in animals resulted
in death. At the age of 72, in 1889, he made a famous and well-publicized
presentation. He had conducted a series of rejuvenation experiments in
which daily injections of testicular extract, along with testicular blood and semi-
nal fluid, taken from guinea pigs and dogs, made him feel thirty years younger.
50 Steroids

He maintained that the injections enabled him to lift heavier weights, work
for more hours, and run up and down stairs. His audience’s average age was
71—not difficult to understand the impact of his presentation on this group of
fellow physicians and scientists!
His presentation made a huge impact on the medical community in general.
Calling his discovery “The Elixir of Life,” Dr. Brown-Séquard (1889) was both
criticized and ridiculed; however, these findings were widely publicized and
actually led to more research and discovery, as 12,000 physicians began using
the same concoction of fluids, extracted in similar fashion, to seek similar
effects. By 1893, studying the use of internal secretion of glands and their
effects on many disorders was a method used by 1,300 physicians. Leading
to a practice called “organotherapy” or “The Method of Brown-Séquard,” sub-
sequent research led to the discoveries of thyroid extract, growth hormone
(GH), and parathyroid extract among others.
Although an extremely energetic traveler from one continent to another
(sixty times crossing the Atlantic between 1853 and 1878) and living in
England, France, and the United States at various times, Brown-Séquard was
known to suffer from depression which often motivated him to move to
another country. He retired in Paris in 1878. His death at age 77 in 1894 rein-
forced the view of other researchers who had tried to duplicate the results of his
“elixir” that the effects on him were, most likely, the result of a placebo effect
rather than an actual physiological rejuvenation of his body. He believed in
the efficacy of his magical potion and, therefore, felt stronger and younger as
a result.
Another scientist, however, who was to produce a wildly popular procedure
for rejuvenating male sexuality, was Dr. Eugen Steinach. Influenced by
Brown-Séquard’s lecture in 1899 in which he described his self-injection of
testicular extracts from dogs and guinea pigs, Steinach began his own investi-
gation in the science of anti-aging. A brilliant scientist, Eugen Steinach
(1861–1944) was an Austrian physiologist and biologist who was a pioneer
in the discipline of endocrinology. Dr. Steinach researched hormones and,
after becoming director of the Biological Institute of the Academy of
Sciences in 1912, began to experiment with testes transplantations. He trans-
planted a male guinea pig’s testes into a female guinea pig and observed the
changes in the female’s behavior. The testosterone in the female resulted in
her approaching the male sexually, behaving as a male guinea pig normally
would in sexual interaction. Steinach now believed that testosterone, secreted
by the testes, was responsible for male sexuality.
Again, in an attempt to retard the process of aging and fatigue, Steinach
sought to increase sexual potency and virility in men. He maintained that
 The History of Steroids 51

the results of the experiment on himself resulted in an increase in strength as

well as an increase in sexual potency. His method was what is now known as
a “half vasectomy” in which sperm would be reduced and testosterone produc-
tion would be increased through surgery on the testicle. This procedure was
called the “Steinach operation” or “Steinach vasoligature.” This procedure
became much sought after by famous actors, artists, physicians, and wealthy
financial moguls. The procedure was applauded by thousands of men who
claimed that their virility had been restored by this operation. The procedure
lasted twenty minutes, during which time one of the ducts that produce semen
was “tied off,” thus producing a partial vasectomy. Other surgeons joined the
surgical parade during the 1920s and 1930s. The poet William Butler Yeats
was “Steinached” in 1934 and claimed that he experienced a “second puberty”
as well as an outpouring of new poetry. Perhaps his most famous patient,
Sigmund Freud, who underwent the surgery at age 67, hoped as others before
him to restore his youthful sexuality.
One of the most interesting theories of Dr. Steinach, and one that has rel-
evance particularly today, was his theory of bisexuality. He believed that each
sex has the potential to develop as the opposite sex. The differences between
men and women, sexually, were the result of the balance between the sex hor-
mones, male and female, within the bodies of each person. According to
Steinach, there was a distribution of these hormones that could be character-
ized as “intermediate sex,” producing a continuum of behaviors and character-
istics. Steinach was not the first, of course, to consider the concept of
bisexuality. The Greeks believed that man and woman were created to divide
a single sex organism.
As with the other anti-aging pioneer, Brown-Séquard, Dr. Steinach was dis-
credited by others in the medical community despite the popularity of the pro-
cedure publicized by newspapers reporting on its efficacy. Dr. Steinach,
ultimately, received six nominations for the Nobel Prize in Physiology from
1921 through 1938 but was never a successful candidate. When he died in
May 1944, he was in exile in Zurich, Switzerland, to escape Nazi persecution;
he was troubled by the criticism he had received about his rejuvenation work.
Today, he is recognized as having a clear impact on biochemists who work
with all of the endocrine glands.
The quest for rejuvenation had not died, however, as Dr. Serge Voronoff,
surgeon for the king of Egypt, carried the experiment further by transplanting
the testes of executed criminals into aging men. The latter were rich and eager
to have the procedure performed. The source of the supply dwindled and was
not adequate for the demand. Dr. Voronoff began, then, to transplant bits of
monkey and chimpanzee parts onto the genitals of his aging male patients.
52 Steroids

It is estimated that more than 1,000 men around the world underwent this
particular surgery with much of the monkey or chimpanzee contributions
coming from the doctor’s own monkey farm.
Continuing to build on all that had come before, as the evolution of scien-
tific discovery does, discussions about these internal communication processes
between bodily organs continued in the medical community. In 1906,
Professor Edward Starling of London began a discussion about his view of
the process that must exist between bodily organs in order for the body to
function properly. Seeing this as a system of chemical reactions, he proposed
that substances in the body, “chemical messengers,” which he named “hor-
mones,” circulated throughout the bloodstream in specific ways and with spe-
cific targets to maintain the body’s equilibrium. By coining the term, and
explaining the “how” of the process, Starling facilitated future work in steroid
research. As the similarity among hormones was recognized, the word “ste-
roid” was created when scientists identified and isolated hormones that shared
a molecular shape (gonane); this permitted them to characterize these hor-
mones as part of a group. The term, itself, comes from the Greek word “sterol”
(similar kind) and a way of classifying the group as “-oid.” Thus, steroids were
now discovered. While previous researchers in Germany and France had
begun to explore this chemically based communication, Starling’s work had
a significant impact on other scientific disciplines: chemistry, epidemiology,
molecular biology, and, ultimately, on human contraception and reproductive
functions. In 1926, scientists discovered that the pituitary gland functioned in
a role with the human reproductive system, leading eventually to the creation
of the pregnancy test. In 1928, University of Rochester scientists in New York
identified progesterone—the ovarian hormone. Their research led them to
agree that progesterone played a crucial part in preparation of the womb for
sustaining pregnancy.
During the 1930s, the interest in isolating and synthesizing testosterone was
prevalent. Androgenic steroid discovery and the desire to reproduce these hor-
mones synthetically increased. The treatment of male hypogonadism (a result
of testosterone deficiency) demonstrated the usefulness of these hormones in
treating conditions that required more strength, bone growth, appetite, and
the synthesis of protein in the body.
In 1931, a German chemist, Adolf Butenandt, was able to identify and
purify the hormone androstenone. He accomplished this quite simply by
extracting it from liters of urine. As a result, this revolutionary event led to
more discoveries that would encourage more study and evolution in the field
of anabolic steroids. Soon after Butenandt’s breakthrough, another German
chemist, Leopold Ruzicka, developed a way to synthesize the hormone so that
 The History of Steroids 53

it was safe for human use. Things now began to move rapidly in the field of
chemistry. In 1935, Butenandt and a fellow chemist, Leopold Ruzicka, com-
pounded (put together) the first lot of synthetic testosterone. Now, anabolic
steroid use would take its place in history. The discovery was considered so
important that the two scientists were awarded the Nobel Prize in Chemistry
in 1939. Clearly, the evolution into recreational drug use with its dangerous
risks and effects was not a vision shared by anyone during that period.
Because of this success, the manufacture of the steroids outside of the
human body increased; the potential for a variety of uses led to the first injec-
tions of testosterone for humans. The history books tell us that the German
army took anabolic androgenic steroids during World War II to increase their
toughness for the exhausting requirements of war: increasing stamina, endur-
ance, and aggression. By the 1940s, anabolic steroid use was becoming more
common. It is known that the Soviet Union was administering steroids to its
athletes; their domination in the Olympics was legendary. Time does not
appear to have changed this approach to competitive Russian Olympic sports
as the Russian team of 2014 is believed to have indulged in a number of syn-
thetic anabolic steroid substances. However, a physician in charge of the
U.S. Olympic team, Dr. John Ziegler, developed a response to that dominance
in the 1950s. He developed a substance known as methandrostenolone, known
today, commonly, as Dianabol or Dbol. The drug was marketed by Ciba
Pharmaceuticals and it was approved by the Federal Drug Administration by
1958. The pharmaceutical company, along with many others, began experi-
menting with anabolic steroids and their varieties and began a rush among
other pharmaceutical companies to produce similar substances. Dianabol was
marketed as a drug for hypogonadism in the therapeutic medical community;
however, it is clear that the substance was targeted at athletes, as early as 1940.
Thus, the first legal androgen-based steroid became popular among athletes
from many countries.
In the 1940s, two researchers, Dr. Edward Kendall and Dr. Philip Hench,
discovered cortisone and used it to treat joint disorders. It was so powerful as
an anti-inflammatory that its results for those suffering from rheumatoid
arthritis were dramatic. It was considered a “miracle drug,” earning the two
doctors the Nobel Prize for Medicine in 1950. Thus, by the 1950s, chemistry,
physiology, biology, and other scientific disciplines had joined the exploration
and increased understanding of metabolic function and its disorder, as well.
This convergence resulted in important developments and further research
into hormones and the endocrine system in human beings. As technology
and biochemistry advanced together in the mid-twentieth century, from
1960 on, scientists were discovering new steroid hormones. These hormones
54 Steroids

provided new information about the interactions that occurred within the
endocrine system as well as enabling science to fine-tune synthetic versions
of steroid hormones, so that previously undesirable traits were decreased and
positive elements enhanced. A result of this was that the technology that was
now available gave biochemists a new perception of steroids, as they were able
to study human physiology at the molecular level. New and effective medical
treatments were developed, therefore, as chemically based interventions for
various health problems of consumers. Therapeutic steroids such as predni-
sone and prednisolone were developed in the 1950s as the first synthetic corti-
costeroid to treat acute asthma symptoms. A number of similar drugs were
developed for asthma treatment during this period. Sales of these medications
were brisk during the 1950s and 1960s. The caution for patients, however,
was the fact that because the body produces its own corticosteroids, patients
have to be carefully weaned off the medication. The body thinks that it has
enough of these steroids when taking the medication; therefore, to take some-
one off it too quickly could result in death. High dose and long-term use of
these medications can have serious outcomes because of their extensive impact
on the body’s overall health. A better alternative, the inhaler, proved to be a
better option for asthmatics. Throughout the 1960s and into the 1980s, inhal-
ers were improved so that the medicine within them could be absorbed more
deeply into the lungs, rather than through injection or oral administration.
The latter methods of administration are able to get into the body’s system
and cause other effects. Up to the 1990s, injection of steroids for severe epi-
sodes of asthma continued with inhaled medication used for other, less serious
attacks. It would be finally recognized that asthma is a chronic condition and,
therefore, the need for daily use of an inhaled corticosteroid was necessary.
This is seen as a preventive measure as well as therapeutic approach. In 1989,
the NHBLI created asthma guidelines to advise physicians on best practices
in treating their asthma patients.
The most dramatic development in steroid research, perhaps, was the intro-
duction of the human contraceptive in 1960. Looking back in history, the
women of ancient Egypt concocted their own version of a birth control rem-
edy: a suppository of cotton, honey, dates, and acacia was used to suppress
conception. In fact, it was discovered later that a fermented form of acacia
actually was effective as a spermicidal. Other forms of birth control in ancient
times (and still used today) was the withdrawal method, references to which
are found in both the Bible and the Koran. Prior to the invention of the birth
control pill, various other methods of birth control had been devised, includ-
ing the diaphragm, douches, sponges, and other ploys. Margaret Sanger, a
female activist and nurse in the early 1900s, opened the first birth control
 The History of Steroids 55

clinic (a term she invented) in Brooklyn, New York, and later started the
American Birth Control League—the forerunner to Planned Parenthood.
At this time, a pill had not yet been created, but other methods of birth control
were taught to women at the clinic. Her friend, Katherine McCormick, the
first woman to graduate from the Massachusetts Institute of Technology as a
scientist, was keenly interested in birth control, as well. Her husband had been
diagnosed with schizophrenia; she was determined not to have children, her-
self, believing strongly in the value of contraception. In 1873, Congress had
passed a law, the Comstock Law, which identified all forms of contraception
as obscenities, outlawing their dissemination through the postal service or
across state lines. Ms. Sanger was indicted in June 1914 for writing about birth
control in her newspaper; she fled to England where she continued her efforts
to encourage contraception. In 1916, she returned to the country to face trial
and the charges were dropped; she continued, however, to fight for the repro-
ductive rights of women and, upon meeting Katherine McCormick in 1917,
the two worked together to realize their passions. The first clinic was opened
in 1923.
In 1954, Gregory Pincus (1903–1967), a biologist/physiologist, had been
working on the sexual physiology of mammals. That year he successfully
conducted an in vitro fertilization of rabbits, producing a “test-tube” rabbit.
The effort was not well received as the public and scientific world looked
upon this milestone as an example of science fiction becoming reality. It is
thought, too, that during that time, the publication of Aldous Huxley’s
book, Brave New World, depicted test-tube babies as zombie-like beings
who had none of the redeeming features of the emotional human being.
The notion of creating such creatures had apparently captured the imagina-
tions of the public. This experience might have ruined him; however, in
1936, two years later, he published a brilliant work on mammalian
eggs, which brought acclaim from scientific circles. However, once again,
Dr. Pincus’s success was delayed by the Great Depression that had over-
taken the country. It was difficult to find any work to support his family until
a friend, Dr. Hudson Hoagland, invited him to Clark University in
Worcester, Massachusetts, to work in the biology department. In 1944, the
two established the Worcester Foundation for Experimental Biology, which
conducted applied scientific research, especially in the growing inquiry
into new steroid research. Dr. Pincus was still struggling in this small,
Massachusetts-based foundation, outside of the usual high-profile university
laboratories with extensive resources. It was here that Margaret Sanger, along
with her partner, Katherine McCormick, approached Pincus in 1953, asking
him to develop a birth control pill.
56 Steroids

Dr. Pincus agreed to work on the project, funded by Ms. McCormick.

Studies had already been done on the ability of progesterone to act as an
anti-ovulent, meaning that it could prevent ovulation and, therefore, the
production of eggs for fertilization. In only a few months, Pincus and a fellow
scientist, Min-Cheuh Chang, demonstrated that repeatedly injecting ani-
mals with progesterone would stop ovulation. The next step, a challenge,
was to produce an inexpensive pill that would act in the same way on wom-
en’s ovulation cycles. Fortunately, two pharmaceutical companies had been
working on developing synthetic progesterone, although not for the same
purpose as Dr. Pincus. Both companies, Syntex and Searle, with some reser-
vation, agreed to let him use the synthetic progesterone for preliminary
trials as contraceptives for humans. Next, Pincus began a collaboration with
a fertility specialist, Dr. John Rock. The two conducted small trials in
Massachusetts with successful results. In 1956, they began much larger
human trials in Puerto Rico, using the contraceptive formulation based on
the Searle synthesis of progesterone. In 1960, the Searle contraceptive was
approved by the U.S. Food and Drug Administration and Dr. Pincus became
an internationally acclaimed scientist. Unfortunately, because of his expo-
sure to laboratory chemicals over many years, he died of bone marrow disease
seven years later at the age of 64.
This momentous discovery, however, received more acclaim than Dr. Pincus.
It was immortalized in music by Loretta Lynn, a popular country-western singer,
who wrote and recorded the song, “The Pill.” The song reached the top of the
charts as women, in particular, saw the discovery as a liberating step toward
greater sexual freedom. It can be said, safely, that the “sexual revolution” erupted
in the 1960s, in great part, because of this discovery. It may also be unlikely that
many people are unaware that steroid research led to this major social
influence.
On another front, new anabolic steroids were being synthesized during the
1960s, especially in Germany where research and development efforts were at
a peak. Prior to 1960, the use of amphetamines as performance-enhancing
drugs was common. Amphetamines increase alertness and vigilance. The mis-
use of this kind of drug, however, also led to unfortunate and lethal outcomes;
on August 26, 1960, at the summer Olympics in Rome, a Danish cyclist, Knut
Jensen, died during his team’s trial race. He collapsed, fracturing his skull, and
was originally thought to have succumbed to heat exhaustion. An autopsy
revealed that it was not the heat, but the use of an amphetamine called
Ronicol that killed him. The focus on anabolic steroids created greater oppor-
tunities for athletes searching for better performances through strength and
stamina. While doping with amphetamines continued (with another death of
 The History of Steroids 57

a cyclist, Tommy Simpson, in 1967), the trend was clearly toward the use of
AAS substances by many of the people in competitive sports.
It is important to note here that a person may be born with an imbalance in
hormones leading to physical or mental changes not ordinarily associated with
gender. A case in point is the presence of polycystic ovary syndrome (PCOS) in
which a woman’s body makes more male hormones (or androgens) than usual.
This causes additional hair growth on the face and body with a thinning of hair
on the head. The syndrome can also cause skin problems, reproductive abnor-
malities, and weight gain. Certain female athletes in the Olympics, for
example, while competing as females, are accused of an unfair advantage
because of their extra testosterone hormones. Nevertheless, it is the gender that
the athlete identifies with that defines, generally, the category into which the
International Olympic Committee (IOC) accepts a competitor. At some point
in history, Olympic athletes as well as other professional players in the athletic
world began to use GHs.
GH is known as somatotropin—or as human growth hormone (hGH) in
human form. It belongs to the category of peptide hormones, which means it
stimulates growth, cell production, and cell regeneration in living beings—
human and other animals. Because of its effects, it is important in human
development. It is an amino acid—one of the “building blocks” of the human
body—which is synthesized biochemically and secreted within the pituitary
gland. The pituitary gland is involved in the body functioning in very impor-
tant ways: producing GHs, producing hormones that act on endocrine glands
and their regulation, on muscles and kidneys. It also stores hormones pro-
duced by the hypothalamus in the brain. It is located in the base of the brain
stimulating the growth of tissues and bone and the breakdown of fat. It is clear,
then, why certain athletes might want to use the substance to gain stronger
bones and tissues. As Chapter 2 discussed, the pituitary gland functions fur-
ther through a luteinizing hormone (LH), which stimulates the male and
female sex organs to release sex hormones (testosterone in men and estrogens
and progesterone in women). It also promotes the production of male and
female gametes (sperm and ova) and promotes oxytocin to support lactation,
social bonding, and sexual arousal. Prolactin stimulates the development of
breasts and milk production in women. The gland is sometimes referred to
as the Master Gland because of its role in directing other organs and glands
to either increase or decrease hormone production.
What does this have to do with the use of hGH both medically and recrea-
tionally? As a hormone with such critical properties, the GH was looked to as a
treatment for children who were deficient in its normal production. The rec-
ognition of the pituitary gland’s importance in the growth process was known
58 Steroids

by the nineteenth century. Efforts to acquire the hormone actually began in

the 1940s, working with bovine and porcine GHs (cow and pig, respectively).
It turned out that these hormones were specific only to their animal source or
species and, therefore, could not be used on humans.
It wasn’t until the late 1950s that this human hormone was harvested from
cadavers for children who were severely deficient in normal growth cycles.
In 1956, Li and Papkoff, in California, and Raben, in Massachusetts, were able
to isolate the chemical (hormone) from this source gland. The pituitary-
derived hormone was not plentiful, however, and efforts to develop it in the
laboratory took a number of years. By 1960, it was established that this hor-
mone was beneficial to children with growth deficiencies. As a result, the
National Pituitary Agency (NPA) was formed to support research specifically
in this area. Between 1963 and 1985, this agency supervised almost all of the
GH treatment in the United States. Approximately 7,700 children in the
United States and 27,000 children worldwide were given GH extracted from
human pituitary glands to treat severe deficiencies in GH. Unfortunately, in
1985, an unexpected side effect emerged among several children: the develop-
ment of Creuzfeldt Jacob Disease (CJD), which is a fatal viral disease. The out-
come of CJD is a deterioration in the brain, acceleration of Alzheimer’s
disease, and similar effects to mad cow disease. There is no treatment for this
disease, and it is usually fatal within one year. One of the frightening things
about CJD is that it can be dormant in the body for years before the infection
becomes apparent.
The connection between the administration of GH and this disease was
confirmed. This brought an end to the research and use of the human pituitary
gland (and cadavers!) in producing GH. A sensational news story in the 1970s
focused on this disease when a man, who had been treated with the hormone
as a child, killed his movie-star mother, Susan Cabot, claiming that his mad-
ness was due to CJD.
Nevertheless, as one can see from previous scientific research, when one dis-
covery or practice fails, another begins. This was true as well of GH. Scientists
were able to identify the biochemical structure of GH in 1972. From this discov-
ery came the development of recombinant DNA-derived hGH through a genetic
cloning process in 1979. In 1981, Genentech developed the first hGH by a bio-
synthetic process. The FDA approved this synthetic version of GH in 1985.
Bacteria were genetically modified so that unlimited amounts of hGH could be
produced safely. This drug was called Protropin. Because of the development of
this treatment, called rhGH, the supplies of the chemical increased and the
FDA began to approve its use for not only GH-deficient children but also those
children who were non-deficient and adults. These populations of patients
 The History of Steroids 59

are able, now, to use the hormone for other medical indications as the FDA
determines.
The use of GH, then, can be applied to a number of other problems. Most
prevalent is the GH deficiency in children, as it was treated in 1985. These
children suffer a disruption in the way that GH is produced in the pituitary
gland, resulting in short stature, slow growth, and a delay in the way the skel-
eton matures. This is accompanied by a reduction in GH. The majority of
children across the world are treated the same; that is, one injection daily to
promote body changes. Another possible root of this problem rests with the
kidneys. Once kidney disease (chronic kidney disease, CKD) becomes
chronic, the risk of failing to grow becomes larger in severe cases. GH improves
the person’s final height and for younger children, providing this medication
over time has proved to increase their chances of reaching higher growth.
Another medical condition that can be treated effectively with rhGH is
Turner syndrome. This affects women and results in extremely short stature.
In 2000, Prader-Willi syndrome was discovered. Described as a condition of
abnormal body structure, the condition is similar to that experienced by chil-
dren with growth hormone disorder (GHD). It is more severe in that areas
of growth such as body mass, body energy capacity, bone density, and cardio-
vascular health are affected; GH treatment addresses these areas of dysfunction
and improves their performance as well as providing growth in height. A list of
other growth deficiencies that occur both in terms of the disease, itself, or in
connection with other growth and proportion problems are found to be
improved with this GH treatment. Here, we can assert that using such hor-
mones in a therapeutic way benefits those in need. What about using these
hormones more specifically for adults? In 1996, the FDA approved this kind
of treatment for adults, which targeted cardiovascular problems, deficits in
bone health, and other factors such as quality of life. Among those with certain
other illnesses, such as HIV, cystic fibrosis, juvenile rheumatoid arthritis, and
osteoporosis, rhGH is an approved medical protocol, despite some studies that
note a small risk to those treated early in childhood.
On the illegal side of GHs, hGH became interesting to athletes and body
builders. Because it promotes cell production and bone and muscle growth,
it was immediately interesting to these athletes. In 1986, the black market in
GH exploded as athletes believed it improved their performances and a drug
called Nutropin emerged in the athletic community on the black market.
For those who use the drug and who do not have preexisting growth deficien-
cies, the results can be severe. Individuals using the hGH can experience
increased cholesterol, risks of diabetes, cancerous tumors, and gigantism (acro-
megaly), which results in enlarged bone growth. The Mr. and Ms. Olympia
60 Steroids

competitions for body builders revealed distortions in bodies and faces in those
who took hGH—extraordinary square jaws, large hands, and so on. Because it
was difficult to detect, however, this kind of doping continued among both
professionals and amateurs. It wasn’t until 2004 that the International
Olympic Committee used a test for this drug but the test wasn’t reliable if
the athlete had taken it more than forty-eight hours earlier. In April 2012,
the first athlete banned because of rhGH use was weightlifter, Pat Mendes.
Testing for GH continues to improve for Olympic athletic competitions as
well as for high school and college sports through the World Anti-Doping
Agency (WADA) (see Chapter 7 for more on anti-doping regulations). It
wasn’t until 2010 that a reliable hGH test was developed and used in profes-
sional sports organizations.
More recently, the use of GH has been found likely to affect the CNS. For
example, using GH to treat individuals who are deficient in the hormone
resulted in a general improvement in their psychological capabilities. In addi-
tion, the hormone shows benefits when used to improve areas such as
memory, alertness, motivation, and the capacity to function. In those children
who are GH deficient, behavioral problems appear to improve when treated
with these drugs. It has been found, in other studies, that GH affects the
CNS as it crosses the blood-brain barrier, connecting to GH receptors in the
brain. By doing so, the hormone binds with areas of the CNS in both humans
and rats. The amount of GH binding, however, is thought to decline as a per-
son ages and, thus, its beneficial properties decrease over time.
A tragic example of hGH abuse with steroids occurred when Lyle Alzado, a
famous NFL defensive-end football player, died of brain cancer. He was forty-
three years old. He stated before his death that he believed his cancer was the
result of more than twenty years of steroid and hGH use.
He had spent as much as $30,000 per year on these drugs. While scientific
research has not established a link between these drugs and brain cancer, cur-
rent thinking is that the GH clearly affects cognition and memory as well as
functions of the body. Another aspect to GH deficiency is that individuals
with this condition are predisposed to the development of abdominal fat accu-
mulation and poor lipid profiles (higher cortisol levels). Medical interventions
with those who have GH deficiencies demonstrate a reversal in fat when taking
the hormone. Some studies also have demonstrated that obese individuals
experience a reduction in body fat with rhGH medication. Because of these
findings, the Internet is replete with sales of GH, claiming the benefits of the
drug for weight loss, increases in muscle mass, improved thinking, and emo-
tional well-being. Some claim that the hormone can be used as an anti-aging
supplement. While small amounts of hGH do, indeed, affect weight and
 The History of Steroids 61

redistribution in body composition, there has been no proof that people

actually lose weight on these drugs.
Another substance developed to treat the medical condition of anemia
occurred in 1980. A pharmaceutical company developed a medication for
anemia by refining a glycoprotein hormone, which had been discovered a
number of years earlier. A product of genetic engineering, their substance is
made from the ovarian cells of the Chinese hamster, produced through
recombinant DNA technology. The drug does not cure the cause of anemia
so it must be taken for life if the underlying cause is not corrected. The com-
pany, Amgen, marketed this drug under the name Epogen (EPO) for its
chemical name epoetin alfa. EPO is a peptide hormone produced naturally
by the body; it is released from the kidneys and by acting on bone marrow
can increase red blood cell production. Because of its ability to increase the
number of red blood cells in the body, resulting in an oxygen-enriched condi-
tion that leads to greater stamina, this was the kind of synthetic drug used in
“blood doping.” An increase in red blood cells improves the amount of oxygen
that the blood can carry to the body’s muscles. Unfortunately, the drug was
discovered, as usual, by the athletic world. It was not detectable, however, until
the early 2000s and was favored by cyclists. It also, unfortunately, is often
implicated in the occurrence of heart attacks, blood clots, and strokes.
Although its proper use can have great therapeutic benefits for those needing
treatment for anemia related to kidney disease, the misuse or abuse of the drug
can lead to serious health problems for athletes who use it to enhance perfor-
mance. EPO thickens the blood, which leads to an increased incidence of fatal
diseases, such as heart disease, stroke, and blot clots in the brain or lung. It also
can lead to the occurrence of life-threatening autoimmune diseases.
Helping athletes who suffered injuries, as well as those patients with arthritis
and other joint diseases, spurred on the research into new methods for healing
and relieving pain without surgery. Over-the-counter (OTC) medications
abound, as do dietary supplements, that contain recombinant forms of steroids
and other substances. For example, a common treatment for the itch of mos-
quito bites is sold as a cream or roll-on stick and contains 1 percent hydrocor-
tisone cream along with other ingredients such as aloe. A search of the World
Wide Web for remedies for skin rashes, itching, dryness, and other ailments
will invariably bring up these products. All of these contain elements of steroid
compounds. Today, many Americans view the use of anabolic steroids as
unacceptable in the world of athletic competition. Even though the use of
therapeutic steroids has been confirmed as valuable to healing from various
injuries or life-threatening diseases, there remains a hesitation to accept these
medications. Side effects can be difficult to manage and often overshadow
62 Steroids

the healthier outcomes that result. Nevertheless, the value of steroids in treat-
ing cancer, brain tumors, lung disease, and a variety of other serious ailments is
undeniable. An example of this effectiveness in relieving symptoms from
chemotherapy is found in the following case study.

CASE STUDY: MS. A

When Ms. A was diagnosed with breast cancer, her physician recommended
a radical mastectomy (removal of both breasts) with subsequent treatments of
radiation and chemotherapy. After a seemingly successful procedure, Ms. A
followed her doctor’s advice and began post-surgical treatments. Five years
after her first surgery, however, Ms. A was told that the cancer cells were evi-
dent in other parts of her body, leading to the need for more chemotherapy
and medical monitoring.
As Ms. A describes it, when chemotherapy is administered intravenously, it
moves through all the veins of the arm with corrosive effects. These effects cre-
ate inflammation that must be controlled. It is at this point that steroids are
introduced into the body, via intravenous tubes, to prevent that inflammation.
This is a state-of-the-art treatment protocol in the early 2000s: a saline solu-
tion is injected to flush the veins for fifteen to twenty minutes, followed by
the steroid liquid medication, and then the chemotherapy drug for thirty
minutes. An injection of a drug called Exgiva is given every three weeks to pre-
vent the bone deterioration that often accompanies chemotherapy. At the time
the steroids are injected, their effects are not noticeable. However, Ms. A
describes what a twenty-four-hour period following the treatment looks like:
after receiving chemo in the hospital at 12 noon, she arrives home around
3:30 p.m., and feels very fatigued. Her attempts to nap last only fifteen
minutes, before she is up and wide awake, unable to sleep. By 9 p.m. that eve-
ning, she finds herself, in her words, “wired.” She cannot sleep, is very clumsy
in her ability to move and ambulate (walk), yet she feels she is moving too fast.
At 1:20 a.m., she forces herself to go to bed; from 2 to 4 a.m., she sleeps. At
4 a.m., she is up again and unable to sleep anymore. At 7 a.m., she notices
how flushed her skin has become from the steroids, turning beet red all morn-
ing. She is able to sleep for forty minutes around 8 a.m. At 3 p.m., she is still
awake, still flushed, and swollen but is able to sleep for another hour from 4
to 5 p.m. Because of these effects, she cannot go out nor drive. At an earlier
point in the treatment, she describes a near accident when she tried to drive her
car and almost went through a stop sign, endangering herself and others moving
through the street ahead. She did not recognize that she needed help with
managing her daily activities during this time. The next night following her
 The History of Steroids 63

return home, she was finally able to sleep from 9 p.m. until 1 a.m., up for
ninety minutes and then back to sleep for another three hours. Two days after
the chemo and steroid injections, she began to experience pain, taking highly
addictive pain medications such as hydromorphone alternating days with
acetaminophen (Tylenol). She was also prescribed oxycontin for episodes of
severe pain. She noticed that she was experiencing aggressive feelings (some-
thing that happens every time she undergoes the chemo protocol). As steroids
affect mood—either creating euphoria or aggression—Ms. A’s experience is
not unusual. By the fourth day, her aggressive feelings had begun to subside
and some depression was evident; Ms. A feels that she has developed strategies
to deal with these emotions now that she has already had ten rounds of chemo-
therapy following the above procedures. One issue about which she is very
mindful is taking her medications; she keeps careful notes about when she
took which drugs and the amount she took so as not to mix them. While
Ms. A continues her therapy, her experience with this variety of drugs and
the effects of the steroids on her body has prepared her to expect this process
each time she undergoes treatment.
Ms. A’s case is more the norm than not for those receiving chemotherapy
treatments. The same characteristics of steroids that affect the physical body
are useful for other acute, chronic, or deadly diseases. As seen in a discussion
of the effects of anabolic steroids on the stamina, physical growth, or protec-
tion of muscle tissues and bones in humans, these therapeutic steroids play a
similar role. Their psychological effects are also similar. Ms. A’s feelings of
aggression after being unable to sleep, for example, may be a result of those
massive steroid doses. Generally, however, for such short-term, specifically
focused administrations, the person who receives this medication will not act
out aggressively toward others.
From the first chemotherapy treatment in 1949 to the newest targeted treat-
ments of today, almost all of these major steps in the field of cancer treatment
are the result of rigorously conducted clinical trials. These trials were, and are,
the result of hard work and dedication by medical researchers and physicians as
well as the participation of thousands of individual patients with cancer. The
nation’s cancer death rate has dropped 18 percent since the early 1990s, con-
trary to previous years’ increases in terminal outcomes of the disease among
the general population. This progress reflects advances over the past forty years
in every area of cancer care: prevention, chemotherapy, surgery, radiation, and
—increasingly—molecularly targeted treatments. The latter includes the use
of steroids in a variety of ways.
In summary, steroids are powerful and effective drugs used to treat a variety
of medical conditions. The most common group of therapeutic steroids,
64 Steroids

corticosteroids, is used now to treat arthritis, asthma, autoimmune diseases,

skin conditions, and some kinds of cancer. Lupus, Crohn’s disease, and multi-
ple sclerosis along with various eye diseases and cancers can be treated with cor-
ticosteroids. In dentistry, steroids are used as anti-inflammatory drugs to
control pain, to treat disease, as well as to relieve anxiety. Steroids continue
to be important in biology, chemistry, and medicine, in general. As in the case
of Ms. A, steroids can also help to prevent or reduce nausea associated with
chemotherapy. Anabolic steroids, while a different group of steroids, are used
less in medicine and are more widely associated with performance enhance-
ment and abuse in competitive athletics and weightlifting. Nevertheless, the
legitimate use of anabolic steroids is commonplace now for a variety of medical
problems such as andropause or menopause, speeding the recovery for burn
victims, improving the quality of life for HIV/AIDS patients, fighting breast
cancer, and controlling osteoporosis. Medications from the anabolic steroids
are valued by the medical community and patients, alike, as state-of-the-art
treatment options. The history of steroids, therefore, in both discovery and
use, is a complicated one. While the research continues to create history, more
and more is being done to enhance the composition of synthetic steroids for
more effective and targeted applications. More companies produce brands
that, today, can pass strict regulations of government agencies. Importantly,
steroids are safer now than ever before. It is the consumer who needs to be well
informed on the latest developments in steroid use; it is the consumer who
pursues the available research to ensure proper use of these drugs. With educa-
tion, the consumer maximizes the benefits of this history to enjoy healthier,
more comfortable, and prolonged life spans.
 Chapter 4

How Steroids Work

Tae Eun Park

Steroids are organic compounds that are essential for various chemical reac-
tions in the human body. There are several types of steroids, and they are
involved in biochemical processes known as metabolism that sustain the func-
tion of the human body. To fully understand the role and importance of ste-
roids, it is necessary to step back and start with an overview of the adrenal
gland where the biosynthesis of steroid occurs in the human body.

OVERVIEW OF ADRENAL GLANDS

The adrenal glands are two endocrine glands that are located on top of each
kidney. The adrenal medulla—the inner part of the gland—covers 10 percent
of the total gland and secretes hormones known as catecholamines, such as epi-
nephrine, norepinephrine, and dopamine. The adrenal cortex—the outer part
of the gland—covers the other 90 percent of the total gland. It is subdivided
into three different zones, and each zone secretes different types of hormone.
The outermost zone of the adrenal cortex is zona glomerulosa, which secretes
aldosterone—the primary mineralocorticoid in the humans. Zona fasciculate
is the middle zone, and it secretes cortisol, the major glucocorticoid in the
humans. The innermost zone, which is located right above the adrenal
medulla, is called zona reticularis. This zone secretes sex hormones (testoster-
one and estradiol).
66 Steroids

CHOLESTEROL
The hormonal steroids are derived from cholesterol and synthesized in the
adrenal cortex, which is the outer part of the adrenal gland. Cholesterol serves
many important functions in the human body. It is found only in animals and
plays a critical role as a fat in the cell membrane, which encloses the cell.
Cholesterol allows the cell membrane to change its structure so that other
compounds can pass through those membranes. Thus, cholesterol is essential
for cells to perform their assigned functions. Cholesterol serves as the precursor
for all hormonal steroids as well as for bile salts and vitamin D. This will be fur-
ther discussed in the following sections. The metabolism of cholesterol regu-
lates how fat is transported throughout the human body. If cholesterol
metabolism is interrupted, it may cause cholesterol to accumulate along the
walls of the blood vessels. This is called atherosclerosis, which may lead to
heart attacks and strokes.
All tissues that have cells with a nucleus can synthesize cholesterol. Most of
the cholesterol in the human body comes from synthesis inside the body and
foods such as egg yolks and animal fat. The synthesis of cholesterol mostly
occurs in the liver and intestine. At the cellular level, the synthesis occurs in
the cytoplasm (inside space of the cell between the cell membrane and the
nucleus), particularly in the endoplasmic reticulum (a network of tubules
inside the cell). Cholesterol is composed of twenty-seven carbon atoms, cyclo-
pentanoperhydrophenanthrene nucleus, which is common to all steroids, and
a side chain. It is made from acetyl-coenzyme A (or acetyl-CoA), which pro-
vides carbon atoms for the production of cholesterol. An enzyme, which is
a protein that accelerates a chemical reaction, facilitates each step of the
synthesis.
Cholesterol is transported from one cell to another by lipoproteins.
Lipoproteins are spherical complexes made of fat and proteins that transport
many compounds, including triglycerides (a type of fat found in the blood),
fat-soluble vitamins (vitamins A, D, E, and K), and cholesterol. There are five
major classes of lipoproteins: chylomicrons, very-low-density lipoproteins
(VLDLs), low-density lipoproteins (LDLs), intermediate-density lipoproteins
(IDLs), and high-density lipoproteins (HDLs). Each lipoprotein has different
density determined by the amount of fat, size, and protein arrangement. Fat is
less dense than water; thus, chylomicrons are the least dense lipoproteins since
they have the greatest amount of fat. On the other hand, HDLs are the densest
lipoproteins because they have the least amount of fat. In terms of the size of
the lipoproteins, chylomicrons are the largest and HDLs are the smallest.
Chylomicrons and their fragments produced from the breakdown of chylomi-
crons by an enzyme called lipoprotein lipase serve as transporters for fats from
 How Steroids Work 67

the diet. VLDLs move triglycerides and cholesterol from the liver to other tis-
sues in the body. When triglycerides are removed from VLDLs by lipoprotein
lipase, VLDLs become IDLs. IDLs also lose triglycerides and become LDLs,
and LDLs transport cholesterol to the tissues in the body. The cells in the
liver and intestine are involved when the body tries to excrete cholesterol.
Cholesterol is excreted into the bile (fluid manufactured and secreted by the
liver and then stored in the gallbladder) in the liver for excretion. In order to
go through the excretion process, cholesterol is sent from the tissues back to
the liver and intestine by HDLs.

HORMONAL STEROIDS
Synthesis of Hormonal Steroids
The synthesis of hormonal steroids occurs in the mitochondria, which is a
structure inside the cell that is important for energy production. Inside the
mitochondria, an enzyme called CYP11A1 converts cholesterol to pregneno-
lone. Then, pregnenolone travels to endoplasmic reticulum and undergoes
several reactions caused by enzymes to finally produce hormonal steroids.
Overall, there are two ways that cholesterol can be transported into the cell.
The first method is called non-selective pathway. LDLs transporting cholesterol
bind to LDL receptors on the surface of the cell membrane. The LDL-receptor
complex moves into an area of the cell membrane called coated pits. These coated
pits become vesicles and pinch off from the cell membrane. Inside the cell, the
vesicles merge with each other to form even bigger vesicles called endosomes.
At this point, the LDL-receptor complex splits, letting the receptor go back to
the cell membrane. The form of cholesterol transported by LDLs is known as
cholesterol esters. Thus, cholesterol is “freed” from cholesterol esters inside the
endosomes, and it travels to the mitochondria for the synthesis of hormonal ste-
roids. Instead of traveling to the mitochondria, cholesterol may go to endoplas-
mic reticulum and get converted back to cholesterol esters, which are then
stored in lipid droplets. Cholesterol esters in lipid droplets may be converted to
free cholesterol by an enzyme called hormone-sensitive lipase. Free cholesterol
then travels to the mitochondria for the synthesis of hormonal steroids.
The second method of transporting cholesterol into the cell is called selec-
tive pathway that utilizes scavenger receptors class B type I (SR-BI) found in
the cell membrane. Cholesterol, as in the form of cholesterol esters, is trans-
ported by HDLs and moves directly into the cell by traveling through a chan-
nel that is created by SR-BI. Inside the cell, hormone-sensitive lipase splits
cholesterol esters to produce free cholesterol, which travels to the mitochon-
dria for the synthesis of hormonal steroids.
68 Steroids

Cholesterol undergoes multiple reactions from which many different types

of steroids are produced. However, only steroids that are synthesized in signifi-
cant amounts in this process are cortisol and corticosterone that are glucocorti-
coids, aldosterone that is a mineralocorticoid, and dehydroepiandrosterone
(DHEA), and androstenedione that are androgens.

Chemical Structures of Hormonal Steroids

The hormonal steroids are classified into two broad groups: adrenocortical
(glucocorticoids and mineralocorticoids) and gonadal steroids. The major glu-
cocorticoid is cortisol (also known as hydrocortisone), major mineralocorti-
coid is aldosterone, and the major gonadal steroids are testosterone and
estrogen in humans.
The synthesis of a steroid involves structural modification of cholesterol.
A steroid is composed of seventeen carbon atoms arranged in three cyclohexane
(six-membered) rings and one cyclopentane (five-membered) ring connected side
by side. This basic structure is called cyclopentanoperhydrophenanthrene
nucleus, which is common to all steroids. The carbon atoms are numbered from
one to seventeen, and the rings are labeled A, B, C, and D. The structure of cyclo-
pentanoperhydrophenanthrene nucleus has three points (at carbon numbers 10,
13, and 17) where the carbon atoms may bind to other molecules. The addition
of one or more molecules on these carbon atoms is what distinguishes one steroid
from another. The difference between the steroids may not be significant; how-
ever, this slight difference makes each steroid molecule unique, making it binding
to a specific steroid receptor (a protein on the surface of the cell membrane
to which a molecule binds). The similarity between the steroids explains the
close relationship between the physiochemical properties of the steroids.
Adrenocortical and gonadal steroids are classified into one of three types: C19 ste-
roids with a keto or hydroxyl group at position 17, C21 steroids with two-carbon
side chain at position 17, and C18 steroids with a keto or hydroxyl group at posi-
tion 17, but without methyl group at position 10. C21 steroids have glucocorti-
coid and mineralocorticoid activities, whereas C19 steroids have androgenic
activity.

How Do Glucocorticoids Work?

The production of glucocorticoids in the human body is regulated by
hypothalamic-pituitary-adrenal (HPA) axis. The production of corticotropin-
releasing hormone (CRH) from the hypothalamus stimulates the anterior
pituitary gland to release adrenocorticotropic hormone (ACTH) in the brain.
ACTH in the human body is released irregularly throughout the day, mostly
 How Steroids Work 69

in the morning between 4 and 10 a.m. ACTH is also secreted under environ-
mental and physiological stress. The secretion of ACTH leads to the produc-
tion and secretion of cortisol from the adrenal glands. When cortisol leaves
the adrenal glands, it binds to a protein called cortisol-binding globulin and
travels the bloodstream. The level of glucocorticoid in the human body is
maintained by the negative-feedback loop. When enough glucocorticoid is
released into the bloodstream, the suppression of CRH from the hypothala-
mus and ACTH from the anterior pituitary gland occurs, so that the body does
not have too much glucocorticoid.
When cortisol comes into the cell, it binds to the glucocorticoid receptor
(GR) and moves into the nucleus to bind to a glucocorticoid receptor element
(GRE) on the genes. A gene is a region of DNA (deoxyribonucleic acid), which
is the material that gives instructions to the cells for living. The cortisol-GR
complex coupled with the GRE creates a copy of the gene. This copying pro-
cess is called transcription, and it produces a messenger known as messenger
RNA (mRNA). Then mRNA interacts with ribosomes, which are acid mole-
cules that read the mRNA and link appropriate amino acids together to create
a protein, and this process is called translation. Proteins that are produced at
the end exert the effect of glucocorticoids. Instead of undergoing transcri-
ption and translation, cortisol-GR complex can bind to and suppress pro-
inflammatory genes inside the nucleus without the involvement of the GRE,
and this process is called transrepression. This is an important mechanism that
gives glucocorticoids their anti-inflammatory ability.

How Do Mineralocorticoids Work?

ACTH also regulates aldosterone, which is the major mineralocorticoid in
the human body. The effect of ACTH stimulation on the secretion of aldoste-
rone tends to be short, only lasting about one or two days. The major regulator
of aldosterone is a signaling pathway called the renin-angiotensin-aldosterone
system (RAAS). In the presence of low-blood pressure or environmental or
physiological stress, the kidneys release an enzyme known as renin. Renin
breaks down a protein called angiotensinogen, which produces angiotensin I.
Angiotensin I is converted to angiotensin II by an enzyme called the
angiotensin-converting enzyme (ACE). Angiotensin II triggers the adrenal
cortex to secrete aldosterone, and it affects two conversion pathways in steroid
biosynthesis: conversion of cholesterol to pregnenolone and that of corticoster-
one to aldosterone. Angiotensin II, however, does not affect the secretion of
11-deoxycorticosterone. The level of aldosterone is maintained by the
negative-feedback loop. When there is decreased volume of fluid inside the
blood vessels, nerves in the kidneys fire signals that increase the pressure inside
70 Steroids

the arteries of the kidneys. This then increases the secretion of renin, which
leads to increased production of aldosterone. Aldosterone makes sodium and
water to stay inside the blood vessels to increase the fluid volume. When
enough volume is reached, the secretion of renin is stopped by the negative-
feedback loop. Another factor that regulates the release of aldosterone is
changes in electrolytes, particularly potassium. It takes only 1 mEq/L increase
of potassium to stimulate the secretion of aldosterone. This small change may
occur after eating, especially if someone eats food that has a lot of potassium.
Potassium is known to trigger the conversion of cholesterol to pregnenolone
and that of 11-deoxycorticosterone to aldosterone.
The mineralocorticoid actions are mediated by aldosterone binding to min-
eralocorticoid receptor (MR), which is structurally and functionally similar to
GR. MR is expressed with an enzyme called 11β-hydroxysteroid dehydrogen-
ase type 2 (11 β-HSD2). This is the enzyme that converts cortisol to cortisone.
Cortisol can bind and activate the MR, which prevents aldosterone from bind-
ing to MR. Thus, 11 β-HSD2 acts to protect MR and reserve the receptor for
aldosterone by converting cortisol to its inactivated form, cortisone.
When aldosterone enters the cell, it binds to MR, which forms aldosterone-
MR complex that goes into the nucleus to attach to hormone response element
(HRE) on the genes. Then transcription and translation as described above for
glucocorticoids occur to synthesize appropriate proteins to exert the effects of
aldosterone.

How Do Gonadal (Androgenic or Sex) Steroids Work?

In men, testosterone is the primary hormone of the testis, which is the male
sex gland located inside the scrotum behind the penis. Two different pathways
may be used to form testosterone: it can be synthesized from cholesterol in the
Leydig cells inside the testes and from androstenedione from the adrenal cor-
tex. In women, testosterone is also the major androgen, which is produced in
the corpus luteum (a structure that develops in an ovary after ovulation or
release of an egg and degenerates after approximately four days before the next
menstrual cycle begins) and the adrenal cortex.
The amount of testosterone produced in men is much more than that in
females, and this explains the physiological differences between two sexes.
The production of testosterone in men involves the release of gonadotropin-
releasing hormone (GnRH) from the hypothalamus, which stimulates the pro-
duction of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
from the anterior pituitary gland in the brain. LH stimulates the Leydig cells
inside the testes to synthesize testosterone. FSH works on Sertoli cells inside
 How Steroids Work 71

the testes to control the production of sperms. When enough amount of tes-
tosterone is produced, testosterone directly inhibits the secretion of LH from
the anterior pituitary gland and GnRH from the hypothalamus in the brain.
There is a protein called inhibin B that blocks the secretion of FSH from the
anterior pituitary gland when there is enough concentration of testosterone
in the human body.
When LH binds to its receptor, steroid acute regulatory (StAR) protein and
other enzymes involved in testosterone synthesis are activated. Cholesterol is
transported to the mitochondria by the StAR protein. Inside the testes and
adrenal cortex, particularly in zona reticularis, cholesterol is converted to
androstenedione by undergoing multiple reactions, which is then converted
to testosterone in the testes. In some cells, testosterone converts to dihydrotes-
tosterone (DHT) by an enzyme called 5α-reductase that can bind to the same
androgen receptor as testosterone. Compared to testosterone, DHT tends to
bind to the androgen receptors more tightly; thus, formation of DHT can fur-
ther enhance the activity of testosterone. Testosterone can be converted to
estradiol by an enzyme called aromatase. The majority of testosterone in men
is produced in the testes (95 percent) and the remainder is produced from
adrenal cortex and other tissues.
Testosterone travels in the bloodstream by binding to two proteins known
as sex hormone-binding globulin (SHBG) and albumin. SHBG binds more
tightly to testosterone compared to albumin. Only testosterone that is not
bound to any protein is available to exert its biological effects by binding to
an androgen receptor. As mentioned above, DHT can bind to the same andro-
gen receptor as well. Although conversion of testosterone to DHT is not
always necessary, DHT is needed for the genital to develop masculine charac-
teristics. The conversion of testosterone to estradiol affects the breakdown of
the bone and release of minerals from the bone, closure of the growth plate,
sexual desire, lining of the inside of blood vessels, and fat. Once testosterone
or DHT reaches the target cell, it binds to androgen receptor to form a com-
plex. This complex travels inside the cell and goes into the nucleus to bind to
androgen-response element on the genes, which starts transcription leading
to translation for the production of proteins that exert the activity of testoster-
one or DHT.
The natural estrogens in humans are 17β-estradiol, estrone, and estriol, and
they are produced in the corpus luteum and the placenta. They are essentially
synthesized from testosterone: an enzyme called aromatase converts testoster-
one to estradiol and androstenedione to estrone. Two cells that are responsible
for producing steroid hormones in the ovary are theca interna cells and granu-
losa cells. Theca interna cells are located inside the ovarian tissue and mediate
72 Steroids

the conversion of cholesterol to androstenedione because they have a large

number of LH receptors. These cells are also responsible for the synthesis of
progesterone. Granulosa cells surround the oocyte (egg) and synthesize estra-
diol when the theca interna cells provide androgens because the granulosa cells
have many FSH receptors. Mature granulosa cells develop LH receptors that
also act to induce the release of estradiol. Similar to men, the production of
estrogen in women involves the release of GnRH from the hypothalamus that
stimulates the secretion of LH and FSH from the anterior pituitary gland in
the brain. LH and FSH lead to the synthesis of estrogen from the theca interna
cells and granulosa cells. When there is enough amount of estrogen, estrogen
inhibits the release of FSH, LH, and GnRH, and inhibin B from the granulosa
cells inhibits FSH production.
There are two types of estrogen receptors: estrogen receptor α (ERα) and
estrogen receptor β (ERβ). The largest number of ERα is found in the uterus,
vagina, and ovaries and that of ERβ in the prostate and ovaries. Many cells in
the human body have both receptors present. These estrogen receptors bind to
estrogen to form a complex, which travels into the nucleus inside the target cell
and binds to estrogen-response element on the genes. Transcription followed
by translation occurs to synthesize appropriate proteins for estrogen activity.
Another steroid hormone important in female reproductive function is pro-
gesterone. It is a C21 steroid unlike estrogen (C18 steroid) and testosterone
(C19 steroid). It is produced from the corpus luteum, placenta, and follicle
(a spherical structure released from the ovaries each month that secrete an
egg). It is an important part of steroid biosynthesis in all tissues since it is
involved with the synthesis of all hormonal steroids. When a large amount of
progesterone is present, it acts on both the hypothalamus and the anterior
pituitary gland to prevent the secretion of LH and ovulation. There are two
types of progesterone receptors: progesterone receptor A (PRA) and progester-
one receptor B (PRB). Like other hormonal steroids, progesterone binds to a
progesterone receptor and forms a complex with the receptor. The complex
goes inside the nucleus of the target cell and binds to progesterone-response
element on the genes to undergo transcription and translation to synthesize
appropriate proteins.
The levels of LH and FSH are closely associated with women’s menstrual
cycles. Day 1 of menstruation is the start of the follicular phase. During the
first four days of the menstrual cycle, which is early follicular phase, FSH level
increases facilitating the growth of follicles. Between days five and seven, one
of the follicles becomes dominant and breaks down to release the oocyte
(egg). This primary follicle causes a negative feedback, preventing the produc-
tion of GnRH from the hypothalamus and FSH from the anterior pituitary
 How Steroids Work 73

gland due to the increased amounts of estrogen and inhibin B. This leads to
the degeneration of remaining follicles that were gathered initially. FSH makes
the follicle enlarge and synthesize estrogen, progesterone, and testosterone.
Testosterone is converted to estrogen in the follicle. A burst of LH secretion
occurs in the middle of the menstrual cycle, which completes the maturation
of the follicle and leads to ovulation. After the ovulation, the remaining fol-
licles turn into the corpus luteum that produces estrogen, progesterone, and
testosterone. This is called luteal phase. During this phase, progesterone acts
as an important hormone that supports the implanted embryo (fertilized egg)
and sustains pregnancy by supporting the surface of the uterus. Progesterone
also blocks GnRH secretion so that new follicles are not created. During the
pregnancy, the corpus luteum is still present for the continuous production
of estrogen and progesterone until the placenta can take over this function.
However, the corpus luteum degenerates if fertilization of the egg or implanta-
tion of the embryo in the uterus does not happen, which leads to the reduction
of progesterone secretion. Estrogen and progesterone levels decline at the end
of the luteal phase, and FSH level starts to increase, and follicles are gathered
again for the next menstrual cycle.

NON-HORMONAL STEROIDS
Bile Acids
Bile is composed of bile acids (also known as bile salts), bile pigments (give a
color to the bile), and other compounds. There are two primary bile acids
known as cholic acid and chenodeoxycholic acid (CDCA). They are made in
the liver directly from cholesterol. The primary bile acids bind to either one
of two amino acids—glycine or taurine—and the complex is released into
the bile. On the other hand, secondary bile acids—deoxycholate and lithocho-
late—are synthesized from the metabolism of the primary bile acids by bacteria
residing in the colon or large intestine. These acids help remove cholesterol
from the human body. They break down fat, including cholesterol and fat-
soluble vitamins, into smaller particles for absorption in the small intestine.
They also affect the flow of bile in the liver as well as the movement of electro-
lytes and water in the small intestine and colon.

Vitamin D
The largest amount of vitamin D, a fat-soluble vitamin, comes from
cholesterol in humans. When the skin is exposed to sunlight, particularly
ultraviolet-B (UV-B) light, 7-dehydrocholesterol (an intermediate in
74 Steroids

cholesterol synthesis) is converted to vitamin D3 (cholecalciferol) in the skin.

Cholecalciferol is converted to 25-hydroxyvitamin D3 in the liver, which is
then converted to 1,25-dihydroxyvitamin D3 (calcitriol) in the kidneys.
Calcitriol binds to vitamin D receptors in the intestine increasing the absorp-
tion of calcium and phosphorus from the intestine to the bloodstream.
Calcium and phosphorus in the bloodstream are used to calcify the bones.
When there is not enough calcium and phosphorus in the bloodstream, para-
thyroid glands located in the neck release parathyroid hormone (PTH). PTH
stimulates the bone to release its own reservoir of calcium and phosphorus into
the bloodstream and the kidneys to secrete more calcitriol.
Aside from sunlight exposure, humans can produce vitamin D through
their diet. Cholecalciferol (vitamin D3) can come from fish and meat, and
ergocalciferol (vitamin D2) can come from dietary supplements, irradiated
bread and milk, and mushrooms. Ergocalciferol is derived from ergosterol,
which is a type of steroid found in plants and fungi.

Cardioactive Steroids (CASs)

People have been using plants containing CASs for many years. Foxglove
(Digitalis species) is one of the plants containing CASs, and it has been used
historically for inducing urination and decreasing swelling. CASs, such as a
drug called digoxin, became widely used for the treatment of arrhythmia
(irregular heartbeat) and heart failure. CASs increase the amount of calcium
inside the cells of the myocardium (heart muscle), which strengthens the con-
traction of the myocardium. They also affect the electrical system of the heart,
primarily in the atria (top chambers of the heart). They slow down the move-
ment of the electrical signals and extend the refractory period at the atrio-
ventricular (AV) node that electrically connects the top (atria) and the
bottom (ventricles) of the heart. Refractory period refers to the duration of
the time that the myocardial cells cannot start another electrical signal.
CASs have a very small difference between the dose needed for treatment
and the dose that causes toxicity. Thus, toxicities may occur if the drug use is
not appropriately monitored. Acute toxicities occur first without symptoms,
and this period lasts several minutes to hours. Then, people start to develop
symptoms such as nausea, vomiting, abdominal pain, confusion, and weak-
ness. They can also have increased level of potassium in the blood and irregular
heartbeat from the acute poisoning. Chronic toxicities may cause various
symptoms but in a very subtle manner. Symptoms include weakness, nausea,
loss of appetite, weight loss, abdominal pain, vomiting, confusion, drowsiness,
headache, hallucination, and visual disturbances particularly formation of
 How Steroids Work 75

yellow halos around lights. Chronic CAS toxicity may cause slow heartbeat
as well.

CONCLUSION
In this chapter, we discussed how hormonal and non-hormonal steroids
work inside the human body. We discussed the role of cholesterol as the origin
of all steroids, and the similarity as well as differences of chemical structures
and mechanisms of action of steroids. In the next chapter, we will focus on
the effects and the use of steroids.
 Chapter 5

Effects and Applications

Malgorzata Slugocki

Chapter 2 described various classes of steroids, their structures, and general activ-
ities that they exhibit, both naturally and in the synthetic form. Glucocorticoids
play a vital role in development of various cells. Furthermore, they have an
important function of ensuring survival at times of stress. This function is
demonstrated by glucocorticoids’ involvement in regulating blood pressure,
maintenance of salt and water equilibrium, immune function, and cellular
metabolism. This chapter will focus more on specific effects that steroids have
on various systems in the body and their applications in clinical practice.

PSYCHOLOGICAL EFFECTS OF NATURAL GLUCOCORTICOIDS

There are three major modes of cortisol release. Cortisol is released in response
to the adrenocorticotropic hormone (ACTH), which is initially secreted from the
pituitary gland. Increased level of cortisol then shuts off the release of ACTH via
negative feedback, when there is no longer need for the hormone.
Cortisol release also follows a circadian rhythm that depends on both day–
night and sleep–wake patterns. Generally, the cortisol level is highest in the
morning and lowest in the middle of the evening. These patterns are altered
by day–night shift work and travel across time zones.
The level of cortisol also rises significantly in response to stress, in order to
protect metabolic functions. Stress can immediately overcome the negative
feedback mechanism and circadian rhythm patterns. Stress results in an
78 Steroids

activation of the hypothalamic-pituitary-adrenocortical (HPA) axis, which

increases the release of glucocorticoids. The type of stress that results in addi-
tional glucocorticoid release includes both psychological (anxiety, bereave-
ment, and fear) and physiological (fever, pain, and surgery) conditions.
Under normal conditions, the levels of glucocorticoids return to their original
state whenever the critical situation (or stress) is taken away. However, when-
ever there is a prolonged, stressful event, the levels of glucocorticoids remain
elevated, and this leads to various damaging effects, which are similar to
adverse effects that come from administered synthetic steroids.

Permissive Action
One of the methods that glucocorticoids can influence metabolic functions
is via permissive action. This effect requires a small amount of glucocorticoids
to be available for certain metabolic reactions but does not involve a direct
action of glucocorticoids for the reactions to occur. Examples of such effects
include the action of glucagon as well as the action of catecholamines, which
are hormones released in response to stress (epinephrine, norepinephrine,
and dopamine). Without the presence of glucocorticoids, those substances
would not be able to cause the increase in blood pressure and bronchodilation,
which are necessary in critical situations.

The Brain
Naturally, glucocorticoids affect behavior, mood, and cognition by regulat-
ing the body’s appetite control, circadian rhythm, and reactions to stress.
These actions result from complex feedback mechanisms, circadian rhythm-
dependent hormone release, and exposure to stress. The impact of glucocorti-
coids on these processes occurs via interaction with glucocorticoid receptors
(GRs), which are present in multiple organs and tissues, including the brain.
Glucocorticoids affect a number of substances that play a role in appetite
control. Initially, during a stressful event, glucocorticoids act to suppress appe-
tite, in order to divert the energy from food-seeking behavior toward more
urgent issues, such as recovering from pain or reducing fever. With long-
term stressors, however, that energy needs to be replaced. Within hours to days
from a stressful trigger, the levels of cortisol remain elevated, leading to
increased fat storage due to its action on an enzyme lipoprotein lipase.
Increased levels of cortisol also increase food-seeking behavior, especially
“comfort foods.” Typically, people tend to eat food that has a lot of fat and
 Effects and Applications 79

sugar (sucrose) when their appetite is stimulated by glucocorticoids, which

may lead to weight gain. This effect of glucocorticoids on eating behavior is
closely associated with “emotional eating” under stress.
Another important appetite-regulating hormone affected by glucocorticoid
(cortisol) levels is insulin. In a critical situation, glucocorticoids stimulate insu-
lin secretion from the pancreas, which decreases appetite. However, a pro-
longed exposure to cortisol leads to the development of body’s resistance to
insulin. This, in turn, reduces the appetite-suppressing effect and ultimately
results in weight gain.
Glucocorticoids also interact with ghrelin, which is also known as a “hunger
hormone.” Normally ghrelin is released just before regular meals as a signal of
hunger. Its level is elevated when there is increased concentration of glucocor-
ticoids under stress. Chronic or severe stress and elevated glucocorticoid level
lead to increased levels of ghrelin and food intake.
In summary, glucocorticoids suppress appetite in critical situations, in order
to channel the needed energy to respond to the stressful event. However, a
prolonged exposure to glucocorticoids leads to an increased appetite, food
intake, and, ultimately, weight gain.
In addition to their appetite-stimulating effects, chronically elevated gluco-
corticoid levels also promote arousal and sleeplessness. As mentioned earlier,
physiologically, the level of cortisol is lowest in the evening, which promotes
sleep. In elderly, the level of cortisol is increased in the evening, which explains
their impaired sleep patterns and early-rising tendencies.
Optimal levels of glucocorticoids are also necessary to regulate moods.
In critical situations, transient elevation in cortisol level has a protective effect
on moods; however, chronic exposure to glucocorticoids can directly damage
the brain, leading to psychiatric problems. Patients with preexisting psychiat-
ric symptoms may experience worsening moods or new onset of mood swings,
depression, suicide attempts, and euphoria (feeling of intense happiness), even
in patients who had never had them before. In these patients, cortisol-level
normalization significantly improves mood and depressive symptoms. It is
believed that depression caused by increased levels of glucocorticoids may
be due to suppression of receptors of another hormone called serotonin in
the brain.
Glucocorticoids may also affect cognition by influencing brain regions
important to memory and learning, such as hippocampus, amygdale, and pre-
frontal cortex. In a critical situation, temporarily elevated cortisol levels pro-
vide a protective effect by impairing long-term memory and inhibit stressful
memory recovery in traumatic events.
80 Steroids

Alternatively, chronic elevations in cortisol levels lead to impairments in

various domains of cognition, such as recall, verbal learning, and other verbal
functions.

Cardiovascular System
Corticosteroids and the effects they have on the cardiovascular system are
not entirely understood at this point. The major effects result from multiple
mechanisms, which are related to the location of steroid receptors in the vari-
ous tissues. As mentioned earlier, the GRs are located in many tissues through-
out the body. There are also mineralocorticoid receptors (MRs), which bind
the mineralocorticoid aldosterone. Endogenous cortisol binds to both GR
and MR, while the aldosterone specifically binds to MR.
One type of cardiovascular effect of glucocorticoids is the direct action on the
blood vessels in the heart and arterial walls. This action increases overall blood
pressure as well as the vessels’ sensitivity to agents called “pressors,” which increase
blood pressure. These agents include both substances naturally occurring in the
body such as angiotensin II and medications, such as epinephrine or vasopressin.
There is also evidence that glucocorticoids affect myocardial responsiveness, tone,
and capillary permeability. Furthermore, they influence many factors that regulate
blood pressure via mechanisms that are not completely understood.
Although studies have shown corticosteroid-associated anti-inflammatory
benefits in cardiovascular tissues, glucocorticoid excess has also been impli-
cated as contributing to the process of atherosclerosis. This effect is multifacto-
rial and complex but involves the influence of glucocorticoids on the
macrophages, which play an important role in the development of athero-
sclerotic process.
Another effect of corticosteroids on cardiovascular system results from their
impact on plasma volume and electrolyte retention, which is mediated by min-
eralocorticoid aldosterone. As opposed to the GRs, which are present in many
locations, the MRs are expressed in only selected tissues, mostly located at
lower levels, such as nephrons, salivary glands, and sweat glands. The cardio-
vascular effects of corticosteroids are summarized in Table 5.1.

Immune System and Anti-Inflammatory Properties

The effects of corticosteroids on the immune system result mainly from
their interaction with GR. The mechanisms via which glucocorticoids exert
their action occur at various genetic and molecular levels and are not fully
understood. Glucocorticoids exhibit activating and suppressing actions on
many components of the immune process as well as play a role in survival and
Table 5.1 The Cardiovascular Effects of Corticosteroids
Site of action Vascular smooth muscle
Glucocorticoid Increased contractility and
receptors sensitivity to “pressors”
Increased proliferation
Decreased migration
Mineralocorticoid Increased perivascular
receptors inflammation
Influence on
vasoconstriction (either
increased or decreased)
Endothelial cells Myocardium Macrophages Non-cardiovascular organs
Decreased endothelium- Influence on cytokines, Obesity, hypertension,
dependent vasodilation increased apoptosis, dyslipidemia, insulin
Decreased angiogenesis decreased phagocytosis of resistance, glucose
apoptotic neutrophils intolerance, prothrombotic
Influence on vasodilation Increased Increased fibrosis Hypertension
(either increased or fibrosis prothrombotic action
decreased)
82 Steroids

actions of specific immune system cells and molecules involved in the inflam-
matory process and immune response monocytes and macrophages; granulo-
cytes, such as mast cells, basophils, and eosinophils; T and B cells, cytokines,
and other mediators. Glucocorticoids are directly involved in lowering the
number of inflammatory cells such as interleukin (IL) and tumor necrosis fac-
tor (TNF) and inflammatory proteins such as basophils and neutrophils as well
as suppressing the maturation of mast cells and cytokines, augmentation of the
pro-apoptotic processes in T and B cells (apoptosis is a programmed cell death
that occurs after the cell is no longer needed), and reduced proliferation of vari-
ous pro-inflammatory protein molecules.
While these effects are physiologically and pharmacologically necessary (in
the treatment of many inflammatory diseases), they become problematic
during the chronic exposure to corticosteroids. This is due to the fact that in
the presence of corticosteroids, the clinical presentation of many infections
(bacterial, fungal, and viral) will be masked.

Carbohydrate and Protein Metabolism

Carbohydrates are stored in the form of glycogen as a result of conversion of
protein to carbohydrate through gluconeogenesis. This process is directly
influenced by glucocorticoids, which increase protein degradation and
decrease protein synthesis. The resulting release of amino acids during this
action serves to move them from the skeletal muscle to the liver, where they
function as substitute sources for glucose production. Glucocorticoids also
inhibit the uptake of glucose and utilization in the muscle and promote the
breakdown of glycogen, which is the form of glucose storage. Most of the
action of glucocorticoids on the glucose and protein metabolism is concen-
trated on regulating the transcription of target genes via DNA binding, and
this action is mediated by the GR. This process is another mechanism for
ensuring survival in critical situations, such as fasting or starvation. Increased
production of glucose with glycogen storage in the liver occurs due to gluco-
corticoids’ direct action on the presence of genes that affect enzymes necessary
for synthesis of glucose and glycogen. Glucocorticoids also reduce the amount
of glucose used by peripheral tissues, which in turn allows more glucose to be
available for the formation of glycogen in the liver.

Musculoskeletal System
Physiologic steroids function to maintain muscle and bone strength. One of
the major tissues supporting the maintenance of glucose balance is skeletal
 Effects and Applications 83

muscle, and about 80 percent of glucose utilization occurs there. Many of the
processes that lead to these effects have not yet been elucidated.
The major metabolic impact of glucocorticoids in glucose utilization
involves the direct effects on muscle fibers, inhibiting substances that promote
the action of insulin and inhibiting enzymes that promote the storage of glu-
cose in the form of glycogen. Insulin is a hormone that lowers elevated glucose
levels. Glucocorticoids act on an enzyme called tyrosine kinase that promotes,
among other mechanisms, the release of insulin.
Skeletal muscle is primarily composed of two types of fibers: slow-twitch
(type I) and fast-twitch (type II) fibers. Slow-twitch fibers are rich in mito-
chondria, have long contraction times, and are slow to fatigue. Fast-twitch
fibers fatigue faster and have short contraction times. Glucocorticoids affect
type II fibers much more than type I. The exact mechanism through which
this occurs is still unknown.
Glucocorticoids are also crucial for the processes of osteoblast differentia-
tion and formation. They also regulate the signaling pathways in mature osteo-
blasts and control skeletal development and maintenance of healthy bones.

Endocrine System
Steroids significantly affect the major hormones in the body. Gluco-
corticoids inhibit ACTH secretion, which represents a negative feedback on
the pituitary. As the circulating levels of glucocorticoids increase, the level of
inhibition of ACTH also increases. The inhibition is primarily due to action
on DNA. Thus, in critical situations, as more glucocorticoids are released from
the pituitary, there is less ACTH secreted.
Another important hormone influenced by glucocorticoids is the growth
hormone. In the pituitary gland, glucocorticoids regulate the expression of
the growth hormone genes, resulting in diverse stimulatory or inhibitory
effects. In general, glucocorticoids stimulate the synthesis of the growth hor-
mone, which is secreted in response to regulation by somatostatin. Findings
regarding the physiological effects of glucocorticoids on the secretion of the
growth hormone are derived from studies involving patients with low levels
of glucocorticoids. These findings indicate that chronically low concentrations
of cortisol lead to impairment of growth hormone secretion.
Glucocorticoids also affect the thyroid cell function through changes in the
concentration of iodine, thyroglobulin, and thyroid-stimulating hormone
(TSH or thyrotropin). These substances are the primary regulators of the thyroid
function. The exact mechanisms behind these interactions have not been fully
elucidated. Normally, the hypothalamus produces the thyrotropin-releasing hor-
mone (TRH), which stimulates the release of TSH (or thyrotropin) from the
84 Steroids

pituitary gland. The TSH then triggers the thyroid gland to release two hor-
mones: thyroxine (T4) and triiodothyronine (T3). Investigation of the relation-
ship between ACTH and TSH has shown an inverse relationship: in stressed
rats, the administration of a TRH was associated with a decrease in ACTH.
TSH synthesis is determined by release of TRH and negative feedback by T3,
which shuts off TSH synthesis and more hormone release. Additional substances
that regulate TSH are somatostatin and dopamine. In studies, administration of
glucocorticoids decreased serum TSH.
Furthermore, there is evidence that glucocorticoids in the thyroid gland also
affect the uptake of iodine. Iodine is essential for the synthesis of T3 and T4
hormones. Physiological concentrations of glucocorticoids stimulate the
uptake of iodine. Because of this, stress and the resulting increase in cortisol
release may be considered a factor in activating the iodine content.
Additionally, glucocorticoids also appear to increase the binding of thyroid
hormones to their receptors.
Overall, the effect of glucocorticoids on the thyroid function under short-
term stress results in increased biosynthesis of thyroid hormones and increased
uptake of iodine. However, the chronic exposure to stress has shown metabolic
and structural changes in the thyroid gland that lead to elevated iodine concen-
trations and decreased metabolism of this molecule by the thyroid gland.
Hence, chronic pathological conditions that disturb the hypothalamus-
pituitary-thyroid axis may result in hypo- or hyperthyroidism.

Gastrointestinal System
The maintenance of gastric mucosal tissue is possible, among other factors,
due to basal glucocorticoid production. Because of existence of a theory that
administration of synthetic or exogenous steroids may have ulcerogenic prop-
erties, it has been suggested that even the physiologic glucocorticoids released
during stress may contribute to gastric ulcer formation, commonly known as
“stress ulcer.” This is still a controversial issue, and there are studies that dem-
onstrate glucocorticoids actually have a gastroprotective effect during acute
stress in animals. Some mechanisms responsible for this effect include main-
taining gastric blood flow due to action on arterial blood pressure, mucus pro-
duction, decrease in gastric motility and permeability, as well as compensatory
and permissive role whenever the natural gastroprotective mechanisms are
impaired (especially those provided by specific substances such as prostaglan-
dins or nitric oxide).
Although the exact gastroprotective effect of glucocorticoids is not known,
studies also suggest that short-term stress may exert a beneficial effect on the
 Effects and Applications 85

gastrointestinal tract, while the long-term exposure to increased glucocorti-

coids may lead to ulcer formation.

Hematologic Effects
Corticosteroids also affect a number of cells involved in producing hemato-
logic effects and lymphatic organs. They increase red cell and hemoglobin con-
tent of blood. Glucocorticoids also increase circulating white blood cells, such
as neutrophils and platelets. Furthermore, lymphocytes, eosinophils, mono-
cytes, and basophils decrease in response to glucocorticoid release, mainly
due to their redistribution to the lymphatic tissues (spleen, lymph nodes, and
bone marrow). The action on these cells is important in normal immune
response as well as during therapeutic use of glucocorticoids. The decrease in
basophils is responsible for the fall in blood histamine levels and reduction in
allergic response.

Lipid Metabolism
Adipose tissue has a crucial role in serving as storage of high-energy com-
pounds and releasing them in times of need. Whenever there is an energy defi-
cit (during fasting or exercise), adipocytes are broken down to fatty acids and
glycerol, which are released into the bloodstream. This energy release and stor-
age is highly regulated by glucocorticoids and other substances. In general, glu-
cocorticoids promote the breakdown of stored lipids, and they do it on a
genetic level via altering the gene transcription through their interaction with
the GR. Recently, it has been suggested that glucocorticoids also have non-
genomic direct pathways that promote the breakdown of the lipids.
Release of stored lipids for energy has been genetically programmed to occur
during stressful events and fight-or-flight response. However, studies have
shown that administration of exogenous glucocorticoids or a pathophysiologic
increase in their levels is linked to increased fat formation and weight gain.
This suggests that chronic states of glucocorticoid elevation (stress) may be
maladaptive and lead to obesity and metabolic diseases.

Other Effects of Glucocorticoids

Glucocorticoids also promote the maturation of lungs in the fetus as well as
production of a surfactant necessary for proper functioning of the lungs out-
side of the uterus. In addition, as described earlier, corticosteroids affect the
carbohydrate and protein metabolism. These effects are associated with a
86 Steroids

number of catabolic actions, including thinning of the skin in elderly,

decreased scar formation, and delayed wound healing.
Corticosteroids also affect the ocular tissue by inhibiting blood factor aggre-
gates (clots), fibroblastic repair and endothelial regeneration, and reducing
inflamed vessel permeability. They also act on intraocular pressure and iris
smooth muscle causing miosis.
Chronic or excessive use of exogenous corticosteroids may lead to exaggera-
tion of these effects and result in the undesirable actions of corticosteroids that
will be described in Chapter 6.

PHYSIOLOGICAL EFFECTS OF MINERALOCORTICOIDS

The major role of mineralocorticoids is to regulate the electrolyte excretion
in the kidney. Aldosterone is the primary physiological mineralocorticoid,
whose site of action involves the distal nephron as the last point of sodium
reabsorption. Aldosterone’s full mechanism of action is still not completely
understood, and the known effects to this point have been discovered only in
the past decade. The primary regulator of the response to aldosterone is the
MR. The mechanism of interaction between aldosterone and the MR depends
on the formation of a ligand, which is a molecule that forms a complex with
the MR and results in its activation. The MR consists of three principal
regions: the N-terminal domain, the DNA-binding domain, and the
C-terminal domain (ligand-binding domain; LBD). These domains interact
with the DNA during the transcription process. There is evidence that the
MR may also act via other pathways that occur outside of cell nucleus.
The effects of aldosterone occur primarily in the distal tubules and collect-
ing ducts of the kidney, where it acts to enhance reabsorption of sodium from
the tubular fluid and increases the urinary excretion of potassium and hydro-
gen ions. This action also occurs at other sites such as colon, salivary glands,
and sweat glands.
Additionally, studies suggest that aldosterone exerts pathological effects in
the heart, vasculature, and brain. These actions seem to occur independently
of the salt intake, which traditionally has been considered as a contributing fac-
tor to the pathophysiological effects of aldosterone. One of the studied mech-
anisms, through which the aldosterone affects the heart, is a pro-fibrotic
(scarring) effect. Both increased heart size and thickening of the cardiac tissue
characterize this process, and it may be another underlying issue behind heart
disease and arrhythmia. The scarring effect appears to also occur in the vascu-
lature, which may contribute to the pathophysiology of heart disease.
 Effects and Applications 87

In a normal individual, aldosterone level increases during the portions of the

day that the individual is performing activities in the upright position. This
effect occurs as a result of decreased rate of removal of aldosterone from the cir-
culation by the liver. In patients who are confined to bed, aldosterone exhibits
a circadian rhythm pattern, with highest values occurring in the morning.

PHYSIOLOGICAL EFFECTS OF GONADAL SEX STEROIDS

There are three major sex steroids that regulate gender differentiation, sec-
ondary sex characteristics, and sexual behavior patterns: testosterone, estradiol,
and progesterone.

Testosterone
Testosterone is almost always referred to as “androgen” because it is mainly
produced by males and is associated with male sex characteristics such as mascu-
linity, facial hair, and a deeper voice. In females, testosterone has a much more
subtle effect. In males, other functions of testosterone include development of
secondary sex characteristics, maintenance of the male duct system, expression
of male sexual behavior (libido), maintenance of the function of the accessory
glands (prostate, seminal vesicles, and bulbourethral glands), maintenance of
the tunica dartos muscle in the scrotum (which aids in maintaining the temper-
ature in the testes), and formation of sperm. The mechanism behind these func-
tions involves alteration of gene expression in the cells of the above tissues and
organs. Additionally, direct receptor binding and activation of several intracellular
pathways is another mechanism of testosterone’s effects.

Estrogens
Estrogens include three distinct compounds: estrone, estradiol, and estriol.
In humans, estradiol is the main type of estrogen.
Estradiol exerts its effects in the hypothalamus, bones, and the entire female
reproductive tract. It is responsible for secondary female sex characteristics,
secretory functions of the female reproductive tract, ovulation, and regulation
of gonadotropin-releasing hormone, enhanced uterine motility, maintenance
of cardiovascular activities, and bone integrity.

Progestogens
As mentioned in Chapter 2, there is a class of hormones that contains a
pregnane structure in its skeleton. All steroids with this structure are classified
88 Steroids

as progestogens. This includes both naturally occurring and synthetic steroids.

Synthetic (exogenous) hormones with a pregnane structure are collectively
termed as progestins.
The major naturally occurring human progestogen is progesterone. Its main
function is to maintain pregnancy (inhibits uterine contractions and promotes
the development of endometrium) and promote the development of mam-
mary glands.
Estrogen and progesterone prepare the uterus for pregnancy and the mam-
mary gland for lactation. They also function together to maintain the regular-
ity and rhythm of the female menstrual cycle. The two main phases of the
female menstrual cycle are proliferative (follicular) and secretory (luteal).
The proliferative phase is characterized by dominance of estrogen, which pre-
pares the reproductive tract for pregnancy. The secretory phase is marked by
higher level of progesterone. The appropriate level of estrogen in the absence
of progesterone serves as a stimulus for the release of gonadotropin-releasing
hormone. This hormone, in turn, activates the follicle-stimulating hormone
(FSH) and luteinizing hormone (LH). These two hormones promote the growth
of follicles and release of ovulation. As the estrogen levels decrease, the increased
progesterone suppresses the ovulation and serves to either maintain or develop
pregnancy (if it occurred), or it promotes the entrance into the new follicular
phase, the ACTH-independent type.
Gonadal steroids also affect the bone. The bone mass and strength is
partly regulated by estrogen, which influences the activity of bone-forming
osteoblasts and bone-resorbing osteoclasts. These actions are mediated at
the cell level via the estrogen receptor and occur in both males and females.
With aging, due to declining testosterone levels in males and estrogen in
females, the bone resorption is increased and leads to bone loss. Unlike in
females, the decline in testosterone in males is rather modest and normally
does not cause pathology unless there is a marked deficiency warranting a
diagnosis.

PATHOPHYSIOLOGICAL EFFECTS OF STEROIDS

Much of what we know about the physiological effects of natural steroids
has been elucidated from certain pathological conditions associated with either
elevated or decreased corticosteroid level. These conditions normally result
from disorders of the adrenal glands. Furthermore, some of them occur as
adverse effects of exogenous or synthetic steroid therapy that takes place for
prolonged periods.
 Effects and Applications 89

Adrenal Diseases
Cushing Syndrome
Harvey Cushing first described the clinical picture of Cushing syndrome in
1932. It can be classified into ACTH-independent type and ACTH-dependent
type. The clinical symptoms of the ACTH-independent Cushing syndrome are
caused by exaggerated production of cortisol by the adrenal cortex. This may be
a result of various disease states, such as glucocorticoid-secreting adrenal tumors,
adrenal hyperplasia, as well as prolonged administration of synthetic steroids.
The second type of Cushing syndrome, the ACTH-dependent, includes tumors
of the anterior pituitary gland that secrete ACTH. The ACTH-secreting tumors
of other organs such as lungs, which also secrete the corticotropin-releasing hor-
mone, may also lead to the clinical picture of Cushing syndrome (corticotropin
is the substance that stimulates the adrenal cortex to produce cortisol). The
Cushing syndrome that is due to those anterior pituitary tumors is often called
Cushing disease because these were the tumors originally referred to, when the
disease was first described by Cushing.
As a result of excess protein catabolism, patients with Cushing syndrome are
protein depleted and have thin skin and hair as well as poorly developed
muscles. Many patients experience an increase in facial hair and acne, however,
this effect occurs because of increased levels of adrenal androgens that usually
occur along with increased glucocorticoids’ secretion. Due to easy bruising,
small injuries will cause ecchymoses (bruises caused by bleeding underneath
the skin). Other symptoms include a “buffalo hump,” which results from
redistribution of fat from extremities to the upper back. Fat also tends to con-
centrate in the abdominal area and causes stretching of the skin, which results
in the formation of reddish purple stretch marks called striae. Whenever gluco-
corticoids are present in excessive amounts, they also exert a significant miner-
alocorticoid action. This leads to salt and water retention and contributes to
the characteristic “moon face” appearance. Additionally, the increased salt
and water retention leads to hypertension.
Other effects of excess glucocorticoids include bone loss and osteoporosis,
increased appetite, insomnia, and psychiatric symptoms.

Hyperaldosteronism
Hyperaldosteronism is a condition that results from elevated mineralocorti-
coid secretion. This process results in reduced potassium levels as well as
sodium retention, and it is characterized by weakness, producing large urine
90 Steroids

volumes, hypertension, and intermittent muscle spasms. This condition may

be caused by primary adrenal disease such as tumor of the zona glomerulosa,
adrenal hyperplasia, or adrenal cancer. Secondary hyperaldosteronism results
may be caused by cirrhosis, heart failure, and nephrosis.

Addison’s Disease
Addison’s disease is an example of adrenal insufficiency that results in
decreased levels of all hormones produced by the adrenal gland: glucocorti-
coids, mineralocorticoids, and androgens. This is called primary adrenal defi-
ciency, and the most common cause of this disorder is an autoimmune
process of destruction of the adrenal cortex. The symptoms of the deficiency
include weight loss, tiredness, chronic hypotension, and small heart size.
Severe hypotension may lead to shock, called Addisonian crisis. This is a result
of inadequate levels of both mineralocorticoids and glucocorticoids. Any fast-
ing or stressed state in patients with Addison’s disease may lead to fatal hypo-
glycemia and cardiovascular collapse. Other hallmark symptoms of Addison’s
disease include tanning and spotty pigmentation of the skin.
Secondary adrenal insufficiency occurs due to pituitary diseases that lead to
reduced levels of ACTH. Adrenal insufficiency that is caused by hypothalamic
disorders that interfere with the corticotropin-releasing hormone secretion is
called tertiary. These forms of adrenal insufficiency result in a milder symptom
presentation because they do not affect the electrolyte metabolism as signifi-
cantly as the primary adrenal insufficiency.

THERAPEUTIC EFFECTS OF STEROIDS AND APPLICATIONS

IN CLINICAL PRACTICE
Steroids are a group of the most widely used agents in the treatment of vari-
ous inflammatory and autoimmune disorders, since their discovery in 1940.
Physiologic doses of steroids are used as replacement therapy in adrenal insuf-
ficiency, while therapeutic doses (which are higher than physiologic) are uti-
lized in the management of dermatologic, ophthalmologic, rheumatologic,
pulmonary, hematologic, and gastrointestinal disorders.
As with natural steroids, the mechanism of action of synthetic therapeutic
steroids includes both mineralocorticoid and glucocorticoid properties. Most
of the anti-inflammatory action of glucocorticoids results from their involve-
ment in the up-regulation of DNA transcription of anti-inflammatory genes or
down-regulation of inflammatory genes. They also inhibit secretion of anti-
inflammatory cytokines and interfere with the stability of the mRNA of other
cytokines such as ILs, TNF, and granulocyte-macrophage colony-stimulating
 Effects and Applications 91

Table 5.2 Summary of Clinical Uses of Steroids

Discipline Conditions
Gastroenterology Inflammatory bowel disease (ulcerative colitis and Crohn’s disease)
Autoimmune hepatitis
Allergy and Asthma
Pulmonology Acute exacerbations of COPD
Allergic rhinitis
Nasal polyps
Sarcoidosis
Eosinophilic pneumonia
Interstitial lung disease
Ophthalmology Uveitis
Keratoconjunctivitis
Endocrinology Adrenal insufficiency
Congenital adrenal hyperplasia
Dermatology Atopic dermatitis
Phemigus vulgaris
Acute, severe contact dermatitis
Rheumatology/ Rheumatoid arthritis
Immunology Systemic lupus erythematosus
Vasculitis
Other Organ transplantation
Hematologic conditions (hemolytic anemia, idiopathic
thrombocytopenic purpura)
Disorders with inflammatory manifestations

factor (GM-CSF). Glucocorticoids also have a profound effect on the cellular

functions of leukocytes and endothelial cells, resulting in reduced ability of leuko-
cytes to adhere to vascular endothelium and exit from the circulation (leukocyte
trafficking). The immunosuppressive action of steroids includes inhibition of
the components of both innate and acquired immunity: phagocytes, mast cells,
and basophils, as well as T cells and B cells. These actions are mediated via the
GR in the cytoplasm and then nucleus. Interestingly, it appears that there is only
one type of GR, and no evidence exits of other subtypes that may mediate various
actions of corticosteroids.
A summary of clinical uses of steroids is included in Table 5.2.

Autoimmune Disorders
Autoimmune diseases (broadly termed “rheumatic disorders”) are charac-
terized by the immune system over activity, which attacks its own healthy cells.
92 Steroids

Depending on the type of cells being attacked, each condition has a different
set of symptoms.
Rheumatoid arthritis is characterized by painful swelling and stiffness of the
joints in wrists and small joints of the hand, such as knuckles and the middle
joints of the fingers. Systemic lupus erythematosus attacks the connective tissue,
which not only affects the skin and joints but also other organs in the body:
kidneys, tissue lining of the brain, the lungs, and the heart. Vasculitis is an
autoimmune disorder of blood vessels. It affects both arteries and veins.
The major problem associated with vasculitis is poor blood flow and oxygen
delivery to organs and tissues of the body.
The underlying pathophysiology of these conditions, in addition to
immune system over activity, is inflammation. The usual course of the disease
is a series of flare-ups and remissions. Hence, glucocorticoid therapy plays a
significant role in autoimmune therapy. In patients with rheumatic disorders,
glucocorticoids are primarily used as adjunctive agents for temporary control
of the disease activity and pain during flare-ups. This results in decreased pain,
swelling, and other symptoms.
Glucocorticoids used in rheumatic diseases are administered via many
routes and modalities. Frequently, they are used as “bridging therapy” while
awaiting the effects of other disease-modifying and immunosuppressive agents
to occur. For patients with severe symptoms, prednisone is given for a short
period of time to relieve the symptoms. This short-term use of glucocorticoids
has not been shown to induce any chronic adverse effects associated with ste-
roid therapy. Trials evaluating the chronic use of glucocorticoids in patients
with rheumatic conditions showed conflicting evidence, and the effect of this
chronic therapy is yet to be determined.
Another type of treatment approach is “pulse therapy,” which involves
administration of high dose of glucocorticoids for a short period. This
approach is usually employed during severe flare-ups and sometimes as
bridging therapy. Most frequently, intravenous route is employed for pulse
therapy—usually 1 gram of methylprednisolone per day for three consecutive
days. Pulse steroids can also be given orally or via intramuscular injection.
Patients with rheumatoid arthritis also benefit from injections of steroids
administered directly into the painful joints. This route of administration is
called intra-articular, and triamcinolone is most frequently used in this setting.

Respiratory Disorders
The efficacy of corticosteroids in respiratory conditions, specifically asthma,
stems from their anti-inflammatory properties. The pathophysiology of
asthma involves airway smooth muscle contraction and activation of many
 Effects and Applications 93

inflammatory cells, such as cytokines IL-1, Il-3, IL-4, and others; TNF-α; and
GM-CSF. Those effects lead to airway hyperresponsiveness, a physiological
hallmark of asthma. There are two main classes of medications that are used in
asthma: bronchodilators, which reduce the smooth muscle contractility, and glu-
cocorticoids, which reduce the inflammatory process. Bronchodilators are used
mainly for fast relief of severe exacerbations, while corticosteroids have a “control-
ler” function, which allows for long-term management of the symptoms. Steroids
inhibit the inflammatory cells in the bronchial submucosal and epithelial cells.
They have no direct effect on the contractile response of airway smooth muscle,
but they have positive effect on the chronic airway inflammation and hyperres-
ponsiveness. A single dose of steroid has no effect on the immediate response to
allergen but inhibits the late response (which may be due to an effect on macro-
phages, eosinophils, and airway wall swelling), and it also inhibits the increase in
airway hyperresponsiveness.
Due to these actions, it takes several weeks or months to achieve the maxi-
mal effect on air hyperresponsiveness, possibly reflecting the slow healing of
the damaged, inflamed airway.
Since their discovery in 1950s, oral corticosteroids have been introduced
into the treatment approach to asthma and remain the most effective “control-
ler” medication. The concern for adverse effects associated with the use of
chronic corticosteroids has prompted the research of alternative routes of
administration. As mentioned in Chapter 2, the introduction of inhaled corti-
costeroids has transformed the treatment of asthma. The delivery of these
agents via inhalation allows for direct delivery to the airway, with a much lower
risk for systemic side effects.
The pathophysiology of chronic obstructive pulmonary disease (COPD),
another major respiratory disorder, involves chronic inflammation that leads
to destructive changes and development of irreversible chronic airway limita-
tion. The inflammatory process of COPD is widespread and involves not only
the airways but also the pulmonary vasculature and lung tissue. Because the
underlying pathophysiologic process of COPD is inflammation, it was origi-
nally suspected that corticosteroids would have a significant function in symp-
tom control. Although both asthma and COPD are characterized by the
process of inflammation, the type of inflammatory mediators that predomi-
nate in each condition differs. In asthma, eosinophils and mast cells play a
major role in the inflammatory process, and, in COPD, inflammation is medi-
ated predominantly by neutrophils. For this reason, the response to inhaled
corticosteroids in COPD is not as robust as in asthma, and they are much less
effective and usually reserved for short-term management of patients with
severe exacerbations.
94 Steroids

Oral corticosteroids remain the mainstay of treatment of several other pul-

monary diseases, such as sarcoidosis, interstitial lung disease, and pulmonary
eosinophilic syndrome.

Allergic Rhinitis and Seasonal Allergies

Glucocorticoid nasal sprays are also frequently used in allergic rhinitis. They
inhibit allergic inflammation directly in the nose and relieve nasal congestion,
sneezing, and itching. Glucocorticoids are thought to be more effective than
other antiallergy agents in relieving the symptoms and cause few side effects
if used at recommended doses.
The agents can be classified as first and second generation, and this classifi-
cation refers to their systemic bioavailability. The second-generation agents
have close to an undetectable systemic bioavailability, which greatly reduces
their potential for causing systemic adverse effects. The agents in this group
include fluticasone propionate, mometasone furoate, and fluticasone furoate.
Beclomethasone, flunisolide, and budesonide are second-generation steroid
nasal sprays whose systemic bioavailability ranges from 10 to 50 percent.
The systemic adverse effects can be minimized by appropriate inhaler tech-
nique and short-term use. Agents that are dosed once daily have also been asso-
ciated with lower risk for long-term consequences of steroid use. All available
agents are indicated to be used once daily, except flunisolide, which is used
twice daily. Fluticasone propionate (Flonase Allergy), budesonide (Rhinocort
Allergy), and triamcinolone (Nasacort Allergy 24H) are available over the
counter. Some products (beclomethasone and ciclesonide) are also available
in aerosol formulations and may minimize the after-taste side effects associated
with nasal sprays.

Disorders of the Skin

Glucocorticoids are prescribed in a variety of inflammatory skin conditions,
either in a topical form to be used locally or systemically via intramuscular,
intralesional, or oral routes. Available topical agents, their dosage forms, and
their potencies were described in Chapter 2. Systemic therapy is usually
reserved for severe dermatological illnesses, such as allergic contact dermatitis
to plants, such as poison ivy, or autoimmune dermatologic disorders. The
autoimmune dermatologic diseases include bullous dermatoses (e.g., pemphi-
gus vulgaris, paraneoplastic pemphigus, and dermatitis herpetiformis), which are
debilitating and possibly fatal blistering disorders. Another autoimmune con-
dition where glucocorticoids are commonly used is psoriasis. It is a chronic dis-
ease characterized by a series of flare-ups and remissions marked by the
 Effects and Applications 95

formation of painful and scaly red patches resulting from cells rapidly building
up on the surface of the skin.
It may involve anywhere from small areas of the body to very large
areas, including the scalp. Frequently it occurs in conjunction with other
conditions such as Crohn’s disease, arthritis, multiple sclerosis, metabolic
syndrome, and psychological illnesses (depression, anxiety, and alcohol-
ism). In these conditions, corticosteroids have anti-proliferative, anti-
inflammatory, immunosuppressive, and vasoconstrictive effects. Topical
corticosteroids have been used regularly for the majority of patients with
psoriasis for more than fifty years. The usual approach involves using an
appropriate potency topical product based on disease severity and location.
Different formulations have been developed to enhance delivery of topical
corticosteroids, as described in Chapter 2. Betamethasone valerate in foam
is especially efficacious for scalp psoriasis and preferred by many patients.
Clobetasol propionate spray is also available and it’s easy to apply to large
areas. The main disadvantage of the newer, more convenient preparations
is increased cost.
Systemic steroids are usually not used in psoriasis, and other immune sys-
tem modulating agents are often prescribed in addition to corticosteroids.

Organ Transplantation
Oral corticosteroids constitute an important element of immunosuppres-
sive therapy provided to patients after organ transplantation. This approach
is necessary to ensure successful acceptance of the new organ by the body.
Despite the many adverse effects, corticosteroids have been used as part of
immunosuppressive regimens since the first human transplantations. Today,
30 percent of liver and 60 percent of kidney transplant patients receive cortico-
steroids for at least the first year after the transplant. Corticosteroids’ efficacy in
organ transplantation results from their blocking of cytokine activation and
inhibiting ILs, γ-interferons, and TNF. Other actions include lymphocyte
proliferation and changes in cell trafficking. The most commonly used cortico-
steroids are methylprednisolone and prednisone. The concern for adverse
effects of steroid use initiated an approach of “steroid avoidance” in immuno-
suppressive regimens, especially in low-risk patients. Recent studies of
corticosteroid-free immunosuppressive regiments, combined with newer,
more specific immunosuppressants, may suggest that corticosteroids will have
a lesser role in the future maintenance of immunosuppression. This is an area
of controversy, however, as there are studies suggesting the continued need for
corticosteroids in immunosuppressive regimens as well as lack of long-term
improvement in survival in cases of steroid avoidance.
96 Steroids

Ocular Diseases
Corticosteroid therapy has been widely applied in ocular disease, thanks to
its anti-inflammatory properties. Currently, glucocorticoids formulated for
topical administration to the eye include dexamethasone, prednisolone, fluo-
rometholone, loteprednol, rimexolone, and difluprednate. These agents are
used in managing significant ocular allergy, anterior uveitis (inflammation of
the uvea—the middle layer of the eye consisting of the ciliary body, the iris,
and the choroid), external eye inflammatory diseases associated with some
infections, and postoperative inflammation following corneal and intraocular
surgery. After glaucoma surgery, topical steroids can delay the healing process
by decreasing fibroblast infiltration, thereby reducing potential scarring of the
surgical site. For uveitis, systemic steroids are often utilized as well as intravi-
treal injections, which are administered directly into the eye. These products
are used to treat a variety of retinal conditions, including age-related macular
degeneration, macular edema, and diabetic retinopathy. For ocular inflamma-
tory conditions that do not respond to topical agents, two formulations of tri-
amcinolone are approved for intravitreal administration. Fluocinolone
(Retisert) is also marketed as an implant to treat chronic noninfectious uveitis.
This formulation releases the medication at a very slow rate for about two and
a half years.

Gastrointestinal Diseases
The major application of steroids in gastrointestinal disorders is in the treat-
ment of inflammatory bowel disease (IBD), which is a disorder of unknown
etiology, possibly involving autoimmune, genetic, infectious, and environ-
mental factors. There are two major types of this disease: ulcerative colitis
and Crohn’s disease. Both are characterized by a course of remissions and
flare-ups, with most manifestations related to the process of inflammation
occurring in the GI tract: frequent bowel movements with blood in stool,
abdominal cramping, anal fissures, weight loss, and often blurred vision,
arthritis, and ocular disorders such as uveitis.
In addition to nutritional support, immunosuppressive therapy, and sur-
gery, corticosteroids are used to suppress acute inflammation and may be given
parenterally, orally, or rectally.
Budesonide is a corticosteroid that is metabolized significantly by the liver
before reaching systemic circulation (“first-pass effect”), and for this reason it
is administered orally in a controlled-release formulation designed to release
the medication in the terminal ileum or the colon. Budesonide is used in mild
to moderate IBD for the purpose of inducing the remission. “Topical” types of
 Effects and Applications 97

budesonide are also available in the form of enema. Oral formulations of bude-
sonide include time- and pH-dependent products that work mainly in the
ileum and ascending colon and a multimatrix formulation that extends its
delivery to the entire colon.
Other agents, used in moderate to severe disease, include methylpredniso-
lone, prednisone, and hydrocortisone.

Hematologic Disorders
The rationale for using glucocorticoids in management of hematologic
malignancies stems from their ability to modify both immune and metabolic
functions of cells. This is especially beneficial in lymphoid cancers, such as
lymphoma and leukemia, where steroids significantly reduce the number of
lymphocytes. In addition to these effects, glucocorticoids also decrease
cancer-induced nausea and vomiting, swelling associated with malignancy, as
well as symptoms of inflammation and hypersensitivity associated with some
chemotherapeutic protocols.

Septic Shock
Septic shock is a widespread systemic infection with uncontrolled
inflammation that causes a progressive multiple organ failure and death.
This overwhelming inflammation occurs largely due to the inability of the
body to mount a sufficient hypothalamus-pituitary-adrenal (HPA) axis
response. Although corticosteroids also suppress the immune system and
reduce the immune response, evidence from studies and meta-analyses sug-
gests that exogenous steroids may reverse this effect. Consistent findings
show that the use of steroids as adjunctive agents in septic shock signifi-
cantly contribute to improved cardiovascular stability, promote restored
organ function, aid in eliminating the systemic and tissue inflammation,
and prevent death.

Pneumocystis Jiroveci Pneumonia

Pneumocystis jiroveci pneumonia (PCP) is an opportunistic infection that
occurs in patients who are severely immunocompromised, mainly AIDS
patients. Pneumocystis jiroveci is a fungus that is present in healthy individuals
but rarely produces clinical manifestations until there is a significant level of
immunosuppression. PCP classically presents with pulmonary symptoms such
as nonproductive cough, shortness of breath, and fever. Prednisone is typically
used in addition to antimicrobial therapy to prevent respiratory failure and
98 Steroids

death in patients with severe disease. The usual approach is to administer pred-
nisone for twenty-one days.

Chronic Adrenal Insufficiency

In adrenal insufficiency, steroids are used in order to replace the depressed
hormone levels. This is normally achieved with doses as close to physiologic
doses as possible, rather than therapeutic doses. Acute adrenal crisis requires
urgent intervention. It is characterized by hypotension and electrolyte disturb-
ances that may lead to volume depletion. Dexamethasone as a 4 milligram
intravenous injection is the preferred agent to manage the symptoms, along
with other agents typically used in a critical care setting (e.g., hydration).
Once the patient is stabilized, the precipitating cause of the adrenal crisis
should be examined and appropriately managed. Any new diagnosis of adrenal
crisis can be confirmed using an ACTH stimulation test. This test evaluates
the response of the adrenal glands to ACTH and employs a synthetic ACTH
derivative, called cosyntropin. Patients with adrenal insufficiency have a low
level of cortisol after administration of cosyntropin. Once the diagnosis of
chronic adrenal insufficiency is confirmed, the patient is placed on a replace-
ment therapy. The goal of replacement therapy is to mimic the endogenous
cortisol production with the lowest level occurring at bedtime and highest
right before awakening; minimize the risk of overtreatment and pushing
the patient into Cushing’s syndrome; and allow for easy dose titration and
monitoring. Both short-acting and long-acting glucocorticoids are used in
replacement regimens. Short-acting regimens typically employ hydrocorti-
sone. They approximate the diurnal rhythm and are usually given twice or
thrice per day. Currently, there is a once-daily dual release hydrocortisone tab-
let being investigated as an alternative to twice- or thrice-daily dosing regi-
mens. Longer-acting agents, such as dexamethasone, may be useful in
patients who have difficulty adhering to multiple daily dose schedules, or those
who have severe late-evening or early-morning symptoms, which are not
relieved with thrice-daily hydrocortisone.
Because primary adrenal insufficiency also results in sodium deficiency, vol-
ume depletion, and elevated potassium level, most patients will also require
mineralocorticoid replacement. The agent that is used for this purpose is flu-
drocortisone, a synthetic mineralocorticoid, typically given orally in a dose of
0.1 milligram per day. If patients are also receiving hydrocortisone, then a
lower dose of fludrocortisone may be sufficient, because hydrocortisone has
some mineralocorticoid activity.
 Effects and Applications 99

Many patients, especially women, report a decrease in quality of life despite

adequate glucocorticoid and mineralocorticoid replacement. This observation
encouraged investigation of other therapies, specifically androgen replace-
ment. One investigated agent is DHEA. Studies to date have shown only a
mild improvement in mood and quality of life, and at this point there is insuf-
ficient data to recommend therapy in all patients with adrenal insufficiency,
especially men. This is partially due to the fact that DHEA is considered a
dietary supplement, and as such, it does not undergo the strict quality control
process that is required for prescription agents.

Contraception
Hormonal contraceptives are synthetic hormones, which have several
mechanisms of action. They are available in two forms: those containing
both estrogen and progestin (combination oral contraceptives) and those that
contain the progestin component only. Hormonal contraceptive agents act
by suppressing the hypothalamic gonadotropin-releasing hormone as well
as gonadotropin secretion from the pituitary. They also inhibit the mid-
cycle LH so that ovulation does not occur. An additional mechanism of con-
traceptive agents is suppression of the formation of the follicle in the ovary.
These effects occur in response to the estrogen. The progestin component
of hormonal contraceptive agents primarily affects the endometrium in the
uterus, making it less suitable for implantation. It also alters the cervical
mucus and makes it less permeable to sperm and affects the motility of fallo-
pian tubes. Most available progestins are derived from testosterone and bind
to both progesterone and androgen receptors. Some of the earlier progestins,
such as norethindrone, and levonorgestrel have significant androgen proper-
ties that cause metabolic adverse effects. The newer progestins have lower
androgenic activities, although several studies reported an increased risk for
deep vein thrombosis with these products. The type of contraceptive used
is determined by patient preference; for example, the progestin-only agents
typically provide long-term loss of fertility, while the combination products
allow for faster return to fertility if desired.
Hormonal contraceptives are available in a plethora of formulations, includ-
ing tablets, injectables, implants, patches, and intravaginal and intrauterine
devices. Combination oral contraceptives are also available in either mono-
or multiphasic formulations. These products contain varying doses of estrogen
and progestin in an attempt to lower the total steroid dose, however, studies
did not show a significant benefit from using the multiphasic products.
100 Steroids

Typically, the hormonal contraceptives are taken in a cyclical fashion, with a

hormone-free interval, during which a menstrual period occurs. Extended-
cycle regimens are regimens where active hormone is taken continuously,
resulting in a very thin endometrium and very few or none menstrual cycles.
In addition to prevention of pregnancy, hormonal contraceptives have addi-
tional benefits, and some products are actually FDA-indicated to treat certain
conditions. These include premenstrual dysphoric disorder, premenstrual
syndrome, dysmenorrhea, and prevention of menstrual migraines. They may
also reduce acne and excessive hair growth in women with polycystic ovarian
syndrome.

CONCLUSION
Steroids exert a multitude of effects in humans. The physiological actions are
related to the role of glucocorticoids in the fight-or-flight response and the body’s
reactions to critical situations and stress. Chronic exposure or excess of glucocor-
ticoids leads to many adverse effects, some of which are extensions of their
physiological actions during critical events. Glucocorticoids are employed in vari-
ous disease state management protocols as anti-inflammatory and immuno-
suppressive agents. They are also utilized to replace physiological levels of
steroid hormones. Another important role of steroids is their use in the field of
contraception and fertility.
 Chapter 6

Risks, Use, and Abuse

Alex Bogomolnik

From the discovery of steroids until the present day, steroids fit the chemical
prescription for a diverse number of purposes and reasons. From what we have
learned in earlier chapters, we know that steroids were seen as potential keys to
the mysteries of human metabolism, the functioning of organs, and other
chemical relationships that scientists sought to understand. Particular steroids,
such as the hormonal steroid testosterone, were viewed as gateways to reversing
the aging process and restoring strength and youthful health. Because of these
scientific efforts, steroids are employed, today, for a variety of medical pur-
poses, managing symptoms as well as treating chronic conditions such as
Crohn’s disease, asthma, and arthritis. The anti-inflammatory properties as
well as the quick and effective response of catabolic steroids make them good
candidates for medical interventions. Anabolic steroids, on the other hand,
are used by various individuals, such as athletes, to gain better performance
outcomes and build stronger muscles in a faster amount of time. In the early
2000s, a new group began to emerge that uses anabolic steroids to enhance
looks and self-image rather than to perform physically. Despite the very real
risks of use, steroids continue to gain in popularity globally and are used for
both therapeutic and recreational reasons.

MEDICAL USES AND SIDE EFFECTS

The medical usage of steroids has been linked to the long-term as well as
short-term treatment of various health conditions and their symptoms, varying
102 Steroids

in range and severity. The spectrum of steroid use in the healthcare field con-
tinues to grow because of its effectiveness and targeted interventions. On the
other hand, medical steroid use also has a downside. Continuous dependence
on steroids carries potential health complications and challenges. Individuals
who often rely on frequent use of steroids may experience further negative
health effects as well as worsening of other health conditions. The medical
doctor who prescribes steroids must educate a patient on proper use as well
as on the side effects that come with intake. Costs and benefits must be
weighed in order to arrive at a more appropriate decision of whether to take
them or not. However, despite the risks, corticosteroids continue to be widely
used by the medical industry because of their effectiveness.
There is a variety of different corticosteroids. Each steroid possesses its own
unique properties and treatment protocols. In addition, the goal of steroid
therapy varies based on the presenting problem of each individual. The dosage
of steroid administration also varies depending on the goal. Small-dosage
therapy is different from high dosage in regard to side effects as well as to
how well the medication performs the needed action. Flare-ups of each health
condition can be treated, generally, with low doses of steroids. Long-term use
of corticosteroids therapy, however, such as for five years or longer, has been
associated with a high probability of heart and bone problems as well as infec-
tions. In addition, the timing of the steroid intake can be significant for people.
For example, the time of day or evening to take the medication can be signifi-
cant for someone who has chronic joint problems and morning stiffness.
Corticosteroids such as prednisone and budesonide are used effectively to
decrease inflammatory responses in the body; nevertheless, the chances of
developing side effects for their usage increase after several weeks. In addition,
when using corticosteroids, the amount of time that these medications have
been used, as well as the dosage, is critical in understanding the development
of side effects such as pneumonia and bone problems.
Another factor that comes into play with these medical interventions is the
relapse of the disease; as the frequency of relapse occurs, so does the potential
dependency on the steroid—which in turn becomes a vicious cycle of steroid
misuse, especially if it’s not treated carefully. At that point, the appropriate
method for stopping steroid use is a gradual weaning-off process with mini-
mum pharmacological intervention. In this way, the goal to achieve indepen-
dence from the substance is achieved.
Corticosteroids, which are also known as catabolic steroids, are used for
various medicinal purposes. For example, steroids are used in medicine to help
to decrease inflammation as well as manage chronic health conditions such as
asthma and rheumatoid arthritis. Each type of steroid performs a different
 Risks, Use, and Abuse 103

function. People who suffer from various health conditions such as rheuma-
toid arthritis, lupus, chronic obstructive pulmonary disease (COPD), and
inflammatory bowel diseases may have higher levels of inflammation in their
bodies, and a variety of steroids may be beneficial in reducing and managing
the inflammation to more appropriate levels.
Inflammation is a term that is used to describe the body’s way of dealing
with bacteria and viruses. Inflammation is also a process that assists the body
with making necessary repairs needed for the body to function appropriately.
It is a reaction set primarily by the immune system in order to deal with exter-
nal factors. The inflammatory response occurs in the body as a chain reaction
and triggers various reactions to take place. For example, swelling and releasing
of certain agents by the body to kill foreign pathogens are some of the inflam-
matory processes that take place in order for the body to defend itself against
foreign pathogens. When the process of inflammation becomes more long
term, the human body may begin to experience serious health conditions such
as Crohn’s disease, rheumatoid arthritis, and asthma. In the conditions such as
ones listed above, the immune system may attack its own body tissues and
cause further destruction rather than repairing them and resulting in further
harm of the body.
Many of the steroids created today are synthesized primarily in laboratories.
These types of steroids are very potent in strength and are designed to target a
specific treatment protocol. There are many of these drugs that are used for a
variety of health conditions. Popular types of corticosteroids are prednisone,
dexamethasone, and betamethasone, which are sold in today’s market under
various brand names, not their chemical names. For example, prednisone is
listed under the drug Prelone, and dexamethasone is branded as Decadron.
A popular drug shown on television commercials is Humira. Humira contains
multiple ingredients that help people who suffer from autoimmune diseases,
and it contains a steroid that helps counteract inflammation caused by autoim-
mune diseases such as rheumatoid arthritis, Crohn’s disease, and psoriasis.
This medication can be taken through skin injections. Individuals who
take this medication must also be careful with its interactions and side effects.
For example, people who have tuberculosis as well as other possible infections
could be at risk when taking Humira because of its suppressing effect on the
immune system. In other words, when a person takes Humira, it decreases
the overall functioning of the immune system in order to decrease the level
of inflammation in the body. When this occurs, the person becomes more sus-
ceptible and prone to other diseases and infections. In addition, long-term side
effects of Humira may lead to respiratory and joint complications. However,
with health conditions such as Crohn’s disease in which the body attacks its
104 Steroids

own digestive system and may leave the person in a state of health crisis,
taking this medication may not be a choice. Crohn’s disease is characterized
by inflammation of the portions of GI tract in the digestive system. Corti-
costeroids have been shown to be effective with inflammatory bowel disorders
such as Crohn’s disease if the inflammation is the main reason for its manifes-
tation. Corticosteroid is an effective and safe treatment if used to decrease
inflammation in the body.
Another example of how steroids are used medically is when testosterone
is low, for example, in a medical condition known as hypogonadism.
Testosterone can be replenished through an intake of synthetic testosterone,
which resembles one that is made in the body. By being consistent with a
medication regimen and taking it as prescribed, the person is able to live a
more normal and fulfilling life.
Nevertheless, by following the medical steroid regimen for treatment of
these health conditions, serious side effects can develop. Depending on the
type of steroid being administered, dosage, and accumulated length of
administration, common side effects may include weight increase, diabetes
mellitus, changes in bone calcification, muscle weakness, sleep changes, cata-
racts, as well as other negative effects on the body. In addition, a person who
takes steroids may experience psychiatric effects such as mental health condi-
tions, including anxiety and depression.

ADMINISTRATION AND RISKS

Steroids are administered in various ways such as orally, in a pill form, topi-
cally on skin through the application of cream, with transdermal patches, and
subcutaneous injection (under the skin). For example, hydrocortisone cream,
which is used for various skin ailments, can be put on the outer skin to help
temporarily relieve the skin condition. This cream can be purchased at any
pharmacy and is considered an over-the-counter (OTC) item. The application
of transdermal delivery of the drugs carries potential benefits. This type
of delivery is more convenient and less painful than other methods of
administration. It eliminates the concern for keeping the constant and proper
therapeutic dosage, and it provides a method that is less burdensome than
other methods, such as injection and oral administration. As a result, people
are more willing to use the method of transdermal delivery since there is a
higher probability of compliance with taking medication as scheduled and pre-
scribed. In addition, transdermal delivery can be safer on the organ systems
and less expensive for the person. Steroids that help with breathing by a
mechanism of bronchial dilation are typically administered through a method
 Risks, Use, and Abuse 105

of inhaling the contents of the steroids. Individuals who suffer from conditions
such as asthma and COPDs, such as chronic bronchitis and emphysema, tend
to be prescribed steroid-based medications such as Advair (generic name:
Fluticasone Propionate/Salmeterol Xinafoate), which are typically inhaled.
This medication contains ingredients that are composed of a corticosteroid
known as Fluticasone, which acts to decrease inflammation in the airways of
the lungs. Salmeterol is a bronchodilator that operates to expand the airways,
which in turn enables an individual to breath with ease. Both Fluticasone
and Salmeterol are part of Advair medication and work together in providing
symptomatic control over lung problems. However, Advair is not effective at
providing immediate relief during peaks of problems, such as asthma attacks;
it is prescribed more for nonemergency use. Other medications such as an
Albuterol inhaler can provide quick relief for patients with shortness of breath.
Moreover, there are treatment options available for various respiratory condi-
tions that may or may not contain steroids. For example, a medication known
as Spiriva is also used for various respiratory conditions and contains other
ingredients that are nonsteroidal.
To determine which medication best suits the patient, the medical doctor
must be knowledgeable of the patient’s medical history as well how he or she
reacts to its effects. In addition, the medical doctor must educate the patient
on the pros and cons of treatment, which further allows the person to make
an appropriate decision based on the options provided.
Another important variable that plays a role in steroid administration is the
dosage that is administered. As the dosage of the steroid increases, the steroid
strength increases proportionally. For example, typical hydrocortisone creams
that are used for various skin conditions can be found in many stores and
can be considered as OTC items. Any person who has a need to buy these
creams can do so without any doctor’s prescription or recommendation.
Groceries and other pharmacies may have these creams available at their coun-
ters. However, what determines the difference between a low-strength or high-
strength cream is the dosage. The higher-dosage steroids must be prescribed by
a medical doctor. If a person suffers from a skin condition such as eczema, he
or she can go to the doctor’s office and obtain a prescription for a significantly
higher strength of the steroid cream, which implies that the dosage of the
medication will be proportionally higher. Medically prescribed steroid creams
are only available in pharmacies because they are considered medications and
need to be dispensed by a licensed pharmacist whose area of expertise is med-
ications. However, there are also steroids that are mainly administered by
medical doctors, such as steroids that are injected into the spinal area to
decrease inflammation or into hands of someone who suffers with arthritis
106 Steroids

symptoms. A specific dose of steroid is delivered to the patient’s spinal area for
the purpose of alleviating back pain. The steroid injections that are used for
back pain patients are typically administered using special X-ray technology,
and the doctors have to be specifically trained to deliver these steroid injections
into the spine. These types of steroids work by decreasing the inflammation in
the back. The advantage of receiving injected steroids is that it ensures that a
high dosage of steroid medication was delivered to the site where the inflam-
mation has occurred. In addition, the dosage is controlled, so, therefore, it
completely decreases the chances for the patient to overdose or abuse it in
any way. Since there are significantly fewer steroid injections that are given
to the patient in comparison to the same patient taking it orally, there is a
chance of higher medication compliance on the patient’s part.
However, there are also potential consequences to the use of injectable ste-
roids. For example, if the injections are done frequently and to the same area,
it can create problems with bone, tendons, and ligaments and make them
weaker. The steroid injections must not last more than three months. If the
individual is provided with a non-injectable form of steroids such as in a pill
form, the monitoring of prescribed dosages of steroids is important toward
the prognosis of medical treatment. If the person does not take the medication
as prescribed, this can exacerbate his or her health condition. On the other
hand, if the person takes too much, he or she can suffer from various side
effects that come from abusing the substances.
While corticosteroids are used for various medical conditions as described ear-
lier, abuse of these substances may occur in other ways. For example, in the New
York Times article “Creams Offering Lighter Skin May Bring Risks,” the life a of a
forty-five-year-old woman from the West Indies is described; she uses a
prescription-based topical steroid cream to enhance the color of her skin and
make it lighter. She has been using these creams for years, over her entire body
twice per day. This application of steroid cream does not come without conse-
quences. Even though her skin did become lighter, it also became extremely thin
to a point where her face developed bruising. And even though the labels on the
creams listed the possible side effects, she frequently ignored these and continued
to use the cream. Doctors—dermatologists in particular—are identifying more
and more women, especially those with African American and Hispanic back-
grounds, who tend to misuse topical steroid medications in order to change or
enhance their looks. What is surprising is that many of these prescribed-dosage
steroids can be obtained in everyday places, such as beauty salons and from
Internet sites, rather than substance-controlled facilities.
Another example of the misuse of steroids involves Sammy Sosa, a famous
baseball player in Major League Baseball with a long career history from
 Risks, Use, and Abuse 107

1989 until his retirement in 2009. According to the New York Times, in 2009,
he used topical steroids to make his skin softer, which also made it whiter.
Counterfeit steroids are another concern for topical steroid users, as well.
One of the major concerns of dermatologists who are seeing a pattern of severe
side effects from counterfeit topical steroid use is that these creams can contain
very toxic ingredients, such as mercury, which may react as a neurotoxin on
the body. The prescription-based topical steroids began to reemerge because
of Internet and individuals that used it to obtain prescription based
steroids. In other countries such as the Philippines and India, lighter faces
can be considered a higher status on the social ladder, which in turn reinforces
the use of topical steroid misuse. Also, some topical steroids, such as
Clobetasol—a highly potent steroid—continues to be put into cosmetics,
despite the fact that there may be contraindications for facial uses.
The extended and continued application of these steroid products can often
lead to higher blood sugar and blood pressure as well as skin changes. One ste-
roid ingredient used in skin products is hydroquinone, which has a higher
probability of being misused on the market than any other steroid, especially
in bootlegged and counterfeit items where it can be four to five times the regu-
lar strength for a common dosage. This steroid ingredient is used particularly
for enhancing various skin spots and discolorations that are possibly caused
by various health conditions.
Contrary to popular belief, corticosteroids are not the most effective treat-
ment for children with asthma conditions. Corticosteroid-based ingredients
in asthma medications for children remain the most common way to treat
the illness. However, they do not prevent or reduce the risk in those children
who are considered at high risk. While children keep taking the corticosteroid,
the medication keeps asthma under control; however, as soon as they stop tak-
ing it, the medicinal effect stops as well. Corticosteroids that are inhaled can
help to control asthma but do not work to prevent it. In addition, depending
on the severity of asthma that the child experiences, the steroid medication
does not always provide a sufficient management of the disease. Research has
demonstrated that individuals who took corticosteroids for COPD and then
stopped using these steroids were more than 30 percent less likely to develop
physical health conditions such as pneumonia, suggesting that the steroids
have made the person more susceptible and more prone to respiratory illnesses.
While corticosteroids continue to be a common path of treatment in the
United States, the application of steroids is still fairly new, and there are vari-
ous factors that are still unknown in regard to the constant and long-term
use of them. Many factors must be taken into consideration when deciding
on steroidal medical treatment, including the costs and benefits of each
108 Steroids

treatment. In addition, further studies must be done to show long-term effects

of steroids. However, the research that would show the effect of the cortico-
steroid on the person would be complex and financially burdensome because
of the variety of multiple factors involved in the research. In addition, studying
the effect of steroids on the person’s health would be difficult and would
require a large number of participants as well as a large amount of time to
study long-term effects. Moreover, the long-term effects of steroid use still are
not clear.
From other chapters, we read that other forms of steroids that are common
in today’s society are known as anabolic steroids. Anabolic-androgenic steroids
(AAS) act as catalysts in a chemical reaction that speeds up the recovery process
in performance-based physical activities. Anabolic steroids in the body speed
up the rate of production of protein, which ends up increasing the mass of
muscles and enhances athletic performance as well as decreases the time
needed for the body to recover. Anabolic steroids are synthetically based sub-
stances that resemble natural testosterone. These substances are hormones that
can be used to replenish natural testosterone in the body. If anabolic steroids
are used for alternative purposes other than replenishment of what is missing
in the body, however, the substance acts as a performance enhancer [perfor-
mance enhancement drug (PED) as well as a helper to those who suffer with
excess weight loss.
The abuse of AAS has been linked to a wide spectrum of negative serious
health effects that vary from negative changes in physique, such as the appear-
ance of acne on the skin, to formation of larger breasts for males. But the side
effects of AAS abuse do not stop there. An individual who is taking steroids
may encounter problems with his or her cardiovascular system, leading to
heart problems and serious damage to the liver. Many of the effects of steroid
abuse can be reversed; however, some things cannot be reversed, such as voice
changes in women and heart attacks. There are many side effects from AAS
that affect the whole body system, including modifications done to the hormo-
nal system. For example, if a male takes in synthetic testosterone, this in turn
increases the amount of testosterone in his body. When the body senses that
there is an abundant supply of testosterone, it decreases its own testosterone
production. When natural testosterone production is low, sperm production
is low as well, which then decreases the size of the testicle. This leads to func-
tional problems, which may result in testicular atrophy or reduced ability to
engage in sexual activity. In addition, another irreversible side effect is baldness
in males.
In females who use AAS, there is a process of conversion to masculinity.
The female body goes through various changes such as shrinking of the breasts
 Risks, Use, and Abuse 109

and the dropping of body fat. Other physiological changes that tend to occur
are changes in skin tone, reproductive organs, voice changes, increases in the
rate of hair growth, and changes in bone formation. Images of women body
builders in the early years of AAS usage show women with large muscles,
squared masculine faces, and small breast sizes.
In terms of behavior, studies show that using large amounts of steroids does
contribute to higher levels of irritability as well as aggressive behavior. In some
instances, there are reported cases of physical fights and criminal activities.
People who have abused steroids state that their frequency of malicious behav-
ior increased when they took them. A study conducted in 1999 at a treatment
facility found that out of 227 males who used heroin, close to 10 percent of
them admitted to using AAS prior to heroin. Those in the 10 percent who
did use heroin and previously took steroids admitted that heroin was used to
cope with negative steroid effects such as insomnia and irritability. What is
interesting about this study is that it shows how substance addiction is inter-
linked, even if the substances belong to different classes of drugs. Heroin pos-
sibly becomes a coping strategy for the adverse effects of steroids. Based on this
study, it can be observed that steroids act as gateway substances for heroin, that
is, steroids precede heroin use and provide an avenue for eventual use of nar-
cotics as a medication!
AAS drugs are considered addictive because of their withdrawal symptoms.
Various symptoms of withdrawal can occur, such as mood changes, feeling
restlessness, changes in appetite, as well as depression. In addition, the abuse
of steroids requires the user to constantly finance their use similarly to some-
one who is addicted to substances such as opiates.
The rate and method of AAS abuse varies from individual to individual.
The method of administration of AAS drugs can vary. Some can be injected
into the muscles of the body, and others are used inside the creams that are
placed on the skin to be absorbed. The dosage for AAS users can vary as well
and can go from ten up to one hundred times the normal medical dosage.
There are also various accepted patterns of use in the way that the users
decide to take them. A method known as cycling is used to take AAS for a des-
ignated amount of time in larger amounts and then cease and, again, resume
with the same process of taking and then stopping again. Another method of
taking AAS steroid is through stacking, which means mixing different types
and varieties when taking them. This is done in a methodical and structured
way. The person who is using AAS will mix various types of steroids along with
alternating methods of administration such as going from pills to injections.
The method of stacking AAS allows individuals to have a combined effect
rather than just taking these drugs individually. However, this has not been
110 Steroids

verified by scientific communities. A third type of AAS administration is

pyramiding, meaning gradually increasing the dosage and then gradually
decreasing the dosage, which theoretically gives the body enough time to
develop adjustment to the dosage as well as the body to recover hormonally
at the same time.
Individuals who take these steroids range in age, socioeconomic status, and
gender. There are multiple reasons why people desire to use steroids in the first
place. According to a recent study, bodybuilders are not the main users
of steroids. In fact, the most common and average user of steroids is a
college-educated male, in his twenties and thirties, with a higher-than-average
income, and a higher-end job. The common users of AAS are everyday people
who are not of athletic background and are not driven by sports in any way.
These types of individuals tend to abuse steroids for recreational purposes rather
than for professional bodybuilding or athleticism, as society and the media tend
to portray. Most of these users focus on building increased muscle mass, strength,
and to increase their level of attraction to other people. What is interesting about
this study is how it contrasts with the image of stereotypical use of steroids by
someone such as an athlete who is trying to boost performance.
While it may be appropriate to address the problem of athletes and try stop-
ping steroid use in the professional athletic world, steroid use continues to be a
problem in many other areas of life. Through the media’s scrutiny, we know
that steroid use is popular in athletics. In order to understand how the problem
with steroid begins, we first need to understand motivation for why it starts as
well as the time when the steroid problem begins to escalate for individuals.
There are bodybuilding dynamics that clearly come into play and intertwine
in the social culture of the male. For example, a physical image of someone
who is perceived as strong may work to intimidate those of similar sex as well
as possibly create an attraction from the opposite sex. Being bullied or intimi-
dated by those who are bigger and older can be a definite motivator. Even a
famous bodybuilder who has previously held the Mr. USA title, Craig Titus,
admitted that he was bullied in his younger years until he gained a mass of
almost 300 pounds and the height of 5-feet-9.
Another possible reason for AAS usage is peer pressure and being influenced
by the social expectations of what it means to be a male. Susan Bordo, a profes-
sor in the Women’s Studies department at the University of Kentucky, wrote
in the The Male Body: A New Look at Men in Public and in Private that AAS
drugs are used to change physical self-image for males and to create more
physical attraction and a sex appeal for the opposite sex. Moreover, these ste-
roids are used to create a different image for the male, which has nothing to
do with athletic performance. Men also use AAS so they can stand up to an
 Risks, Use, and Abuse 111

abuser such as a father figure as well as gain a perceived image of someone who
is so big and strong that no one can bully him.
AAS abuse is seen a lot in professional sports and athletics. Anabolic steroids
have been in the news often, and the subject of AAS has been discussed fre-
quently, especially in sports such as baseball. Every year, there is a growing
number of players in major and minor leagues that tend to abuse steroids
despite the consequences of being caught and having to deal with suspension
without pay. A popular AAS that has been used is known by the name of sta-
nozolol. This substance can be tested without much difficulty as well as stay
in the body for weeks at a time. In addition, baseball leagues have been consis-
tent with testing for the drug and having true positive results. Stanozolol has
been used primarily by pitchers as well as those players who are originally from
the Dominican Republic and are between seventeen and nineteen years of age.
AAS is easily available in the Dominican Republic: a walk to a local pharmacy
will frequently be enough to obtain these substances. Many young people in
the Dominican Republic dream of getting out of the cycle of poverty and
living a wealthy lifestyle such as those professional athletes who are in major
league baseball. The motivation to live a better style can be a great motivator
to do what it takes to gain a competitive edge.
There are various factors why AAS is popular in sports. One of the reasons is
that it enhances performance, and these players are able to have significantly
better results in their games. In addition, AAS speeds up the rate of recovery
that enables many players to develop a significantly better skill set and experi-
ence within a shorter amount of time than if they weren’t taking steroids.
Moreover, players are able to acquire more muscle and gain strength more
quickly with AAS. Other motivators may include pressure from those who
trained the players as well as easy access to AAS, which makes it easier to con-
sume. In 2016, there are educational systems put in place to educate players
about the usage and negative effects of AAS. Data show that the number of
players who have tested positive for stanozolol has been dropping since
2012, and use of it is now almost three times less. The punishment for using
AAS varies based on the type of league in which the player currently plays. In
the minor leagues, the player might get penalized by requiring them to sit
out eighty games without pay; but in the major leagues, the punishment
appears to be less impacting.
A famous major league baseball player by the name of Alex Rodriguez was
caught taking AAS in 2013. He scored very high on the boards, enough to
include him on the list of those honored before him in history. But he tested
positive for AAS in 2013, and the New York Yankees suspended him for one
year. He also lost a $6 million bonus that he had earned upon hitting a
112 Steroids

660th home run in 2013. When all of this happened, he created major nega-
tive publicity, and his image continues to be associated with taking steroid
enhancers.
Another aspect of AAS not frequently spoken about is the notion of
aggressive and violent behavior that may or may not correlate to the usage of
steroids. In the world of mixed martial arts (MMA), fighting and violence are
part of the action. A world-famous organization known as Ultimate Fighting
Championship (UFC) stages multiple fights every year in which various
experts in the field of multiple arts get together in a tournament. Fighters come
from different parts of the world and have both males and females participat-
ing. The fighters go through a series of continuous battles until the best martial
artist wins. In order to be part of UFC, a fighter has to be well ranked above
other fighters as well as go through a series of battles. The fighters have to be
well trained, deliver strength, power, technique, and, simultaneously, they
must be able to sustain damage to their bodies during the fight. The fighters
must also have knowledge and skill set of more than one type of martial art.
For example, a typical UFC fighter would be trained in boxing as well
have skills in taking their opponents down through grappling and choking.
This type of fighting is known as Mixed Martial Arts (MMA. Various organi-
zations formed under MMA worldwide. However, UFC remains the most
popular and usually has the most highly trained fighters.
The UFC as well as MMA have had problems with their fighters taking
AAS before the fights. Multiple fighters have tested positive for AAS, which
raised a concern for these MMA fighting associations. One of the drugs that
the fighters tested positive for was Drostanolone, a type of PED. Various fight-
ers in different weight categories were found to be using the PEDs. One of
the most famous cases of UFC’s connection to AAS was with fighter Jon
Koppenhaver, known as “War Machine.” As a fighter he was in top shape, very
skilled, and was able to sustain a good fighting record and continue with
his competition. At the time, Koppenhaver was dating Christy Mack.
One night Koppenhaver caught Mack being intimate with another man, and
Koppenhaver physically assaulted her to the point of almost killing her as well
as the other man. There were multiple charges against Koppenhaver, including
attempted murder. Mack reported that steroids may have contributed to his
mood swings and aggressive behavior. She stated that he used to take steroids
on a frequent basis, and each time she noticed a change in his behavior.
While it is difficult to prove whether it was the steroids, a mental health prob-
lem, or other factors that caused him to become violent, one thing is certain:
AAS contributes to the already known potential for violent behaviors.
As stated earlier, AAS creates a change in the brain, alters hormones, and
 Risks, Use, and Abuse 113

creates changes in one’s psyche. In a study completed in 2008, it was con-

firmed that there was a link between AAS and an increase in violent behavior.
The study showed that males who used AAS exhibited more violent activity in
contrast to those who did not use AAS. AAS users also scored higher on the
violence scale in comparison to nonusers. Elevated amounts of AAS have a
wide variety of psychiatric effects such as aggression, violence, and depression.
These behaviors seem to increase as the dose of AAS increases.
In a study done on the effect of AAS, more than 1,000 adolescent hamsters
were injected with doses of AAS that equaled indicators of steroid abuse. What
they found was that rodents became much more aggressive. The aggressive
behavior was observed by how the rodents acted after they were injected
with AAS.
The dosage of steroid is extremely important in understanding the extent
and nature of aggressive behavior. While this test was done on rodents, it
may or may not give us clues as to how steroids can actually alter the brain
and behavior of humans. Even though there are many variables that come into
play in terms of understanding the reasons for violent and aggressive behavior,
nevertheless not putting AAS into the formula may undermine its contribu-
tion to the cause.
Another aspect of MMA fighting brings a spotlight on women who are
trained professional fighters and who test positive for taking AAS. While the
world of MMA continues to be dominated primarily by men, women con-
tinue to show interest and motivation in the professional arena as well.
A famous female UFC fighter by the name of Cris “Cyborg” Justino, who is
originally from Brazil, tested positive for AAS in 2011. Justino won a feather-
weight MMA championship that year in another organization known as
Strikeforce, which is similar to UFC. Justino stated that her dietary supple-
ments were to blame and she did not purposefully used steroids to gain an ath-
letic advantage in fights. What Justino was actually admitting was that she was
not aware that the dietary supplements could, in fact, contain steroids.
In 2009, the FDA issued a warning to all consumers that bodybuilding
products sold in many locations, including local shops and on the Internet,
which target bodybuilders, may contain ingredients that are either steroids
or steroid like in their chemical structure and function (USFDA, 2015).
The products that are sold as dietary supplements may in fact be misrepre-
sented and may misguide the typical consumer into thinking that they are
supplements for health. Instead, they end up containing serious drugs that
potentially carry hazardous side effects such as liver and cardiovascular damage.
Moreover, the other issue with supplements is that they are not evaluated by
the FDA and do not go through the same rigorous testing as drugs typically
114 Steroids

must undergo. What ends up happening is that they fall through the cracks
and straight into the consumer market without having to go through any
medical testing. As a result, products such as Tren-Xtreme, Mass Xtreme,
and TT-40-Xtreme end up in vitamin shops along with health supplements
and are sold in a similar fashion. However, what differentiates these supple-
ments from typical vitamins such as vitamin C is that they may contain steroid
or steroid-like substances that may have serious health hazards without warn-
ings—hormonal changes and long-term consequences for men, women, and
children. In 2013, the FDA issued another warning where the makers of B
vitamins called B-50 were using two types of AAS methasterone and dimetha-
zine as part of vitamin supplements, without listing it in the ingredients; these
were sold to anyone on the consumer market without legal regulations. Steroid
drugs are hazardous in other ways, as well, causing harmful effects such
as impotence and low testosterone in men, fatigue, and muscle problems.
The reports show serious health effects, such as liver and thyroid problems.
What makes combining steroids with supplements such as vitamins very dan-
gerous is that it is hard to put the two together, chemically. In addition, man-
ufacturers of supplements do not advertise the supplements as drugs and
mislabel them by omitting hazardous information. Such practices make the
drugs very difficult to detect and test. In 2012, of the 465 drugs that were
recalled by the FDA, 51 percent were dietary supplements that contained
potentially hazardous substances to a person’s health. The three types of sub-
stances that had the highest number of recalls were sexual enhancement sup-
plements, bodybuilding products, and weight-loss chemicals. In addition,
the supplements that are placed on the recall list may end up on store shelves
for six months.
The effect of AAS on mental health continues to be studied today. While
there is an overwhelming amount of evidence that anabolic steroid use nega-
tively affects the body, research continues to unveil new effects of AAS on
the mind. As previously observed, there may be a link between steroid use
and aggression. Individuals who use AAS tend to show elevated amounts of
alertness and decreased levels of impulse control. One case study analyzed a
connection of AAS to violence in a thirty-two-year-old bodybuilder male
who murdered his wife. The bodybuilder did not appear to have either a psy-
chiatric or a violent history. However, three months prior to committing the
crime he had begun using AAS, and three weeks before it happened, both
mood and sleep changes occurred. In another study, AAS was linked to
elevated anger, violence, and decreased levels of self-control.
In another study, a twenty-three-year-old bodybuilder who was trying to
stop steroid use was observed as having extreme symptoms of drug withdrawal
 Risks, Use, and Abuse 115

such as depression, fatigue, and dizziness. Based on various studies, there also
appear to be symptoms of anxiety and other mood disorders in users as well
as incidences of suicide upon AAS withdrawal. Thus, there is a link between
AAS withdrawal and depression, which may eventually lead to suicide ide-
ations. Multiple studies indicate that the use and misuse of AAS, which was
intended to grow the muscle mass, may in fact cause drug dependence and lead
to withdrawal and negative physical and mental side effects. One case study
observed the life of a thirty-four-year-old substance user, who we’ll call Mr.
A. Mr. A has been using various substances such as alcohol and nicotine since
age seventeen. He has been in multiple treatments for other drugs such as
OxyContin and cocaine, and he was using steroids on and off. However, since
the age of thirty-one, he took AAS consistently without stopping. He stated
that when he stopped using them, he felt a sense of fatigue and depression
and a decrease in his sex drive. He reported that he decreased his dosage but
did not stop using because he knew his body would go into withdrawal. He
also reported high HDL cholesterol and had developed gynecomastia, which
is a breast enlargement.
Studies continue to shed light on the effects of steroids and dependence.
While modern studies continue to explore the issue of what causes the depen-
dence on AAS, there are various hypotheses that attempt to explain this phe-
nomenon. One of the hypotheses is the preoccupation with one’s body, such
as in body dysmorphic disorder, also known as muscle dysmorphia, in which
an individual feels that his or her body does not appear to have enough muscles
and more are needed to correct that look. There also may be a connection
between having eating disorders and taking steroids. While the women focus
on being thin and losing significant amounts of weight to fit a certain social
image, men would make every attempt to grow in size and build muscle to
fit a masculine social image. Studies also show that the personality profile for
anorexia and female bodybuilders was very alike in nature. However, body-
builders perceive themselves as having a more positive self-image versus that
of anorexic females.
Other studies show that when individuals take AAS during their develop-
mental states such as adolescence, AAS may modify the normal functioning
of the brain. Moreover, with the changes concurring in the brain, there may
be a change in hormonal production, which can lead to behaviors such as
aggression. The research on how AAS has effects on the brain and body contin-
ues to the present time.
There are many reasons why individuals become addicted to both catabolic
and anabolic steroids. In order to understand the addiction side of it, we need
to be able to recognize that addiction is an ongoing process that happens over
116 Steroids

time rather than something that is static. For example, in the case study of
Mark (see Chapter 1) who is an athlete, steroids served a performance-based
purpose. Despite the fact that he was an accomplished athlete and very diligent
in his training, he saw steroids as a way to give him a stronger competitor’s
edge. This gave him the initial spark and motivation to start on his long-
standing habit. The case study also pointed out that Mark was inspired by
information from popular magazines and celebrities such as Alex Rodriguez.
While the popular media tends to expose some aspects of celebrities’ lives, very
often it withholds information. For example, the media would discuss the per-
formance of baseball and football players, but it would not discuss the amount
of work, energy, effort, and stress that went into it. The invincible efforts and
struggles that sports celebrities go through to get to where they are often are
not discussed by the media. In fact, it tends to focus on the results rather than
on the processes of getting there, and, for Mark, these results are what inspired
him to begin taking steroids. For good, young athletes who are dreaming of
becoming professionals, the negative consequences connected to taking AAS
is complex. For them, the idea of becoming wealthy and famous overrides
any of the negative consequences. Young athletes tend to get heavily influ-
enced by this idea of success, which the popular media often portrays.
However, for Mark, the dream of being a professional athlete is coupled with
strong dedication and drive, which makes him a perfect candidate for AAS
addiction. For him, in the early stages of AAS use, he was able to see great per-
formance results on the ballfield as evidenced by strength and sports perfor-
mance on the field. Social reinforcement came from the coaching staff,
which praised him as one of the great athletes at school. For anyone, especially
a high school athlete whose dream is to go into the profession, this means
everything in the world. But this type of reinforcement can also place Mark
in a zone of denial about potential consequences. Mark also later began using
injectables to increase his performance results. Eventually, he was experiencing
negative moods and becoming argumentative and irritable—common traits
for people who abuse AAS.
As discussed earlier, violence and aggressive behavior are not uncommon
with AAS use, due to hormonal changes and alterations that take place physio-
logically in the brain. However, these changes begin later in the addiction
since the body first goes through various chemical and biological changes.
Once the biochemical reactions begin to take place, AAS users may begin to
feel more stress, and some experience a sense of depression. In Mark’s case,
he became more confrontational and argumentative. Mark’s AAS addiction
was interrupted by him testing positive for steroids and being thrown off the
team. Had he not experienced these consequences, his steroid addiction would
 Risks, Use, and Abuse 117

have continued to progress with more serious, permanent, and irreversible

health and life problems.
One of the most popular events that put AAS into the public eye was during
the summer of the 1976 Olympics in Montreal. At the time, Germany was
split into two parts by the Berlin Wall—the East and the West. East
Germany was under a Communist regime and wanted to express its power
and strength through its athletes.
East Germany was so concerned with winning gold medals that the country
was willing to sacrifice its professional athletes for the sake of national pride
and achievement. Scientists and pharmacologists were working closely
together in a lab to create a specific chemical formula that would alter the per-
formance of every professional athlete so that the country could win multiple
gold medals. What ended up happening was a creation of a state-sponsored
program with the collaborative efforts of the East German government, scien-
tists, athletic coaches, and trainers who would utilize AAS in full mode in com-
bination with their regular athletic preparation for the games. Individuals were
specifically picked when they were as young as twelve years old and were given
these pills as part of their workout regime. The chemical name used for AAS
was Oral-Turinabol (O-T), a synthesis of testosterone hormone, typically
given in a form of a pill. The athletes were not to question their AAS intake
and were increasingly monitored by the Ministry of State Security (STASI)
—a sect of government that made sure everyone was complying with the pro-
gram. Those athletes who did not comply faced punishment. Likewise, ath-
letes who showed superior performance were rewarded. What was dangerous
about O-T was that it had serious hazardous effects on cardiovascular, liver,
and reproductive organs, and there were other serious problems related to
health, in some cases, including death. In addition, some athletes reported that
their physical appearance was changing, such as their voice became deeper,
their shoulders became wider, changes in their facial characteristics started to
take place, and some athletes experienced increased hair growth. The health
effects were not limited to physiological effects; some athletes developed
psychological problems such as depression, anxiety, and eating disorders.
However, despite these dangers of using O-T on young athletes, the GDR
moved forward with the program, under the careful supervision of the state.
At the 1976 Olympics, the East Germany team took forty gold medals, an
extremely high achievement for the country, especially in comparison to
GDR’s previous Olympic history. The women’s swimming team dominated
the victories, and East Germany won more than 84 percent of competition
in the entire Olympics (Braw, 2014). However, this victory came with a giant
price tag for these athletes. One of the athletes died of cancer in her early
118 Steroids

thirties, even though her death was not proven the cause of AAS abuse. Other
athletes developed serious health problems to their cardiovascular system as
well as reproductive systems, leading to miscarriages and infertility. There were
those who developed serious joint injuries due to steroid use. However, one of
the most terrifying cases was with a female athlete Heidi Krieger. Because of
being exposed to extremely high dosages of AAS steroids at a young age, her
whole physiological makeup was altered to a point where her body was trans-
formed into a male. The administration of steroids allowed her to train and
perform beyond normal physiological limits and levels. She was able to
develop significantly greater strength and high pain tolerance. However, her
body changed dramatically and, as a result, she made a decision to have surgery
and fully transform into a male named Andreas Krieger. Her new identity was
heavily contributed by her intake of AAS and its physiological effect on the
body. Living as a male and married to another female has fully changed her life.
To the present day, steroid use continues in both athletic and nonathletic
arenas. Multiple efforts by various agencies have been made to combat the
spread of steroid use, especially in professional athletics. However, this battle
has been very challenging and simultaneously complicated. New types of
drugs and chemical ingredients are coming out that resemble synthetic testos-
terone, which makes it more difficult to detect on drug tests. Scientists and
organizations must be up to date with all the new steroid innovations. In addi-
tion, new types of doping techniques are used to minimize and make steroids
virtually untraceable to testing. While in the past, steroids have been limited
to professional athletics, in today’s world, the populations are much more
diverse, resulting in a more complicated and complex battle against steroid
use. Despite the research that shows how dangerous AAS is to human life,
AAS continues to be popular today in different areas ranging from recreational
to professional sports as well as used by some individuals to create a more
socially acceptable and idealistic image for people.
In 2014, the Russian Federation was accused of doping athletes with AAS.
In cooperation with various professional agencies along with whistle-blowers,
Russian athletes were reported as testing positive for AAS, and Russia
attempted to prevent the information from spreading globally. One of the
whistle-blowers was a Russian Olympian herself, who spoke about her experi-
ences of having to take AAS. She continued to take Oxandrolone, a knowingly
illegal substance that was not permitted by the International Olympic
Committee (IOC). According to this whistle-blower, athletes who were testing
positive for AAS on urine drug tests were given different treatments that were
frequently based on their athletic performance and popularity. If the person is
not a high-ranking athlete and not famous in his or her field, the drug test
 Risks, Use, and Abuse 119

results were treated differently than for someone who is famous and on top of
the list. Investigation regarding these claims continues to the present day.
Interestingly, catabolic steroids, which are primarily used to treat inflamma-
tion in the body, do not have such global popularity, even though they are
widely popular and continue to be used by many individuals. As in the case
of Angie from the previous chapter, her intake of catabolic steroids was based
primarily on decreasing the inflammation caused by her psoriasis condition.
Since there is no cure for psoriasis now, the treatment revolves around treating
the inflammation, which decreases her chances of having skin problems. For
Angie, however, keeping her stress down and having a healthy lifestyle along
with taking steroids is a way to cope with her condition. She has to take her
medication as prescribed for a lifetime. By staying on track and balancing dif-
ferent aspects of her life, she is able to keep psoriasis under control. However,
other cases of chronic diseases can affect people differently. For example,
someone with Crohn’s disease can have a life-threatening emergency if he or
she is not on a strict regimen of catabolic steroids. If a person has a severe case
of Crohn’s disease, his or her digestive system can sustain serious damage if not
treated appropriately. An autoimmune disease can be detrimental toward the
human body, causing possible irreversible destruction in its own path. For
someone who can develop holes in his or her intestinal walls, bleed, and face
serious life-threatening emergencies, taking steroids is not a choice but a sur-
vival strategy. At the same time, having to know the risks of taking steroids
in the long term, such as acquiring cancers and other serious illnesses, can
often be an extremely difficult situation. The double-edged sword that is
present for the person suffering from severe chronic illnesses is oftentimes very
difficult to manage. Careful collaboration and working closely with appropri-
ate medical staff are of great importance since targeted treatment on a specifi-
cally designed, timely basis is what can keep a person more healthy and alive.
In addition, having a healthy lifestyle is important for overall function and
well-being. For this individual, having appropriate help and support is very
important.
In today’s society both catabolic and anabolic steroids have various uses and
purposes. In the medical field, catabolic steroids are prescribed for various
health conditions and symptoms. For people suffering with certain life condi-
tions, such as psoriasis and Crohn’s disease, steroids can be part of the medica-
tion regimen. On the other hand, individuals use these catabolic steroids in
ways that are not approved by medical community, such as to enhance their
skin or create a different skin image. This type of alternate use of steroids
may lead to serious health problems that unfortunately come with abuse of
the substance. However, looking at different types of steroids known as AAS
120 Steroids

the use can be rather different. The field of athletics can be very demanding
and pressuring for the individuals those are committed to sports. Anabolic ste-
roids can provide additional help that athletes may think they need in order to
obtain a competitor’s edge.
As the abuse of AAS continues, people abusing them are continuing to play
a Russian roulette with their lives. And despite the overwhelming amount of
research and evidence of the use and dangers of AAS, steroids continue to be
used today. They are not only limited to athletics but also are used by everyday
individuals to create enhancements that fit socially acceptable expectations.
The availability of AAS supply and distribution routes as well as ease of use
and difficulty with detection makes the use and abuse of steroids a very com-
plex problem in today’s society.
 Chapter 7

Production, Distribution,
and Regulation
Joan Standora

It is not a secret that the United States consumes more drugs than any other
country in the world!
This desire to use substances has fueled a huge industry in its production of
both therapeutic and recreational drugs, including steroids and their deriva-
tives. There are various safeguards in place to ensure that the quality and num-
ber of legal substances are produced with strict regulations and enforcement by
the government. This carefully controlled industry, however, is sometimes
unable to prevent the distribution and sale of these substances in an illegal way.
The illegal production of illegal steroids is as difficult to control as any other
illegal drug trade that provides psychoactive, addictive drugs to the United
States. Performance enhancement drugs (PEDs) abound in various forms
and in many different distribution sites for sale to people who believe that, as
their physical image changes, their lives will also change. With the advances
in technology, not only is the production of these substances increased but also
the ways in which they are distributed to the public. In particular, social media
has boosted the efforts of producers to make a great deal of money through
relatively easy methods on the Internet.
In this chapter, we will look at the production, distribution, and regulation
of both the therapeutic steroids and those that are considered recreational and,
often, toxic or deadly.
122 Steroids

PRODUCTION
Steroids that are used for medical purposes are produced by the laboratories
of pharmaceutical companies or through partnerships with universities that
have scientific research departments. The U.S. Food and Drug Admin-
istration (FDA) is responsible for approving all therapeutic uses of com-
pounded, synthetic chemicals for an enormously diverse number of illnesses
or disorders. A visit to the FDA website illustrates how many areas of public
health are covered by the agency (www.fda.gov). As stated on the website:
The FDA, an agency within the U.S. Department of Health and Human Services,
protects the public health by assuring the safety, effectiveness, and security of
human and veterinary drugs, vaccines and other biological products for human
use, and medical devices. The agency also is responsible for the safety and security
of our nation’s food supply, cosmetics, dietary supplements, products that give off
electronic radiation, and for regulating tobacco products.

All FDA-approved drugs are listed on the website with answers to frequently
asked questions and other information pertinent to the public’s use of these sub-
stances. The generic names of each drug are included after the popular name so
that one may look for substances such as hydrocortisone and find its prescribed
name. This also works in reverse. It is possible to look up the prescription and dis-
cover the chemical makeup of the medication. Even those medications developed
for therapeutic treatment can be diverted to the people seeking performance
enhancement or body change. One example of this is the case of a biopharma-
ceutical company, Amgen, which refined a glycoprotein hormone (erythropoi-
etin)—a hormone discovered many years before. This drug was distributed
under the name of Epogen (also called EPO) and was approved by the FDA as
a treatment for anemia in the late 1980s. Because this hormone increases the
number of red blood cells through injection, it began to be used by athletes, espe-
cially cyclists, as a method of “blood doping”; that is, it increases the amount of
oxygen available to the performer, thereby increasing stamina. It was not until
the early 2000s that it could be detected through drug tests and determined to
be a violation of anti-doping regulations. There are other examples of the way
in which these therapeutic synthetic steroids are diverted to illegal use. In the
1950s, synthetic human growth hormones (called hGH) were used to treat
dwarfism in children. By converting insulin into a growth factor for bones,
muscles, and other tissues, children were able to reach different, stronger physical
condition by using hGH. In 1980, when doctors discovered a link between
natural hGH and a fatal neurological disorder known as Creutzfeldt-Jakob dis-
ease, a pharmaceutical company, Genentech, developed a synthetic form of
hGH. The drug, Nutropin, was offered to medicine in 1985 to eliminate the
 Production, Distribution, and Regulation 123

Creutzfeldt-Jakob risk. After this, it was possible to manufacture more of this

synthetic growth hormone and help numbers of children. The FDA approved
the synthetic hGH (Nutropin) as a therapeutic treatment for a number of
other serious conditions in adults and children, including the previously men-
tioned wasting conditions often suffered by those with AIDS.
However, once again, athletes discovered this steroid and found it useful, as
it did not have some of the side effects of other anabolic-androgenic steroid
(AAS) substances. Despite stringent controls over the manufacture and distri-
bution of this drug, the drug became a part of the black market. It is believed
that, given the huge financial gains reaped in any of the illegal drug trades,
greedy doctors may have initiated this situation, as they could supply many
athletes who were phony patients with their prescriptions. Through books
on how to identify the various forms of ergogenic drugs, such as EPO, hGH,
and other AAS, consumers were able to obtain and engage in the various meth-
ods and techniques for using these substances. It was not until 2004 that an
anti-doping agency—part of the International Olympic Committee—was
able to detect hGH through a blood test. In 2008, a urinalysis test was devel-
oped that could detect hGH within a two-week period. It took until 2010
for more effective tests to be developed. In 2012 and 2013, the testing was
implemented among professional sports organizations. There was a urine test
and a blood test that had been developed in time for the 2000 Olympics, but
only the urine test received the go-ahead. It was the same urine test used to
back-test old samples from the 1999 Tour de France.
What about those health supplements that Americans take in great num-
bers? How safe are they? And what do they actually contain? Dietary supple-
ments have come under more scrutiny by the FDA, as the claims of
manufacturers and distributors lead unknowing consumers to buy products
that they believe are safe. According to the U.S. Department of Agriculture,
the United States is the biggest producer of dietary supplements, with China
supplying the greatest number of health food ingredients to the United
States and to the rest of the world. As much as 60 to 70 percent of the dietary
ingredients are supplied by the Chinese manufacturers—the most frequent of
which are herbal supplements. A major herbal extract from China is from lico-
rice and plant extracts with medical functions. Individuals seeking such sup-
plements can browse Internet sites that sell the manufactured supplements
from China and find products that promise better muscle mass and strength,
as well as better sleep and other common dietary supplement claims.
Some websites, however, can lead to the purchase of products that cause
life-threatening effects, such as kidney failure, stroke, and other serious effects.
Many of these substances are marketed as dietary supplements to increase
124 Steroids

strength and build mass. These supplements can be far more potent than the
natural steroids sometimes prescribed by doctors. For example, a supplement
called “1-testosterone” is claimed to be seven times more potent than testoster-
one. Another, “4-hydroxy-testosterone,” is said to be in production for an even
greater effect on bodybuilding regimens.
As described more fully in Chapter 6, the need for regulation of these over-
the-counter chemicals, in both their claims and also their availability, is vital to
prevent tragic outcomes for users.

DISTRIBUTION
In 1970, the U.S. Congress passed the “Controlled Substances Act,”
which focused on the regulation and distribution of a number of substances.
The legitimate manufacture and distribution of chemicals are monitored
under the Compliance Act of 1971, providing a five-class structure for identi-
fying and regulating controlled substances. Under this Act, the Drug
Enforcement Agency (DEA) is authorized to register all dispensers, practi-
tioners, and pharmacies. The Act further addresses the creation, signature,
and retention of all prescriptions/records. This is a stringent oversight pro-
gram, yet the ability of individuals to continue to buy illegal steroids in the
form of “dietary supplements” illustrates a simple fact: the manufacturers of
these illegal steroids, primarily anabolic steroids, are able to change the chem-
istry of substances to avoid regulation on a regular basis. Dietary substances are
not regulated by the FDA; the time that is required to review, analyze, and
determine the risk of these substances allows their production to continue.
The manufacturers of legal, steroidal medications bring them to the market in
several ways: (1) directly to the physician as part of a marketing campaign; (2) dis-
semination of information to pharmacies and the pharmaceutical industry; and
(3) to the public in the form of television, Internet, and print media outlets.
For a prescription to be legitimate, it has to be written for a specific medical
purpose by a physician or practitioner who is working within the accepted
scope of his or her profession (21 CFR 1306.04). The practice of prescribing
is regulated under the Prescription Drug Monitoring Programs (PDMP),
which exists legislatively in thirty-nine states (only twenty-nine have imple-
mented this database program and made it operational). This PDMP
approach has a number of benefits in the need to control prescription abuse:

(1) Investigators can obtain data from a number of pharmacies at once, rather than
one at a time.
(2) “Doctor shopping”—going from doctor to doctor to obtain prescriptions for the
same drug—is deterred.
 Production, Distribution, and Regulation 125

(3) Indiscriminate prescription writing or forgeries of prescriptions can be curtailed.

(4) Physicians or pharmacists can obtain patient-specific information upon request.
(5) Physicians can be notified if their patients are receiving the same drugs from
multiple prescribers.
(6) Health care for patients can be managed more qualitatively by practitioners.

How do illegal steroids reach the market? As nonprescription drugs, these

substances are most often smuggled into the country from countries such as
Mexico, South America, and Europe. Often these steroids may have been
stolen or inappropriately prescribed, even produced in secret laboratories.
Their sale on the black market is usually the result of legitimate sources losing
control of their inventories; that is, companies that produce the chemicals have
had their stock diverted without their knowledge or direction. According to
the DEA, the following steroids are among the most abused today: Deca-
Durabolin, Durabolin, Equipoise, and Winstrol. In addition, manufacturers
in India, China, and other countries sell illegal steroids on the Internet through
sites such as tradeindia.com, which makes and sells the actual products. In the
United States, the now famous Bay Area Laboratory Co-Operative (BALCO)
lab utilized biotechnology to develop its illegal products through biochemical
engineering. Receiving payment from well-paid professional athletes, the lab
would help them improve their performance directly and secretly. BALCO
developed the first designer steroid, norbolethone, in 1999. This steroid had a
most desirable feature for users: it could not be detected by the testing proce-
dures in place at that time. The drug was not identified until three years later
by the anti-doping community.
Many of these substances are marketed as dietary supplements that are sold
to increase strength and build mass. These supplements can be far more potent
than the natural steroids sometimes prescribed by doctors. For example, a sup-
plement called “1-testosterone” is claimed to be seven times more potent than
testosterone. Another substance, “4-hydroxy-testosterone,” is said to be in pro-
duction for an even greater effect on bodybuilding regimens.
In 2010, Senator John McCain (R-AZ) introduced a bill to Congress that
would require those who manufacture these supplements to register them
with the FDA. Ingredients in these supplements would have to be revealed
so that the athletes, themselves, would have knowledge about whether or
not they should ingest them. Called the Dietary Supplement Safety Act,
the legislation is felt to be a protective action on the part of Congress in
response to a number of young athletes who have died taking these unregis-
tered and unapproved supplements. The FDA would be able to force the
listing of ingredients while also conducting tests to ensure their safety.
Sometimes, young athletes are not even aware that they are taking certain
126 Steroids

substances within the supplements that are considered performance enhanc-

ing and, potentially, risky to their health.
It is an easy matter to surf the Web and find numerous American-based out-
lets for steroids that are marketed as dietary supplements. A review of the blogs
associated with these sites reveals that conversations between consumers and
companies focus, primarily, on how much more effective the products are than
prescribed steroids. In the United States, supplements such as androstene-
dione (street name “Andro”) and tetrahydrogestrinone (THG) could have
been previously purchased legally—over the counter—at many commercial
outlets, including natural food stores. For example, a popular site for the pur-
chase of supplements promising weight loss, muscle growth, and strength
boasts a large inventory of chemicals, which, it promises, will bring the results
users want. The website, like others of its kind, is designed attractively with
major claims of success to those who order and use their products. In their
own words:
Let’s face it guys—testosterone is king! Whether you are in the weight room, the
boardroom or the bedroom, having more of it increases performance—plain
and simple.

This can be very inviting to individuals who do not feel physically attrac-
tive and lack social skills. Selling a supplement called 2,6,17-androstene-
trione as a testosterone booster, the company claims it is the most effective
chemical of its kind on the market. It is also touted as the safest, causing no
side effects but doubling a man’s testosterone level in six weeks. The com-
pany further states that the FDA has not evaluated this drug, thereby
releasing itself from any governmental oversight or regulation. With the
exception of dehydroepiandrosterone (DHEA), the purchase of these sup-
plements became illegal in 2004, following the passage of amendments to
the Controlled Substances Act.

REGULATION
Before the 1960s, little attention was paid to regulating PEDs. It wasn’t
until the risks of use to a person’s health—over a brief period or for prolonged
periods—became evident. There are a number of laws now in the United
States that seek to reduce the supply of drugs as well as the demand by the pub-
lic. It is illegal to use these substances to enhance performance in athletics in
addition to the ban on such use in professional and amateur sports.
The Controlled Substances Act of 1970 was a primary attempt to control
distribution and sales of all illegal drugs through categorizing their use for
 Production, Distribution, and Regulation 127

medical purposes, the likelihood of abuse, and the risks associated with their
use. This law regulated substances on a broad spectrum with the identification
of the severity of these categories through the use of “Schedules.” For example,
heroin is classified as a Schedule I drug, as it is not used in medicine, can clearly
be abused, and can cause a number of problems for the user. Drugs at the other
end of the spectrum are not considered dangerous nor particularly risky to the
user (cough syrups that contain codeine, for example).
Things changed for steroid users, however, when the government passed the
Anabolic Steroid Control Act of 1990. Under this legislation, anabolic steroids
are considered Schedule III drugs, placing them alongside other substances
that fulfill use both for therapeutic and medical reasons, as well as recreational
reasons. The first offense for simple possession of this drug, illegally, is punish-
able with a minimum fine of $1,000 and up to one year in prison. For those
who sell the drugs, the punishment can be ten years in jail and a fine of
$250,000. These are federal crimes, which bring serious consequences to those
who both use and sell them. Therapeutic prescriptions, of course, are not sub-
ject to this kind of legal mandate and punishment but will be equally pros-
ecuted if found to be illegally obtained, used, and/or sold.
Back in the United States, in 2004, the list of illegal drugs was expanded to
include “precursors” to steroids; that is, those substances that the body, itself,
can convert into steroids. In addition, Congress included substances that can
be used to manufacture synthetic steroids in the laboratory. Clearly, the
government recognizes the dangers of allowing such use, production, and
distribution as a risk to the American public, especially youth. It has not
stopped its investigations into the ongoing development and use of these ste-
roids; it is said that there is a possibility that Congress will pass a law that
mandates universal anti-doping policies in all of the professional American
sports leagues.
In addition to federal law, state laws may be more stringent in these cases
and can add penalties to the charges if there are prior offenses, the role of
the person (dealing, buying, steering), how strong the case is, and, even, the
strength of the legal defense. Most of the time, a first-time offender of a simple
possession charge will see no jail time; however, if the charge includes the
intent to distribute, then a good defense team will be the difference between
a lighter sentence or more time convicted and incarcerated. Sometimes, too,
a state court will seek to make an example to the community and order a
harsher judgment on a personal user; generally, it is believed that state courts
tend to be more punitive in these cases. A person who offers his or her anabolic
steroids to a friend, for example, without selling it, can also be subject to arrest
under the intent to distribute category.
128 Steroids

There are five classes of scheduled drugs in the United States. Anabolic ste-
roids are considered Schedule III drugs, which puts them in the same category
as lysergic acid diethylamide (LSD) and barbiturates.

• Schedule I: Drugs with no viable medical purpose that have high rates of
dependency and abuse, which can lead to severe physical damage.
• Schedule II: Drugs that have a particular medical purpose but could also be
potentially abused, which can lead to severe physical damage.
• Schedule III: Drugs that have a particular medical purpose but could poten-
tially lower the risk of dependency and physical damage than Schedule II
drugs.
• Schedule IV: Drugs that have a particular medical purpose, yet have a
slight potential for abuse and a very slight risk of physical damage or
dependency.
• Schedule V: Drugs that have a particular medical purpose, yet have a lower
potential for abuse than Schedule IV drugs. These carry a very slight risk of
physical damage or dependency.

One famous steroid abuse case involved a man named Donnie Keith Wall
in Texas. He was sentenced to thirty-five years in prison for a felony charge
of possession with intent to sell anabolic steroids. When Wall was pulled over
by the police, he lied about his name and then produced an expired driver’s
license with his real name on it. The police spotted drug paraphernalia in the
car, which led to the search. He was held at the scene until a search warrant
could be issued, as he had denied the police the right to search. Because, under
Texas state law, penalties for this crime are based on the weight of the sub-
stance, a measure of 200 to 400 grams of the steroids, and a punishable win-
dow of five to ninety-nine years. While this is a Schedule III felony charge,
the state’s laws were more stringent in their inclusion of additional criteria to
that charge; thus, the more serious penalty of time incarcerated.
Another aspect of law enforcement and substance abuse involves youth and
schoolchildren. A controversial approach to dealing with the drug use by
schoolchildren is that of drug testing in the schools. Called “mandatory test-
ing,” students are required to submit to this random testing procedure as a
way to prevent drug use and to educate students on the serious side of using
drugs, whatever they may be. The most recent Supreme Court decision
(2002) on this has indicated that it is not unconstitutional to conduct these
tests but that, legally, these can be requested only from those students involved
in sports activities, clubs, and other extracurricular activities. Usually, if a stu-
dent tests positive, the student cannot participate in the activities for a certain
period but will not be expelled or suspended from the school. Sales of drugs,
 Production, Distribution, and Regulation 129

however, on the school’s premises will result in an arrest by the local author-
ities, and the student will be removed from the premises. While it might be
the child who is not involved in sports and social activities at the school who
would be more likely to use substances, the decision focuses on those who
are engaged, thereby missing in all likelihood the children who are quietly
using substances without detection.
The international athletic community was struggling to control the use of
PEDs among its athletes in the 1990s. In 1998, in France, a border patrol
check on the Belgium border revealed that a French cycling team in the
Tour de France competition had loaded its vehicles with large amounts of
ergogenic drugs—EPO, hGH, steroids, and other agents that would be used
to prevent detection. The race that year started in Ireland, and a team’s mas-
seur had been discovered with these drugs three days before the race began
(he was found on the Belgian-French border). Arrests didn’t happen, though,
until the race entered France, and then the team’s director and doctor were
both arrested. As a result, local police conducted a number of searches of other
cycling teams, implicating a number of other European sports organizations.
At the end of the race, only half of the cyclists remained to finish the Tour
de France. Public reaction was strong, and the implication that these organiza-
tions were complicit in the use of such substances demonstrated the ambiva-
lence between competitiveness and fairness. As a result of this scandal, the
International Olympic Committee responded by forming a new inter-
national and independent agency, the World Anti-Doping Agency (WADA).
This agency exists as an independent entity; its mission is to set the standards
for drug-free competition among the international community of amateur
and semi-amateur players associations, including the testing and enforcement
of the standards. The U.S. Olympic Committee established its own national
anti-doping organization in 2000, called the United States Anti-Doping
Agency (USADA).
The penalties for violating WADA and USADA anti-doping policies can
be harsh. An athlete who uses ergogenic drugs is stripped of any titles gained
while using the drugs, and his or her achievements in other competitions
during that same event will be disqualified. The athlete will have to show
some kind of accidental use or ignorance of use in order to be reinstated.
The first time this happens, the athlete will receive a two-year suspension
from all competition; the second time could bring a ban for life. Those
who work with the athletes, such as coaches, trainers, or others, who are
found to be supplying these drugs to players will receive a ban of at least four
years for a first offense. Depending on how significant the behavior, however,
suppliers can be banned up to a lifetime. If drugs were supplied to a minor,
130 Steroids

the ban will last a lifetime. Any athlete who does not cooperate with testing
appointments or by not filing paperwork as to their location (for random
drug testing) might be penalized by a one- or two-year ban. Athletes are
expected to file therapeutic use exemptions (TUE) before legitimate treat-
ments can be violated if a poor test result occurs because of the treatment.
The athlete is responsible for advising testers of this before the fact. Any
dietary supplements that include banned substances are not allowed, so ath-
letes are also responsible for failed tests should these chemicals appear in the
test results. All athletes, coaches, trainers, and support staff should be ready
for random testing and are expected to know the rules of both the WADA
and the USADA. The samples taken in random drug tests are stored for eight
years. This is in anticipation of a designer steroid that is difficult to detect
now but may be detectable in the future. Therefore, it may affect athletes
whose use was not detected but who may face penalties years later when
the technology for testing has advanced. A shock to the public illustrated this
fact when cyclist Lance Armstrong was charged and confirmed to have
engaged in blood doping years after his seven consecutive Tour de France vic-
tories. At the time of his wins, blood doping was undetectable, as players
used their own stored blood with the chemical composition of the blood
being exactly the same. In 2012, new detection technology compared the
RNA values within his blood sample to distinguish between fresh and stored
blood, thereby proving that he had used the additional benefit of extra oxy-
gen to maintain his energy and stamina during the races. Consequently,
Armstrong was stripped of his victories and banned from competitive cycling
for life.
The jurisdiction of WADA and USADA programs only applies to amateur
and semi-amateur sports associations. Professional sports associations are not
members of these two organizations’ standards. The exception is the individual
athlete who wants to compete in the Olympics or another WADA-sponsored
event; in that case, he or she is expected to know and comply with the stan-
dards. The National Basketball Association (NBA) players have competed in
the Olympics on a regular basis since 1988 and are playing within the guide-
lines of WADA. When they return to their teams, they are bound by the
NBA’s own anti-doping policies.
The media often reports on the epidemic of opioid drug abuse (heroin, oxy-
contin, Vicodin, and others) and subsequent criminal activity; it is rare, how-
ever, to find mention of law enforcement actually pursuing the sales and use
of illegal steroids. A number of operations have occurred since 2002 to inves-
tigate and prosecute illegal trafficking in anabolic steroids. A well-publicized
federal action took place in 2002 when the DEA raided a laboratory that
 Production, Distribution, and Regulation 131

became known for its ties to professional baseball. Previously mentioned under
the manufacture of illegal steroids, the BALCO appeared to be distributing its
product to professional athletes, such as Jason Giambi and Barry Bonds (base-
ball), Marion Jones (Olympic track star), and Bill Romanowski (football).
Ostensibly, the business was opened to specialize in assessing the physical con-
dition of athletes followed by recommendations for individualized supple-
ments to improve on any weak areas and to improve overall performance.
The scandal surrounding this company and the resulting punitive actions
against not only the business, but also many athletes, is an outstanding exam-
ple of the damage done to professional sports and its athletes.
Again, in September 2007, the Drug Enforcement Administration (DEA)
announced the largest steroid “enforcement action” in the history of the
United States. Working within an international case, identified as Operation
Raw Deal, three U.S. agencies released the outcome of their work targeting
the international underground trade of hGH, anabolic steroids, and insulin
growth factor (IGF). The three agencies—the U.S. Postal Inspection Service,
the FDA Office of Criminal Investigations, and the DEA—worked together
with nine other countries to investigate this trade as well as other trafficking
of counterfeit medications. Other agencies cooperated in this investigation:
Immigration and Customs Enforcement (ICE), the Internal Revenue Service
(IRS), the National Drug Intelligence Center (NDIC), and the Federal
Bureau of Investigation (FBI). The countries involved in the operation were
China, Canada, Mexico, Australia, Belgium, Denmark, and Germany. The
public may not be aware of why these various agencies would be included on
the Operation Raw Deal effort. Each one is involved in at least one aspect of
controlling illegal drug trafficking, and the international nature of the steroid
trade created the necessity for all of them to participate. The operation used
a four-part strategy: the raw material suppliers or manufacturers from other
countries, such as China and other countries; AAS laboratories operating ille-
gally in Mexico, Canada, and the United States; a great number of websites
that promote the purchase of conversion kits (to make steroids out of raw ste-
roid powders); and bodybuilding Internet sites that support discussion boards
instructing individuals on how to illicitly find, purchase, and use PEDs under
the radar of law enforcement, including anabolic steroids. Many illegal labs are
endorsed by those who maintain the discussion boards.
According to the DEA news release, 143 federal search warrants were served
nationwide, which resulted in 124 arrests, the seizure of 56 steroid labs across
the United States, and more than 11 million steroid dosage units, including
242 kilos of raw steroid power from China. In addition to the materials to
manufacture steroids illegally, the action netted $6.5 million, three boats,
132 Steroids

twenty-five vehicles, seventy-one weapons, and twenty-seven pill presses. The

individuals who were apprehended in this operation faced criminal charges in
California, Maryland, New York, Pennsylvania, and Rhode Island. The
charges included narcotics distribution offenses, such as money laundering
and conspiracy to import anabolic steroids. The way in which these cases are
adjudicated in these states varies. For example, in the Southern District of
California, a grand jury indicted individuals for purchasing raw anabolic ste-
roids in other countries, manufacturing them in underground labs, and dis-
tributing them through the Internet. The charges were conspiracy to launder
money and conspiracy to import and distribute anabolic steroids.
Another example involves the District of Maryland, in which an individual
was charged with conspiracy to illegally distribute hGH, which he had received
from a Chinese manufacturer. The indictment also sought the forfeiture of
$863,534 in property and monies directly related to this criminal activity.
In state after state, the undercover activity of these government agencies
resulted in the apprehension of similar illegal trafficking in anabolic steroids.
An interesting outcome of this operation was the information that it provided
to the public in terms of the conditions under which these substances are manu-
factured. The DEA pressed the dangers of using these drugs, which were made in
unsanitary, underground labs with no attempt to employ safety measures. At
times, these materials were being mixed in bathtubs and sinks without any sani-
tary precautions and were often labeled improperly so that the buyer would not
really know the actual chemical composition of what he was buying under the
name of anabolic steroids. Clearly, this successful operation forced the recogni-
tion that steroid use and abuse is a major problem in this country and a major
source of illegal revenue. But this recognition did not stop the flow of illegal ste-
roid production and distribution. In 2015, once again, the DEA announced
another major operation. Called Operation Cyber Juice, this investigation involved
more than thirty different U.S. investigations in twenty states. The action
resulted in more than ninety individuals, the capture of sixteen underground lab-
oratories, 636 kilos of raw steroid powder, thousands of liters of raw steroid
injectable fluids, and more than $2 million in money and assets. During this
same operation, the DEA participated with foreign steroid investigations coordi-
nated by Europol. The latter is the European Union’s law enforcement agency
that works to achieve a safer life for all EU citizens. The agency assists the EU’s
states in fighting international crime, including terrorism.
More recently, the Office of National Drug Control Policy (ONDCP), an
agency located within the executive office of the White House administration,
has issued a number of strategic papers pertaining to the distribution, use, and
interdiction of drugs in the United States.
 Production, Distribution, and Regulation 133

Office of National Drug Control Policy

A component of the Executive Office of the President, the Office of
National Drug Control Policy (ONDCP) was created by the Anti-Drug
Abuse Act of 1988. ONDCP members advise the president on drug-
control issues, coordinates drug-control Activities and related funding
across the federal government, and produces the annual National
Drug Control Strategy, which outlines administration efforts to reduce
illicit drug use, manufacturing and trafficking, drug-related crime and
violence, and drug-related health consequences.

According to ONDCP, every illicit drug (except cannabis) requires chemi-

cals to be synthesized and refined to its final and consumable form. It is keep-
ing the chemicals away from drug traffickers that can effectively prevent or
reduce production. The problem may be, however, that many of these same
chemicals are used legitimately in the manufacturing of therapeutic drugs.
For this agency, finding ways to prevent the distribution of chemicals from
legitimate outlets to illicit drug manufacturers is a major challenge. Here,
too, lies the importance of international cooperation, as so many of these
chemicals are manufactured all over the world.
The International Narcotics Control Board (INCB) and the UN Com-
mission on Narcotic Drugs (CND) are international entities that are critical
in this effort to police the export and import of licit precursor chemicals (those
needed to synthesize or refine the steroid product). The CND from the United
Nations is a central policy-making group that deals with drug-related matters,
and the INCB is a judicial body that monitors the implementation of three
UN drug control conventions. (Partly or quasi-judicial means that the body
has the right to hold hearings and conduct investigations into illegal conduct
and to make decisions as though it was a court.) A resolution in 2006 from
the CND requests governments to provide an annual account of lawful
requirements by manufacturers. They, along with the United States, can track
the import and export of these chemicals by sharing the information with
regulatory agencies and law enforcement around the world. At home,
ONDCP supervises drug trafficking through the High Intensity Drug
Trafficking Areas (HIDTA) program. In this program, ONDCP brings
together law enforcement agencies at the local, state, federal, and tribal law lev-
els, providing support and funding to enforcement agencies “operating in areas
determined to be critical drug-trafficking regions of the United States.”
134 Steroids

On May 29, 2014, Congressman Joseph Pitts of Pennsylvania introduced a

bill that would amend the Controlled Substances Act, which, when it passed,
became known as the Designer Anabolic Steroid Control Act of 2014.
The bill makes it easier to take harmful products and classify them as con-
trolled substances. It also increases criminal penalties. An initial goal was to
close a loophole in the previously existing law that allowed steroid sellers the
opportunity to modify chemical compounds in their manufacturing processes
in order to avoid detection by the Administrator of the DEA and keep off the
controlled substances list. The bill targets dietary supplements intended pri-
marily for bodybuilders. Of particular concern is that some advertisers have
stated their muscle-building formulas are more effective than others are and
that these compounds sometimes contain chemically altered versions of ana-
bolic steroids. However, the law requires that herbal or botanical substances
shall not be considered a drug or hormonal substance that claims to be an ana-
bolic steroid, and anyone making that claim will need to provide appropriate
evidence to the contrary. The burden falls on the manufacturer to prove their
products are not anabolic substances. In addition, if a product is proven to be
non-anabolic, there must be proof that there is no relation to any other ana-
bolic substances. The law directs the DEA to report every two years on the ana-
bolic steroids that have been placed temporarily on the schedule of controlled
substances. This allows the U.S. Department of Justice to have complete
authority over anabolic steroids. The bill adds twenty-seven known anabolic
steroids to the DEA’s list of controlled substances.

LEGALIZATION AND DECRIMINALIZATION

What do the numbers tell us? According to the Center for Disease Control
(CDC) Survey, Substance Abuse and Mental Health Services Administration
(2014), it is estimated that the number of American adults who have used ste-
roids is 1,084,000. Forty-one percent of users claim that it is easy to get steroids.
The penalty for illicitly obtaining steroids (one time) is $1,000; however, traffick-
ing in steroids can bring up to $250,000 and five years in prison for the first
offense. This is for an individual selling these drugs. The second offense for traf-
ficking will result in a penalty of $500,000 and ten years in prison. Perhaps, most
alarming is the CDC fact that most synthetic anabolic steroids contain as much as
one hundred times the naturally produced testosterone steroid in the human
male body; for women, this represents 2,000 times as much naturally produced
testosterone in their bodies.
The issue around legalizing anabolic steroids is comparable, perhaps, to that
of the discussion about legalizing marijuana. While medical marijuana has
 Production, Distribution, and Regulation 135

been shown to relieve symptoms of a number of serious illnesses, from glau-

coma to seizures to palliative care for terminal patients, its addictive properties
and effects on the brain development of young smokers represent a serious
consequence in the eyes of the public. Those supporting the legalization of
anabolic steroids point out that most athletes who are found to be using ste-
roids have not demonstrated any immediate health risks. In addition, there is
agreement among some that steroid use continues but continues to be masked
by various, new methods developed by underground manufacturers and sup-
pliers. Nevertheless, the consequences of long-term use, unsupervised, paint
a different picture in terms of physical and psychological dangers. In general,
the public does not support the use of anabolic steroids in competitive sports
nor do the amateur and professional athletic communities. The medical use
of certain anabolic steroids, however, as discussed in other chapters, has
been effective in helping those with wasting symptoms or growth problems.
The pro-legalization argument presents its clear evidence that certain legally
used substances, such as alcohol, have greater health risks than anabolic ste-
roids. Tobacco, one of the most addictive substances and legally available, is
also identified as having serious, long-term consequences, not only for the user
but also for those “passive” smokers. More people probably agree on decrimi-
nalization, as it will remove a criminal record for someone using these illicit
drugs. While a person may have to pay penalties, lose a license or a job—very
serious in any case—the ability to change a lifestyle or behavior is not dictated
by a jail or probation sentence.
The dangers of any drug developed synthetically, whether for therapeutic
reasons or recreational advantage, depends on the individual using it—how,
when, where, and why. Concern for the role modeling offered by professional
sports to young people has created a backlash against those accused or con-
firmed of using anabolic steroids or other PEDs while participating in com-
petitive games. While attitudes about these drugs have changed over time,
the American ethic of fair play and honest competition seems to overrule any
eventual lessening of sanctions against these substances.
 Chapter 8

The Social Impact

of Steroid Use Today
Alex Bogomolnik

In order to understand the process of those who decide to take steroids, we

need to look at how the problem initiates in the sociocultural nature of our
society. According to some medical experts, there are 500,000 to 1 million
high school students who end up taking steroids, even though education about
steroids is provided to youngsters as a preventive measure. The study showed
that slightly more than 50 percent of people of age eighteen to twenty-nine dis-
cussed steroids with their teachers, and many of these people were active in
sports and had discussions with their athletic coaches about steroids. Slightly
more than 30 percent of the same people discussed steroids with their parents,
which can give us a clue if society perceives steroid use as a problem for the
adolescent population.
While bullying and obesity scored higher than 50 percent among the public
as serious problems for adolescents, the use of steroids only scored 19 percent
as a serious issue in adolescents. These statistical data raise important ques-
tions: Does the perception of society minimize the impact of steroid use on
adolescents? And does this social factor impact the motivation and use of ste-
roids for this young population? In order to answer these questions, we need
to further look into how society views anabolic steroid use in general. Close
to 20 percent assume that high school athletes have a serious problem with ste-
roids, as opposed to more than 60 percent thinking that professional athletes
have a serious steroid problem. The media place professional athletes in the
138 Steroids

spotlight but tend not to do that with high school athletes. In addition, based
on statistical data, the reason given as to why adolescents tend to use steroids
mainly focuses on athletic performance and not on other factors such as peer
pressure. Another study shows that the majority of data are on males and ste-
roid use and only one-third of that is on females; this neglects the fact that
women athletes use these drugs in greater numbers than commonly believed.
According to these studies, only about 62 percent of teenagers had a discussion
with their teachers about the negative health effects of steroids, and 71 percent
among those who participate in sports, spoke to their coaches. The lack of
knowledge about the negative consequences of steroid use can be a serious fac-
tor why adolescents continue to self-administer steroids. The lack of appropri-
ate education about steroid use, combined with media attention on
professionals who use steroids, can leave adolescents with unreliable informa-
tion, and they may not perceive it as a serious problem with hazardous conse-
quences. Steroid use can also be connected to self-image issues. Those who are
affected by peer pressure may be ignored and neglected in the perception of
society and the media altogether.
Another serious problem, and one that may contribute to youth administer-
ing steroids, is pressure on them from parents. Beginning in childhood,
parents often pressure children to excel and be strong competitors in various
sports. In addition, coaches and celebrities, who may serve as role models in
an adolescent’s life, create great pressure on him or her to be the first and the
best. In other words, the goal is to win the race, and second best is not an
option. This type of programmed mind-set by society not only creates pressure
on the younger generation but may also put them at risk for developing guilt or
various kinds of self-esteem problems. What is even more intriguing is that the
messages that are sent on how to get to the finish line may not be those
accepted by society. For example, in one study of steroid users, more than
50 percent of parents knew their children took anabolic-androgenic steroids
(AAS), while a majority of those parents also favored higher grades in school
versus higher performance in sports. Likewise, other parents of the steroid
users favor sports versus obtaining good grades in school. In addition, more
than 60 percent of the steroid users who are also trained by coaches do
not believe that their coaches think that taking steroids is bad for them.
These are conflicting views that an adolescent must navigate if he or she is to
understand appropriate decision making about taking such drugs.
While parents and coaches have a significant influence on adolescents, so
too does the entertainment industry. For example, famous celebrities in sports
have a big influence on adolescents’ mind-set. Many steroid users may assume
that many professional athletes have taken AAS to get to where they are, which
 The Social Impact of Steroid Use Today 139

can also create a form of indirect acceptance, compliance, and behavior model-
ing: “If he or she has done, it may be acceptable for me to do it as well to get to
that goal.”
All of these types of mixed messages can create a state for disequilibrium and
confusion. The adolescent can feel confused as well as pressured to excel in all
areas. This type of mixed message may encourage adolescents to do whatever
it takes, with any means necessary, and paying any price to reach a goal.
For example, sending mixed messages to adolescents can often create confu-
sion and internal conflicts for them. Winning in sports can create tremendous
pressure if the goal is to be the best as well as excel in school and career. This
can reinforce the notion that being perfect is the accepted norm. While these
messages continue to be sent to adolescents, having strong knowledge regard-
ing the serious health hazard of steroid use does not appear to stop them from
experimenting with these substances. In fact adolescents may be in a bit of
denial that health problems will not occur in their life. Also, they believe taking
steroids can have tremendous benefits to obtaining their self-goals and may be
worth the risk. And for those individuals who stopped using steroids, health
problems were a major deterrent once it happened to them.
However, experts believe that education is a significant component in creat-
ing a positive change. They believe deterrent efforts must be multidisciplinary
and that the chain of deterrence has to include everyone who surrounds the
user in a chain-like fashion, where everyone pitches in to help the user be absti-
nent from steroids. However, when taking a closer look at why some coaches,
for example, are not fully against steroid use, it becomes clear how little
informed they are about steroid use by their athletes. Upon surveying 474 high
school coaches, researchers found that coaches assumed that the steroid prob-
lem only touched a small percentage of athletes in their school and usage was
minimal. Moreover, those who were informed about the use tended to have
an inaccurate picture about its early signs and symptoms, not knowing what
to look for when someone began using them.

PREVENTION
In order to create a strong prevention program against substance use, a more
collaborative effort is needed, and an increased variety of strategies must be
made to tackle the problem of steroid use. An example could be focusing on
education that targets one of the causes of the problem: peer pressure. Much
influence on adolescents to start using steroids comes from school and physical
fitness, where they are exposed to social and peer influence. Another way of
assisting the education process is through creating a better and more effective
140 Steroids

communication strategy to send messages to adolescents. Starting to educate

them early enough by teaching the consequences of steroid abuse can facilitate
more effectiveness in treatment as well as including other educators, such as
parents and coaches. In addition, this education can help adolescents break
the internalized thought patterns of perfection and winning through finding
more appropriate role models, support, and setting healthy and realistic goals.
A variety of other interventions can be used to deprogram the negative social
influence. Some anti-steroid advocates believe drug testing can serve as a way
to stop steroid use; however, this method has been shown to carry a high
financial cost. There are varieties of other economic proposals that may help
facilitate the ban of illegal steroid use.

HOW STEROID ABUSE BEGINS

As previously described, multiple forces shape the motivation for use of
steroids in adolescents. In order to understand how steroid use begins, it’s
important to understand the process of social influence and its effect on people.
For example, a study done to determine if there is an effect of parental involve-
ment and sibling relationships on the adolescent’s substance use demonstrated
that the greater the parental involvement in the earlier stages of adolescence, the
lesser the chance of substance use later on. The study showed that parental influ-
ence is an important contributing factor in possibly decreasing the use of substan-
ces. In another study done to identify various patterns of substance use by high
school students, there were various factors found that had a significant effect on
adolescent substance use. The fact that parents were monitoring their children’s
daily activities had significant importance in lowering their substance use going
into adulthood. This study also found a connection of mental health to a higher
prevalence of substance use in high school students.
While there are multiple reasons why adolescents pick up and use substan-
ces, social environment can be a significant contributing factor toward sub-
stance use. For example, the influence of peers can have a major effect on an
adolescent. Adolescents can pick up information from their friends and their
surroundings. Social activities facilitate learning. The type of activity that the
individual is involved in sets an important foundation for his or her future as
well as promotes social learning. For example, peer influence can be positive
to negative. A type of positive influence occurs when the individual is involved
in positive activities such as sports, physical fitness, art, and possibly music.
In these types of activities, there is an opportunity for growth, development,
and self-improvement. An individual becomes involved in an activity, such
as physical fitness, and makes it his or her priority. In addition, these activities
 The Social Impact of Steroid Use Today 141

may also serve as daily structure builders and possibly as outlets for stress and
other challenges. It’s during these social activities that a person becomes influ-
enced by his or her peers who can ultimately shape his or her perceptions and
beliefs. Likewise, experts have found links between negative social influence
and negative social behaviors and crimes. Factors such as negative peer pressure
and socially learned negative behaviors and attitudes may contribute to his or
her deviant behavior. What is interesting is how these types of activities—both
negative and positive—have the possibility of shaping one’s life. For example,
research shows that positive youth activities can have a significant effect on
cognition and emotions as well as the social development of an adolescent.
Moreover, since adolescent social roles and levels of responsibilities, compared
with those of an adult, may be less, their level of structure may be weaker than
that of adults with full responsibilities. In addition, seeking activities that bring
excitement and thrill can be more of a focus for an adolescent than an adult, as
youth tens to be more open to experimenting. On the other hand, adolescents
who are involved in positive social and structured activities such as sports and
afterschool programs can experience a positive effect on their overall well-
being. The person can be focusing on how he or she can develop his or her
strengths and be a better person in society versus seeking a certain type of
instantaneous gratification. The type of peers who surround him or her would
be different than those who are involved primarily with drugs.
What happens to kids when positive activities are not practiced? One study
looked at the effect of boredom on adolescent risk-taking and negative behav-
ior. It was found that perception about having leisure activity and various atti-
tudes about it have shaped how adolescents perceive the idea of free time.
In terms of substance use, research has shown that substance users were more
prone to be bored during leisure time than others who were not taking sub-
stances recreationally. In other words, there is a connection between substance
use and experienced boredom.
One case study involves Tony, who was a native New Yorker, growing up
mainly in suburbia. His parents were middle-class, hard-working people who
did everything possible for their child to be in a safe and healthy environment.
Tony was an above-average student in school and had an adequate social life
filled with friends. He was not very involved in sports or other athletic activ-
ities. He rode his bicycle occasionally. He occasionally felt bored living in sub-
urbia and lacked more recreational activities in his life. Tony also worked as a
pizza delivery driver on per diem basis. However, during the same time he
became involved with friends who smoked marijuana. Tony was the type of
the person who was open to trying new things, but he preferred to stay away
from trouble. However, the more he hung out with these new friends, the
142 Steroids

more he was exposed to drugs and alcohol. One day, he began to hang out with
people who were using opiates. Initially, he was against the idea since he heard
that heroin is very addictive and dangerous. His friend told him that nothing
was going to happen with the first try, and he could stop at any time. Tony ini-
tially resisted the idea, but then he felt that there was nothing wrong with just
trying one pill. When he took it for the first time, he felt a sense of euphoria.
He gradually began taking these pills more frequently, almost on daily
basis. Soon, he was at the point where not having a pill meant he wasn’t feeling
well. He could not function without having his daily dosage. All his social
circles were filled, now, with people who were using pills. In addition, even
at school, Tony would purchase the pills from someone he knew. As more
time passed, he became dependent on them both physically and mentally.
One day Tony realized that all his money he was saving and working hard
for had been spent on pills. He had no choice but to start getting money from
his parents. His parents tried to do everything they could to stop him from
using the pills, but unfortunately they could not. Tony tried to seek profes-
sional help for his substance use. But he was not consistent with his treatment
and stopped attending. He also began cutting school and was fired from work
due to bad performance. He felt physically and mentally sick when he didn’t
have his daily dosage of opiates. He could not think straight, and the only
things that mattered to him were his drugs. His friends also kept using drugs.
Tony’s relationship with his family began to deteriorate and, at one point, his
parents told him to move out, since he had attempted to steal more things
from them. Tony felt broke emotionally, physically, and financially. He could
no longer financially support his habit. At that time, his friend Ron under-
stood what he was going through and knew that opiate pills were an expensive
habit to maintain, so he introduced him to heroin. Tony trusted Ron, as they
had been good friends since childhood. When Tony heard what Ron had to
offer, he was initially taken aback. Tony never in his life thought that he would
try heroin—he thought that was only for “junkies,” and he was not one. He
had a preconceived notion of an image of someone who uses drugs, and that
was not him. However, upon feeling sick and not being able to afford opiates,
he tried heroin. When he injected his dose, he felt like he was in heaven.
He instantly became attached to this substance. As more time passed, he pur-
chased more from Ron, and heroin became a way of life for him. However,
from pressure of his parents and other family members as well as having no
structure in his life other than his drug, he attended a twenty-eight-day drug
rehabilitation program. Miraculously, he completed the program successfully
and went on that day to a higher level of care. He was clean, sober, and ready
to continue his life. His counselor set up an appointment for him to go to an
 The Social Impact of Steroid Use Today 143

outpatient treatment facility. Tony was ready and motivated when suddenly
he received a phone call from his pal Ron, and it was the last phone call of
his life. Tony died of opiate overdose that day, after he met up with Ron.
He stopped breathing, and he had respiratory failure. Had it not been for
taking his last dose and being in treatment he could have still be alive.
That is the power of social influence on personal decisions. Social influence
may not be the only factor that affects individuals’ behavior and the choices
they make, but it does place one into an arena of risk and potential danger.
Unfortunately for Tony this was his last chance. While steroid users may start
out differently and have different motivation for why they start using, the pro-
cess is the same, and each decision carries within itself a serious potential risk.
Many factors can affect an individual’s choices and reasons for using drugs;
however, social influence is a significant factor in decision making. A negative
social influence can be a tremendous force in the life of an individual, espe-
cially adolescents and teenagers who may be more prone to peer pressure.
The social aspect of their life can also shape their identity. Their sense of self
can be learned through their social circles. Substance use is not only limited
to personal use by young people but individuals in various careers tend to
abuse anabolic steroids as well.
While most of the drug use and experimentation, including abuse of
steroids, begins at the adolescent state of development, steroid use appears to
follow a different pattern. In a study done in 2012 by the Centers for
Disease Control and Prevention (CDC), it is shown that more than 50 percent
of adolescents had experimented using alcohol and 40 percent had tried mari-
juana as well. What was particularly interesting is the pattern of experimenta-
tion. While both alcohol and marijuana were initially used on one or
possibly a few occasions and then ceased, the use of AAS seemed to continue
in periods of up to eighteen weeks in various cycles. In addition, the usage
was particularly unique. Users were mixing in other steroids, and the dosages
were significantly higher than what is intended by medical staff. While in
today’s society the public is more aware of the abuse of steroids through profes-
sional sports such as baseball and bicycling, many people are still unaware of
how often the problem occurs with everyday people. While the media tend
to focus attention more on celebrities in sports, such as Alex Rodriguez and
his homerun record as well as Lance Armstrong and his winnings at the Tour
de France, the attention seems to be drawn away from the source of the prob-
lem and the average person who is impacted by AAS use. Another study of
1,000 adults showed that more than 40 percent of the people who were taking
steroids were taking them as prescribed by a medical doctor for conditions
such as asthma and rheumatoid arthritis.
144 Steroids

The frequent occurrence of steroid use appears to increase as the person

ages, which means that the younger population, such as adolescents, does
not engage in pursuing prescriptions of such substances. The use of steroids
increases as somewhat older individuals pursue athletic activities. When the
same 1,000 people were interviewed regarding their interest and exposure to
sports, however, the data seemed to follow a rather different pattern. For exam-
ple, more than 70 percent of interviewed people held an interest in sports,
while more than half of those people were actively participating in sports.
Another study showed that individuals older than sixty-four years barely knew
anyone who was taking steroids through illegal means. However, when the
adults were asked the same question—if they knew of anyone abusing steroids
and taking them without prescription—one of the five people knew another
person who they believed was using steroids in this way. The research may
indicate that those who are younger are more active in sports and therefore
have more interaction with others who use steroids and play sports. The
notion that the usage of steroids is learned through social influence is an
important point in understanding how the impact of social influence affects
an individual who uses steroids.

MOTIVATION
The motivational factor for steroid use appears to have a strong connection
with social norms and values. For example, a typical drug user is concerned
about obtaining a drug to achieve an altered state of reality. The person who
typically uses a drug may perceive the drug as a way out of a particular situation
as well as a mechanism of coping due to his or her life situation. The goals of
the individual using drugs can frequently be diminished by the drug use and
can cause a person to be focused primarily on obtaining the drug. In addition,
instant gratification for many substance users becomes the way of life and they
have difficulty with self-control and, frequently, are driven by automatic
behaviors and actions. The typical substance user may become neglectful
about other life areas such as their body, not taking responsibility for their
actions as well as manipulating their way to obtain the substance.
On the other hand, steroid users may be motivated by factors that have no
meaning to typical drug users. Some of the motivational factors behind steroid
use might be physical appearance to make the user more socially appealing.
The steroid users tend to possess overachiever qualities and be more goal ori-
ented versus the typical substance user who typically lacks life goals because
of substance use. The steroid user may be a great athlete whose goal is to train
hard and be a champion in everything he or she works on. They can be very
 The Social Impact of Steroid Use Today 145

health oriented and have a very healthy lifestyle focusing on enhancing the self.
Steroids may be a way to enhance the performance to get to a particular goal as
well as expedite the result, which otherwise seems to be significantly more dif-
ficult to obtain. The user may also become more obsessed with the physical
self-image that may be connected to his or her self-esteem. In addition, the physi-
cal effects of steroids are not instantaneous compared to heroin or cocaine, where
the person feels a high after receiving the dose; this means the person needs
adequate self-control and greater frustration tolerance. The process of enhancing
self-image is also not quick and happens over time. The steroid user must be
patient, diligent with workouts, and have adequate diet to obtain great physique
results.
In the mind of adolescent males, the steroid use can be motivated by
their desire to enhance their appearance and their social status in the society.
The male adolescent often values physical strength and the notion of being
masculine. These factors play a tremendous role in motivating adolescents to
experiment with steroids. While financial gain and obtaining academic schol-
arships may be motivational for some adolescent users, the pursuit and
achievement of being happy and increasing self-confidence are typically the
stronger motivators. In addition, developmentally, being an adolescent cer-
tainly places stronger emphasis on peer approval. Many adolescents who use
steroids are frequently influenced by their social networks and other athletes
at fitness facilities. Those users who rely on steroids also hold a belief that it’s
as important as diet and exercise, which helps to enhance their physical
strength and appearance. The use of steroids by individuals who engage in
physical workout regimens and accompanying steroid use is motivated by
the results of that use. In addition, continuous use leads to more social
reinforcement by other peers. The other social dimension of AAS use comes
from the notion of becoming wealthy in one of the most effective ways pos-
sible—dreaming of becoming a professional athlete.
There are many who would follow this path, whether it’s in the United
States, the Dominican Republic, or other countries where someone has a
dream of becoming a professional athlete or has a goal of enhancing something
in his or her life. That person is willing to suffer the price of his or her life for
the goal of becoming successful. Unfortunately, as a society, we are driven by
positive results such as those experienced by our celebrities or those who suc-
ceed in other ways. Many of these inspired athletes look up to the famous
models as guide for their own future.
An example of these athletes may be the tragic story of Taylor Hooton.
The tragic story took place in Plano Texas for this adolescent athlete,
Taylor Hooton. Hooton, an athlete who was motivated to play baseball for
146 Steroids

his high school, ended his life by killing himself at the age of seventeen. Both
parents and doctors attribute his suicide to his depression, which they believe
had something to do with stopping his use of steroids. Hooton was known
for being a social person, admired by his friends and those around him, with
no history of emotional issues. Hooton was perceived as someone who
smiled frequently and was respected by many peers as well as liked by oppo-
site sex. According to Hooton’s high school coach, he was popular as well as a
respected person in the social arena. Hooton appeared self-conscious about
his self-image, however, as evidenced by his colored hair and frequent use
of a mirror to examine himself. To his friends, he stated that his motivation
for steroids was not related to baseball, but it was something personal to
him. According to his psychiatrist, Hooton appeared to have issues with
self-esteem. His parents began to notice changes in his behavior, mood, tem-
per, and gradual increase in weight. He began to develop anger problems as
evidenced by hitting objects against a wall and hurting other persons, which
led to them being medically treated. While Hooton’s friends may have
known about his behavior and outbursts, adults were not aware of the
present situation. While his coach was aware of his changes in his physique,
Hooton’s behavior did not appear any different to him. His relationship with
parents began to change when he took money from them without their per-
mission. As time went on, Hooton’s family found about his steroid use and
decided to give him a drug test. However, the drug test was more designed
for street drugs rather than steroids—tested negative for steroids. His mother
also was alarmed by his strange behavior when he told her he would use a
knife to end his life. At that time, Hooton reported to medical staff that he
was on AAS. He later reported that he had stopped using steroids; however,
a rather different set of behaviors began to appear. During his family get-
away, he stole expensive electronics from them, which was very atypical of
his behavior. Hooton’s parents had punished him for this type of negative
behavior. The next day, Hooton went to his room and hung himself from
his bedroom door. What led him to taking his own life? What were the rea-
sons to make this drastic decision? And what factors were involved that
may have triggered these events to take place? Upon an inspection of his
room by his father and police, drug paraphernalia was found, as evidenced
by needles, syringes, and steroids. When Hooton’s autopsy was completed,
multiple steroids were found in his body. Unfortunately, Hooton’s life may
have turned out differently had it not been for contribution of steroids.
Unfortunately, this was not the only case of suicide related to the mental
health side effects of taking steroids. Another person in the late 1980s had
also committed suicide by hanging himself; one month prior to that he had
 The Social Impact of Steroid Use Today 147

stopped taking steroids. This was suicide as a result of withdrawal from

steroids.

DECREASING STEROID USE

While there are multiple issues with why people take steroids, many factors
can be controlled for it on a social level to decrease its use: for example, making
everyone among the staff at the school or organization aware of the problem
with steroids, providing close monitoring, specifically, of the more vulnerable
populations such as athletes, and noticing any unusual changes that take place
with the person. In addition, an effort to provide proper drug testing to test for
various steroids needs to be implemented. Hooton and his friend reported they
did not believe their high school staff were concerned much about steroid use.
Even the principal reported that the death of this high school student was his
first experience with this drug. Other staff reported that they never saw any-
thing related to steroids in more than twenty years. According to Hooton’s
friend Ajello, however, steroid had been widely used by those high school stu-
dents. The other issue of where they get it from and what types of substances
they use was not addressed since there could be anything in any containers
brought into the school by teammates. Ajello also said that, while coaches do
not encourage their athletes to take steroids, they tend to send messages that
may indirectly motivate someone to start using them. For example, phrases
such as “You are not big enough” may trigger someone at least to start contem-
plating steroids if he or she really values sports and this is his or her life. On the
other hand, Ajello also spoke about how some coaches may know that their
athletes use steroids but decide not to address this issue and keep it suppressed.
When discussing the issue of drug testing in that high school, a public official
said he was not against drug testing; however, he pointed out that they were
unable to test the students because of financial cost.
Another story that ended tragically for a person involves a seventeen-year-
old female who wanted to have a defined “six pack” of abdominal muscles.
Dionne was a cheerleader and a gymnast for her high school. In addition, she
held the vice president’s position at her club in high school. Her main motiva-
tion in starting to using steroids was to enhance her looks and was not related
to her athletic performance. Based on the data gathered by the CDC in 2003,
about 7 percent or more of seventh grade females were reportedly using ana-
bolic steroids, mainly for altering their physical image. In addition, the CDC
reported that about 5 percent of teenage females end up using AAS for cos-
metic reasons as well as to possibly form protective barriers. Dionne admitted
during an interview that her reasons for trying AAS were mainly due to social
148 Steroids

pressure. Her perception of reality and self-image were shaped by what she
observed in the entertainment industry, such as Hollywood and pop culture.
There is a sense of defined ideal image that is portrayed by the entertainment
industry. According to Dionne, for a young female there are always issues with
physical image and self-esteem. Adding to this the values of the entertainment
industry, which often shapes the perception of self-image for teenage girls, the
influence can be tremendous. After using steroids for five weeks every other
day, Dionne wanted to commit suicide. She also reported that 50 percent of
her high school football team was taking steroids as well. She stated that
parents and coaches did not mind the fact that there was steroid abuse around
them. However, others at the school reported a different story such as they
were aware of the problem as well as those that threw steroids away at first
sight. Despite the controversy, the use has continued. What was interesting,
particularly, about this example is that the culture of football in that school
was significantly contributing to the use of steroids by other students.
In Dionne’s case, she became familiar with steroids as well as received her sup-
ply mainly from a football player. Even though for Dionne her reasons for tak-
ing steroids were to enhance her looks, she wasn’t aware of how damaging it is
to take it on psychological and physical levels. Prior to taking steroids, she
stated that she did not suffer from any mental health disorders other than typ-
ical teenage developmental milestones. Her relationships with her parents and
her boyfriend were tense as a result of her feeling temperamental and argumen-
tative. She was engaged in high-risk behaviors such as taking a large quantity of
over-the-counter pills at home, randomly, just to feel better, as well as drinking
alcohol excessively. A close call with drunk driving helped her to realize the
consequences soon enough, and she felt that this was a sign to stop and not
wait until it was too late. After taking a closer look at her life, she no longer
has used steroids. However, she received a call from another female who
claimed she also wanted to start on steroids for the same reasons that Dionne
had started and that a football player who had the necessary supply for it was
available to her. Luckily this girl had someone to talk to like Dionne who gave
her a reality check. Some people may not get such chance and will end up
using steroids. In addition, it is important to recognize the level of influence
that the entertainment industry has on the younger generation, may be signifi-
cantly stronger than other social aspects of their life such as parents and
teachers.
Because these incidents occurred among the adolescent population, schools
became more aware of how serious this issue really is in these lives as well as for
families of the adolescent steroid users. One of the strongest proponents of
drug testing was Don Hooton, the father of Taylor Hooton. Having to go
 The Social Impact of Steroid Use Today 149

through his son’s death because of using steroids gave him the drive and moti-
vation to protect and prevent future incidents of adolescent steroid use.
However, there are many issues that have emerged about steroid testing
despite our best effort to address them. There are multiple ways to beat steroid
tests, as long as the user becomes educated and creative about going through
the procedures. The Internet provides multiple resources for those who want
to beat the test. In his own state of Texas, Don Hooton was a strong advocate
for steroid testing in schools. In fact, the programs were instituted there, and a
bill was passed to provide financial funding to deliver steroid testing in schools.
When the program was implemented during the year of 2007 through 2008,
the costs of actually performing rigorous testing were extremely high.
The other problem was that the number of students who tested positive for
AAS was minimal. In 2008, Texas delivered more than 10,000 tests to stu-
dents out of whom about fifteen showed to be positive. However, approxi-
mately another 200 were thought to be positive based on multiple reasons.
Three million dollars were allocated for this steroid testing, with a result that
only a few people tested positive. This was seen as a strain on a state budget.
A few years later, the program was cut to about $650,000. And finally, in the
year of 2013, only nine students tested positive out of more than 3,000.
While there is a significant steroid problem, the amount of money spent on
the program up to 2015 was approximately close to $10 million and resulted
in no more than forty students testing positive for steroids. When the program
was designed, there were specific substances that they were testing for such as
the chemical makeup of each steroid product. Many tests that are designed
to see if someone has used steroids are designed for those particular chemicals.
For example, the World Anti-Doping Agency (WADA) identified about 120
steroids for the test. However, each of the substances can act like steroids but
has completely different chemical compositions. In addition, states such as
Texas could not test for so many substances and were lucky if they could test
for ten of them. The testing could have been easily manipulated since agencies
that control the testing and regulations of steroid testing tend to publish which
types they are testing for. This makes it easier for AAS users to stay away from
those drugs. While the typical cost of testing per student is about $100, this
does not include the rigorous testing for all major types—only a small portion
of steroids are tested for. While other states attempted to fight the problem of
steroid use, the testing outcomes and fiscal costs as well as barriers to treatment
did not appear to be worth the effort despite the growing problem of steroid
use. The budget that must be allocated for such advanced testing must match
that of large organizations such as Major League Baseball and the Olympics,
which most states simply cannot afford. According to statistical data published
150 Steroids

by the CDC in 2013, about 3 percent of students experimented with steroids

in their lifetime both with athletic and nonathletic backgrounds. Despite the
fact that the number is only 3 percent, this amounts to approximately
500,000 students who experimented with these substances. While Don
Hooton still continues to advocate for the fight to prevent AAS use, his focus
seems to turn toward education of using steroids rather than testing. As of
July 2014, there were about thirteen Major League Baseball players in his
organization. These organizations play a very important role for the younger
generation; they attempt to educate, prevent, and instill consequences as well
as change the beliefs of those who are considering trying steroids. Through
education and positive role models, younger generations will hopefully under-
stand the real price tag behind the steroid use.
Despite the continued efforts to fight steroid use on a national level, there
are many other links found that trigger the use of steroids. In a study done
on female athletes, about 13 percent of them, ten women, showed that there
was a history of sexual assault. What was particularly interesting is that nine
out of ten of these females increased their workout routines for becoming bet-
ter defenders against males as a way of protecting themselves against attacks.
In addition, some women began to increase their muscle weight. This study
has showed, in fact, that there is a connection between sexual trauma and ana-
bolic steroid use. However, in this case, the steroids served as a shield to protect
oneself from sexual assaults. What also appears to be a factor here is that ste-
roids serve as a coping mechanism for sexual trauma. Nevertheless, steroids
may not be the only way to cope with trauma such as sexual assaults, as various
studies demonstrate. For example, other behaviors such as food addiction may
be linked to child sexual abuse. The food may serve as a way to cope with
childhood sexual trauma. The food also serves as a way to suppress trauma.
Some women felt that by suppressing the trauma with food, they are able to
be physically bigger through weight gain and that larger size would serve as a
protective barrier against sexual attacks such as what they experienced when
they were younger. In addition, upon interviewing some of the women who
were sexually abused as children and who later had massive weight gains as
adults and had stomach surgeries to reduce the weight, it appeared that they
later suffered from intense psychiatric episodes when they were unable to use
food as a coping strategy. In a story of one woman who had a history of child-
hood trauma, after going through a bariatric surgery to stop weight gain, she
felt suicidal and was hospitalized multiple times a year because of psychiatric
reasons. What is interesting about all these observations is that factors such
as steroid, drug, and food use are just the symptoms of the problem. Obesity
may have significantly deeper roots that may be interlinked with trauma and
 The Social Impact of Steroid Use Today 151

self-image. While the individuals who tend to abuse these substances may be
judged and criticized from the outside as weak or incapable of having will-
power, on the inside there is likely quite a different story. Many of these indi-
viduals who use steroids may have learned early on in their lives that steroids
protect them from ever being assaulted again due to increased power that
comes with AAS. Or, for those who overeat, food may be their best friend in
times when they are down as well as create a larger form for someone to have
a self-protection and never to experience a feeling of assault ever again. What
these factors may indicate is that any substance abuse may be just the tip of
the iceberg for someone who is suffering deep inside; the substance becomes
his or her way out of this suffering.
In the early 2000s, steroid abuse was often in the global headlines. In the
Winter Olympics of 2014 that took place in Sochi, evidence was found of
multiple steroid abuses by athletes of the Russian Federation. The report came
from a director, Dr. Rodchenkov, who was the director of the laboratory that
designed the drug tests for athletes since 2005. He is also a researcher who
published in scientific journals and participated in global events regarding
anti-doping with the United States. As many as fifteen athletes who won gold
medals on an Olympic event from Russia were found to be utilizing various
doping techniques. The director who publicly came out with this information
has tested thousands of athletes; he reported that he designed a special formula
of multiple substances along with alcohol that was given to these Olympians.
In addition, according to Rodchenkov, this masking operation had been
planned for a long time and involved multiple Russian anti-doping profes-
sionals and intelligence personnel who were utilizing and tampering with urine
of the athletes. The samples were modified throughout the night, working
multiple hours in specific conditions to be able to deliver a perfectly designed
sample ready for the Olympics. Approximately one hundred urine samples
have gone through his process in order to pass the Olympics drug testing.
Among the athletes there was no one who tested positive for steroids. Russia
took the highest number of medals in that Olympic event. While others in
Russia felt that this was a very offensive statement on the Russian sports, and
the directors’ claims were very difficult to confirm, the WADA agreed with
the exposé based on the information provided. In addition, according to the
director, this operation has been making this testing product for a very long
time along with the multiple efforts and organization that took place to deceive
the International Olympic Committee (IOC). Recently Russia began accusing
the director of money extortion from athletes as well as suppressing drug test
results and tampering with urine because of him discussing this information
with WADA. He also reportedly stated that he has eliminated as many as
152 Steroids

thousands of urine samples. Moreover, as the news began to open up, he

resigned voluntarily from his job as director and relocated to the United
States for safety (since two of his working associates have passed away unex-
pectedly, one of whom was a former director of this agency, Kamayev, and
the founding chairman, Khabriev). According to the director, multiple sports
in the Olympics were manipulated through the usage of steroids by the
Russian Team. He reported that there were multiple types of steroids used
along with alcohol as a cocktail for Olympians. One of the Olympians who
was caught with the steroid use was Elena Lashmanova in the London 2012
Olympic games. She won a gold medal for race walking.
Rodchenkov’s job was to prevent these substances from testing positive and
exposing athletes for the steroid use. However, he stated that these athletes also
took substances outside of his control, which made them more vulnerable,
such as what happened to Lashmanova. In addition, he provided names of
all athletes and the method by which these individuals took and masked their
steroid use. When WADA became involved in this case, Russia was issued a
suspension on track and field sections of the Olympics as well as future events
such as the next Olympic event of 2018 in Rio de Janeiro. Russia has denied
the statements regarding steroid use to the present time and stated that in
the Olympics Russia took the most medals overall. Some of the questions that
may arise when reading this story are: Is the evidence compelling enough to
state that everything the director said was true? Also, how much did steroids
play a role in giving Russia the leverage to win all the medals? In today’s soci-
ety, steroids are gaining both national and global attention. As evidenced in
this Olympics case, steroid abuse is not to be taken lightly since it affects all
areas of our lives as well as those around us in all aspects. Starting with an ado-
lescent who may use steroids to achieve personal goals, all the way to the world
nations that may use it as a way to gain a competitive edge, steroid abuse con-
tinues to the present day. The testing for steroids appears to be very complex
and very expensive and while creating more strict regulations regarding steroid
abuse may seem to be effective, in practice that may seem very difficult to
enforce.
A more recent phenomenon of anabolic steroid use has been found among
members of the military. Although anabolic steroids were not so commonly
used as supplements, a soldier can obtain these supplements even on the mili-
tary base where they are commonly sold. In fact, there are multiple reasons
why soldiers may use these supplements in their daily rigorous regimes.
Many soldiers may simply use these supplements to gain muscle mass and
strength. In fact, multiple supplements come in variety of forms such as pow-
der and pill form. Moreover, in a recent investigation of steroid abuse in the
 The Social Impact of Steroid Use Today 153

military, when the rooms of soldiers were searched for these supplements,
many of them were found and some rooms even had a bulk supply of them
that appeared as a small-sized pharmacy. The supplements varied from weight
loss to energy boost. The use of these types of supplements appears to be a
common practice among military members. One of the soldiers reported that
sleep can be a luxury during intense trainings in one of the most famous mili-
tary academies such as West Point. The soldier by unknown name reported
that he even used the supplement in order to function and remain awake and
pursue his studies. Other drugs were also reportedly circulating around such
as Adderall, a stimulant that is only legally prescribed by medical doctors for
specific health conditions, such as Attention deficit Hyperactivity Disorder
(ADHD). Another form of energy boost supplement is a liquid drink that is
popular in the military arena and is known as RIP It. This drink offers high
energy to soldiers who need to work for an extended amount of time. Even
high ranking officers such as sergeants would distribute it to their units in spe-
cific ratios. The drink’s primary ingredient is caffeine in very large amounts.
The purpose of this ingredient is to create a high stimulation of the central
nervous system, which allows the person to function and be alert for longer
periods.
Of course, there is a price to pay for these practices. For example, in 2003, a
tragic incident occurred because of two U.S. airmen who delivered an acciden-
tal airstrike and killed four Canadians in Afghanistan. The U.S. pilots
attributed their erroneous decision to taking stimulant pills known as amphet-
amines that contributed to their impaired judgment during the flight. Despite
the consequences of these substances, these pills are perceived as additional ad-
vantage in the military for the purpose of night battles and extended battle per-
formance. In addition, medical experts agree that these chemical substances
could help with performance especially when there is a need to function and
stay awake for forty hours and longer. In addition, falling asleep during mis-
sions can be costly to both an individual and the military. There is also another
problem with flying—there may be no place to stop at a rest area like there is
when you drive; a pilot must keep going, and pills may be the only choice at
this life and death situation. For these pilots, not taking a pill can mean failing
a mission or not even be selected for another one. However, there is also
another controversy. These pilots reported that they were not well informed
about any Canadian military operations in that area, while others say these
stimulants were not responsible for pilot misjudgment. Researchers who study
the effect of amphetamines on the person find that the effect varies from per-
son to person as well as whether he or she is rested affects how he or she feels
after taking them. Another potentially dangerous issue in the Air Force is the
154 Steroids

burnout and feeling overwhelmed. In fact, a twenty-year study on the Air

Force concluded that more than one hundred accidents occurred due to mem-
bers feeling overwhelmed. Nevertheless, taking these drugs to fight the fatigue
may be a dangerous game. There are also studies that show that amphet-
amines, when taken in large amounts, can have potential negative effects such
as anxiety, heart problems, and paranoia. Despite problems with use of various
chemical substances, it may be difficult for soldiers to stop using them. The
constant availability of supplements and supply right on the military base
makes it easier for anyone to obtain and abuse it. In addition, the pressure of
being in the military and performing the jobs necessary to complete military
missions may put an additional strain on the soldiers, which gives them little
choice or flexibility on this matter. The demand of military occupations and
the nature of the job put a hard strain on the military personnel. Physical exer-
cise and healthy diet may only take them far in terms of performance and stay-
ing functional for longer missions. The desire for performance-enhancing
substances increases when these types of jobs need to be done. On the other
hand, taking responsibility for putting these substances into the body is
important.

CONCLUSION
The use and abuse of both corticosteroids and anabolic-androgenic
steroids continue to the present day despite consequences that come with its
administration. There are various reasons why people abuse these substances.
For many individuals such as athletes as well as those who intend to increase
athletic performance in their life, AAS can provide them with an additional
catalyst to make results happen more quickly and efficiently than the ordinary
way of simply dieting and exercising. However, for others, steroids can be used
to alter and possibly enhance their self-image to fit the social criteria. Research
studies continue to uncover reasons as well as ways to prevent steroid abuse
due to their hazardous side effects, and it shows that some of the past victims
of horrendous crimes such as sexual assaults may contribute to use AAS.
Other research data show that peer pressure can be a large enough catalyst to
trigger AAS use in adolescents. Society may also be affected, such as the use
of these substances by military as well as police. In order to understand how
AAS affects these various dimensions of society, we need first to understand
the purpose that steroids serve for the individuals.
Anabolic steroids have been, and continue to be, widely used in today’s soci-
ety. Beginning from professional athletes to those who want to enhance their
self-image, steroids are used in a variety of cases and for a variety of people.
 The Social Impact of Steroid Use Today 155

Despite the potential benefits and purposes, they continue to carry potentially
negative effects and dangers with them. The users who are not conscious,
aware, and educated about the side effects may pay the price with their lives
and the lives of those around them. Society as a whole may need to have a
higher level of awareness of how dangerous the effects are of taking steroids.
The idea of educating everyone—from siblings to parents to military training
personnel—may be an essential factor in saving people from making danger-
ous decisions. In addition, having an understanding of factors such as negative
social influence, media, peer relationships, and authority figures has a signifi-
cant force on individuals around them. The notion of having socially ideal
images that are often portrayed by the entertainment industry can come with
a price tag. Moreover, proper monitoring and understanding what to look
for when someone is using steroids can potentially save someone’s life. In addi-
tion, role models may need to take a more responsible stand at the messages
they portray.
Educating people about the use of steroids is only one part of an appropriate
strategy; it may not guarantee, however, that it will stop the abuse of these sub-
stances. Once individuals are educated on the nature of steroid use and its
effect on their lives as well as those around them, they at least may have a
greater chance at stopping the illegal steroid use before it harms them to a pos-
sibly fatal degree. In addition, multiple disciplines and efforts may need to
come together, ranging from local all the way to global, to be able to deal
with the steroid abuse problem. Collaborative efforts may be more effective
in finding new solutions to steroid abuse in our society.
 Chapter 9

The Future of Steroids

Management
Alex Bogomolnik

Both catabolic and anabolic steroids are being used in various fields such as
medicine, bodybuilding, and athletic performance as well as in enhancing
and modifying one’s physical image. The notion of reaching a higher altitude
on the hierarchy of needs continues to dominate the decisions made by indi-
viduals taking steroids. However, in the field of medicine the usage of cortico-
steroids has shown to have beneficial effects, especially for those who suffer
from chronic medical conditions that currently do not have a cure. Serious
medical conditions such as asthma and Crohn’s disease may require steroidal
intervention in order to decrease the escalation of attacks as well as make it
more manageable for the person to live a more functional life. Moreover, seri-
ous medical conditions such as asthma can pose a threat to a person’s life if
medical interventions are not directed appropriately.
In other words, for an asthmatic individual a serious attack can mean
suffocation or death if he or she does not address asthma appropriately.
Similarly, to someone with Crohn’s disease, lacking sufficient and consistent
steroidal treatment can mean a serious and devastating destruction to his or
her digestive system, leading to high-risk chronic problems such as internal
bleeding, malnutrition, and long-term hospitalization. In addition, such severe
problems can also lead to possible death due to complications. As described in
the previous chapters, functions of steroids can vary depending on the sub-
stance, dosage, and usage. More importantly, taking steroids as prescribed for
158 Steroids

a medical condition is completely different than taking them to enhance

athletic performance and physique. However, as time passes, the field of medi-
cine, pharmacology, science, and technology evolves as well.

TECHNOLOGY AND STEROIDS

As technology becomes more advanced, the role of the steroid industry may
start to change as well. For example, steroid testing can become more complex
and more rigorous due to the invention of new chemicals and chemical proper-
ties that will make substances much more difficult to detect. As more scientists
are involved in drug testing and develop more sophisticated ways of detecting
steroids, companies and laboratories will keep enhancing their approaches as
well. In 2016, there are facilities and labs that are working just to come up with
new substances that are more enhanced than the previous ones. It’s almost like
a cat-and-mouse game: there is always something new and innovative that
makes changes to the previous ways using which steroids were designed.

Internet and Steroids

The Internet and its effect on steroid users may also change the steroid indus-
try. For example, the Internet introduced online shopping, and steroids became
easier to obtain and at the same time more simple. For example, buying steroids
prior to the Internet meant a user had to have connections with people and places
that typically dealt with steroid distribution. The buying of steroids was available
through particular contacts. However, the Internet meant ordinary people could
buy steroids online through multiple sources that were available not only locally
but also globally. Someone sitting in the basement of his or her mother’s home
in the United States could make a simple purchase from somewhere in a backyard
lab such as in Dominican Republic or China, where there are significantly less
restrictions to production and distribution.

MANUFACTURE OF STEROIDS PAST, PRESENT,

AND FUTURE
Even though steroid purchases became simpler, ingredients were not neces-
sarily tested and could contain anything that the distributor would consider a
steroid product. In other words, while products can be labeled “steroid,” there
is no guarantee what those products actually contain. In fact, many times, “ste-
roids” might not even be steroids, and whatever is consumed could be
extremely hazardous. Moreover, these ad hoc laboratories are becoming more
 The Future of Steroids Management 159

sophisticated; it can be extremely difficult to determine the difference between

steroids that have been professionally tested and developed compared with
those that are made in the amateur labs of someone’s residence. There are sim-
ilar patterns of this with the illicit drugs of heroin, cocaine, and ecstasy.
However, looking back to the 1950s, the entire drug situation was completely
different. The drugs were much more homogenous and did not contain as
many additives. For example, cocaine was simply cocaine, and heroin was
heroin. However, in 2016, heroin can and possibly will contain chemicals such
as fentanyl—a potent opioid that can be used during chemotherapy—as well
as many other chemicals that have nothing to do with heroin at all. By putting
these chemicals in the bundle, the cost for a drug dealer would be considerably
cheaper as well as give a user an intense feeling of euphoria with a particular
mix of chemicals. For example, fentanyl, which is known to be a strong opioid,
gained widespread attention because of its potency and recent episodes of acci-
dental deaths, such as with pop star Prince. Actor Philip Seymour Hoffman
died due to fentanyl and heroin use.
The problem of mixing multiple chemicals together is it can cause serious
health problems as well as potential overdoses that could lead to death. In
the early 2000s, the drug that became fairly popular in New York clubs and
festivals was known as Molly, which is also known by the name of Ecstasy.
Molly is slang for “molecular.” A test done on ten people who used Molly
showed they also tested positive for multiple other chemicals such as bath salts,
which were created in the chemical lab. However, what is so unique about
these chemicals is that they are very hazardous to people’s health and can lead
to serious consequences. The new designer drugs, such as bath salts, are being
created in illegal chemical labs and are considered very dangerous to people’s
health. The name “bath salts” is misleading and is not intended for relaxing
baths, but rather can cause serious consequences such as altered mental status,
vision changes, hallucinations, and violence. Bath salts have become quite
popular and have been connected with strange, violent episodes of people
who ingested them.
What tends to happen is that many drugs are mixed into the basic formula
for a user, and the user has no way of knowing exactly what he or she is
ingesting. For example, heroin may contain large amounts of other ingredients
that have nothing to do with opiates whatsoever. And the source of where the
drugs are produced is questionable since ingredients can often come from
overseas. The ingredients could be industrial compounds that anyone can pur-
chase in local stores or pharmacies. However, these are global problems and
could continue into the future because it’s so profitable for the seller and the
demand is usually significantly high.
160 Steroids

This pattern does not seem to stop with a particular geographic location; it
can occur in any part of the world. For example, the drug that was started in
Russia in the early 2000s and made its way to the United States was known
as crocodile. Crocodile is composed of multiple chemicals, including gasoline,
hydrochloric acid, codeine, lighter fluid, and paint thinner. The chemicals that
make up this drug are similar to desomorphine (which comes from morphine
and is fast-acting) and are considered more hazardous and toxic due to nature
of the ingredients. Crocodile is shown to be extremely addictive—in many
cases similar to or even worse than heroin—as well as cheaper and possibly eas-
ier to make. Users of this drug can have serious consequences such as scale-like
lesions to the skin that can cause serious damage to veins and increase the like-
lihood of body infections, gangrene, and the potential loss of limbs. The use of
Crocodile in Russia and other European nations has impacted as many as
1 million users. The drug is typically injected. The drug has also spread across
many states such as Utah, Illinois, and Arizona. The five people in the United
States who reportedly tested positive for desomorphine thought they were pur-
chasing heroin. This is an example of how a simple and dangerous drug such as
Crocodile can travel from part of the world to another, while the user may be
completely oblivious to the fact that it’s not a drug at all but something entirely
different and exponentially more life threatening.
This is similar to what is happening with steroids. Since many people
currently purchase steroids online, a game of Russian roulette could quickly
ensue in which they might think they know exactly what they are purchasing,
but which turns out to be something else that still carries a steroid label.
Moreover, the future does not appear to be any less dangerous. More labs are
producing steroids, and more chemicals are coming out in different combina-
tions (known as designer drugs). And there may be more replications of those
steroids that do exist, which may be popular in the market but are produced in
cheaper form. In addition, there are many Internet forums that provide steroid
education to the user about how to use these substances in the way that’s more
efficient and effective.
The steroid user of 2016 is exposed to more information and communica-
tion than a user was in the 1980s, as well as prior to that when the Internet
was not the dominant source of information and communication. Users in
2016 can be more creative and effective because of multiple exposures to vari-
ous sources that discuss and distribute steroids. And users can receive steroids
quickly by shopping online. While in the 1970s drug dealers sometimes
sold on street corners, in 2016, drug dealers can be reached with a cell phone,
e-mail, and the Internet, and they can deliver the drugs to someone’s house.
 The Future of Steroids Management 161

As technology evolves, so does the steroid industry. For example, a former

police officer, along with others, was caught obtaining shipments from China
with ingredients to make steroids and then distribute them locally. They were
also caught with opiate pills, illicit drugs, testosterone powder, and firearms.
This is an example of how technology can be used by criminals to harvest
and distribute chemicals to make and distribute anabolic steroids or any drugs
that have the potential to be sold locally.
Delayed gratification has been replaced with instant gratification, which has
become the norm of everyday life. Things like computer tablets that were seen
on the episodes of Star Trek have become the new norm in schools for children
learning specific skills. All these factors create the new ways of living and com-
munication and shape the way people think and act and utilize tools to
enhance our lives. With these new and innovative ways, there are tremendous
benefits as well as possible side effects.

MEDICAL STEROIDS AND THE FUTURE OF MEDICINE

Medical steroids or catabolic steroids continue to be a powerful treatment
for multiple ailments, and they may always provide an extra hand in managing
serious diseases such as asthma and lupus. However, utilizing steroids can be a
double-edged sword for people who suffer from these diseases. From one per-
spective, the symptoms can be well managed and the person can feel tremen-
dous relief in the short time. However, in the end the same people can
experience serious side effects such as bone problems and cancers. However,
scientists and other researchers are working on more effective treatments with
fewer side effects. In addition, the knowledge of genes and interactions with
the environment helps these professionals have a better understanding of these
diseases. In the future, these diseases, if not cured, can be managed more effec-
tively. For example, some serious diseases such as hepatitis C now have a cure.
It can be extremely debilitating and destructive to the liver. But now, Hep C,
which has affected many people for decades, can be cured with pharmaceutical
intervention. The Food and Drug Administration (FDA) approved a new drug
that can potentially cure around 170 million people globally. This liver condi-
tion that used to wipe out more than 300,000 every year globally and more
than 10,000 locally now can be cured with fewer side effects than regular treat-
ments. However, such a cure did not come without a price tag. The drug con-
tinues to be extremely expensive at $84,000 for a full cure. This occurs in
twelve weeks, costing $12,000 per dose. While the drug is still pricy and is
going through a process of whether insurance companies want to approve it
162 Steroids

due to its cost, there were also other medications in 2011 to stop Hep C,
however they carry serious side effects and limited treatment outcomes.
However, as research for a new and more effective drug continued by pharma-
ceutical companies, more efforts were put not just understanding how the
body functions and ways it deals with the virus but understanding the missing
genetic link.
A pharmaceutical company was working on molecules that act as genetic
codes similar to what we already have in our bodies and that can act to interfere
with the replication of the gene of the virus and breaking the virus replication
pattern. In addition, more companies added their research to the formula and
have created a drug that was targeting specifically the destruction and elimina-
tion of the Hep C virus with significantly fewer side effects and increasingly
higher outcomes. Moreover, more drugs are created to help people with varia-
tions in their genetic code for Hep C. In addition, companies understand the
cost may be overwhelming for people and may lower the prices accordingly.
For example, in countries such as Egypt with one of the most elevated num-
bers in population of Hepatitis C, medication can be purchased at $300 per
month, which makes it much more affordable. While the future is uncertain,
combined efforts by researchers, scientists, and professionals along with much
needed efforts make it not only believable but also achievable to get these types
of maximum results. Understanding that cures for these medical conditions
are not simply from accidents but from big efforts made by individuals and
companies perhaps offers hope that many things are possible. In addition,
the results may continue to evolve. For example, diseases such as lupus and
asthma may become a thing of the past, much like Hepatitis C. However,
more effective management of these conditions is needed so that the sufferers
can live a better and more functional life. In health conditions such as autoim-
mune disorders where the body frequently attacks itself, steroids are needed as
part of the essential management of the condition.
While various types of steroids continue to be used in order to obtain spe-
cific enhancements, as well as manage chronic health conditions, other forms
of alternative therapies are evolving and are currently available to the public,
and they have shown potential positive results. For example, an innovation
that seems to make its way into the future has to do with understanding and
modification of one’s genetics, stem cell research, and ways for the body to re-
cover quickly and efficiently.
The field of genetics offers many potential benefits that weren’t derived
from other fields of science or technology. Moreover, it appears as we go into
the future more and more research is being conducted on various genes in
the human body. There is an interesting and true story about a boy who was
 The Future of Steroids Management 163

born in Germany; ever since he was born he looked different than other boys
his age. He possessed a musculature that was significantly more defined in
shape in different parts of the body. For a typical infant, the muscles have a soft
texture to them. However, in this boy the muscles were more bulging and sig-
nificantly more defined. When the baby was born, his muscle had a jerky
movement as though he had epilepsy. However, his development of muscles
was rather different than anyone else his age. What was amazing in this child
is that he had the same genes which deactivated myostatin and thus causing
significantly higher muscle production yielding more strength and muscle def-
inition to the child. Even at age four and a half, the child was able to lift almost
7 pounds in each hand and hold them horizontally as well as his muscles in
both arms and legs were significantly larger than those of his peers. As more
scientists became interested in this phenomenon, closer analysis was made
about his family line. It was uncovered that his mother actually had a some-
what similar genetic makeup to the boy where she had one copy of the gene
that was malfunctioning versus the boy had actually several of them deacti-
vated. Moreover, the mother was a sprinter who was competing professionally
in 100 meter competitions and showed great strength as well as her grandfa-
ther too was working physically and able to lift weight of around 330 pounds.
It appears he has a family line of strong people. Much research can be done to
possibly explain phenomenon regarding strength, muscle mass, and how
much genetics play a role in muscle building and sport performance which
may or may not be attributed to myostatin substance in the body.
Scientists that study genetics find that the genes that control the substance
in the body known as myostatin were not activated in those that develop such
muscle definition and strength. For example, researcher Dr. Se-Jin Lee at
Johns Hopkins University, who has been studying mice and genes, found that
when the genes that govern myostatin are turned off, the mice developed sig-
nificantly leaner, more defined, and stronger musculature in comparison to
those mice that don’t and he coined the term “mighty mice.” According to
professor of genetics Dr. Ferrell, individuals such as Arnold Schwarzenegger
already possessed musculature prior to working out even in his teenage years.
Dr. Ferrell’s interest lies in understanding science and pattern behind muscle
development.
Moreover, the future has many potential benefits of understanding how
these genes develop. For example, understanding the growth of muscles may
lead to findings where medical conditions such as muscle dystrophy can be
not only helped but possibly reversed.
For example, in one research study done on mice, the inactivation of myo-
statin has benefited the mice by altering the process of muscle of loss of muscle.
164 Steroids

In addition, there may be a tremendous benefit to understanding and assisting

with aging as well as conditions that negatively affect loss of muscles. Similarly,
to steroids this technique of blocking myostatin can be used to enhance
muscles as well and used as a way to alter human physiology. However, the
problem with all this research is it does not know the long-term effects of
blocking myostatin and how it impacts the rest of the body. It’s not yet known
how the human organism will respond to this gene deactivation and how it will
respond to this change in later years. Perhaps the boy with this unique muscu-
lature may need to be studied throughout his lifetime in order to determine
what kinds of changes are possible when this substance is blocked. These kinds
of researches will also allow us to understand reasons behind how a body recov-
ers and ways to optimize its functions.

GENETIC DOPING AND ITS POSSIBILITIES

We are currently faced with a new concept known as genetic doping. In the
studies done in 2004 at Salk Institute for Biological Studies in California,
the mice were injected with genes that code for muscle building. As a result,
the mice became stronger and had more stamina and when placed on a tread-
mill were able to run significantly further in distance as well able to exercise
longer in length giving them competitor’s edge over mice that did not receive
the gene. What was particularly interesting as well is that these injected genes
acted as exercise regime and a catalyst for endurance as well as inhibited mice
from becoming overweight despite their diets and level of activity. Moreover,
even once these modified mice stopped exercising they appeared to be fit and
abstained from becoming obese. In addition, the researcher also found the
genes that may trigger fat release in the body and even with the activation of
these genes the mice did not become obese without the presence of exercise.
While this concept of gene doping is new, it presents a wide interest to those
such as professional athletes who are constantly looking for ways to enhance
their athletic performance. In addition, genetic doping may not only assist
them with building a more athletically enhanced body but also give them a
rather minimally detectable method of manipulating professional organiza-
tions and still being able to compete worldwide without being accused of
cheating. However, the experimentation of genetic doping is still limited to
mice and when done on humans has led to one participant dying. However,
the concept of activating fat switch may be an important finding in creating
a drug that can increase the good portion of cholesterol.
For example, a gene doping expert by the name of Lee Sweeney continues
to conduct further experiments with genes focusing on helping people with
 The Future of Steroids Management 165

chronic health conditions. Genetic doping can have potential benefits such
as fewer side effects than medication as well as more direct triggering of spe-
cific genes and not affecting bloodstream as medication or other medical
interventions do. In addition, this approach can be very appealing to profes-
sional athletes. Many professional agencies are concerned with the notion of
gene doping and the complexity of the testing to determine if the athletes are
utilizing them. Sweeney’s work has important contributions in understan-
ding muscle modifications as well as changes that occur with the muscles
due to process of aging. The mice that he was working on were named
“Schwarzenegger mice.” What was interesting about this gene doping is that
Sweeney also received phone calls from Pennsylvania Junior College football
coach in regard to gene doping the whole football team despite him saying no
to all requests. However, Sweeney’s approach to gene doping was to place
genes into an organism in order to create a reaction.
Another known hormone called Erythropoietin (EPO), which facilitates
red blood cell quantity and elevates levels of blood oxygen supply that in
the past could be detected only by lab testing, can now go virtually undetect-
able due to being inserted straight into the DNA. What began to happen
because of these gene therapy modifications was that coach Thomas
Springstein of Germany was suspected of utilizing gene doping on his female
athletes. At the time EPO was still new and in experimental phases; however,
despite the potential health risks, the demand by athletes continues to the
present day. The question becomes: How would these agencies test and
detect these substances since this is such a new and futuristic approach to
athletic enhancements? In 2016, the agencies such as the World Anti-
Doping Agency (WADA) are concerned with gene doping since that can be
the future and next level of anabolic steroid enhancements. Further research
is needed in determining ways to find which genes were altered through
traces of these substances, but the challenge remains because these substan-
ces may frequently bypass blood and be placed directly into particular muscle
groups. This form of gene doping would require significantly more complex
and sensitive systems for detecting trace substances in the body. The U.S.
Anti-Doping Agency is in the process of creating programs where athletes
would have multiple blood and urine exams and compare changes over time
as well as being able to see specific patterns of before and after and assess if
any changes have taken place. However, gene doping continues to be in the
experimental phase. What remains particularly concerning is that the reward
of winning a gold medal for the athletes can override a fear that one day they
will pay the price of using these experimental means. Additionally, there are
other technologies available to athletes to make them even more resistant to
166 Steroids

various factors such as increased endurance and recovery time without the
actual steroids.
The question then becomes: What would the Olympic Games look like in
the near future with all these new technologies? Would it be the same as it is
in 2016? Would it continue to be a showcase for athletes, or would it be
treated as scientific experiment with all the technologies combined for a syner-
gistic effect? Whether anabolic steroids will continue to evolve into more pre-
cise, virtually undetectable substances with fewer side effects or not is yet to be
determined. The desire to modify his or her performance, strength, and abil-
ities in a faster, more reliable and direct way is clearly a goal for some.
On the other hand, is it gene doping that will take precedence of all the future
enhancements over other methods? Perhaps it can be a combination of both as
well as a touch of neurofeedback and some glove for cooling effect. It seems
that when we combine all of these approaches the effect can be significantly
more powerful. Would it be more appreciative to see sports in its raw form
where it’s all about strength, speed, skill, and competition, or would it involve
altering one’s DNA to see how far we can push the human organism and see
the ultimate peak performance involved? These are great questions and only
future will show as to which direction it will go. However, it seems that field
of sports is always looking for innovations—chemical, physical, scientific,
and mental. Various technologies are coming out that take the competition
to the new level. And there are always individuals including those around them
such as couches, peers family members who want to be at the top of the game.
For example, anyone growing up in poverty or any type of difficult condition
would love to grow up being wealthy and financially problem free. In addition,
the passion for sports and competition can be a tremendous motivator to any
of these technologies since it’s the edge over the competition that earns the
win for the athletes. Moreover, the coaches too are motivated by these suc-
cesses and no-one likes to lose. So, perhaps, as the evolution continues, so does
the evolution of an athlete. The next evolution might be the era of creating and
altering genes that remove weaknesses and build strengths, the age of robots.
In addition, because of these possible changes to sports, maybe the whole com-
petition of separating gender will merge where opposite genders would com-
pete with each other in the same place without biases. Also, what would the
selection of athletes look like in the future given all these gene modifications?
Would the athletes be chosen based on just their performance or their genes
patterns? What would technology bring once this occurs? Moreover, the future
appears to be exciting, different, and possibly filled with multiple challenges, as
a result of all the changes that are currently taking place in medicine, computer
technology, and genetics.
 The Future of Steroids Management 167

UTILIZATION OF CATABOLIC STEROIDS WITH

OTHER MEDICAL TREATMENTS
There is also a future to catabolic steroids. As civilization progresses so does
everything else, including medicine. In addition, steroids can also be used in
conjunction with other modern treatments, which not only enhance the
strength and potency of steroids but also magnify and synergize the effect of
the substance mixed with steroids. For example, there is significant amount
of research that discusses the treatment using stem cells of the body. Stem cells
in the body have the ability to form into various forms of other cells. They are
usually present during the earlier part of development in humans. These cells
are also present in various parts of the body and act as a repair mechanism
for the organism. The cells also act like a precursor for other cells such as one
in muscles, brain, and other tissues. The stem cells are very special in the
body because they don’t have a specialization, however, they potentially
can form other parts in the body such as tissues, possibly organs. For example,
in some places in the body such as bone marrow as well as the gut, the
stem cells can repair and clean out the old cells and form new ones
because of division. While, in other organs, the stem cells have various
other functions. Through modern discoveries scientists realized that the stem
cells have the potential to do many regenerative and replace the wear and tear
cells in the body as well as be used for various purposes. In addition, research-
ers have also used stem cells from animal and human embryos to conduct
multiple experiments. Researchers can utilize stem cells for testing new sub-
stances and medications and come up with various theories related to growth
and development as well as identifying various problems with birth. In addi-
tion, further research may benefit outcomes of fighting chronic diseases as dia-
betes and heart problems. Modern research on stem cells continues to the
present and possibly to the future due to its possible potential and practicality
in the modern medicine. Stem cells are also slowly appearing in various fields
such as medicine and helping to restore injuries and help with chronic diseases
such as joint and spinal problems. Scientists also begin to see connections
between stem cells and genes and see how they are integrated. In addition,
there is possibility of taking stem cells and being able to create cells that are
in the heart muscle. Other research shows that it may be possible to transplant
bone marrow stem cells into another organ such as the heart, which has some
potential rejuvenating properties as well. There are currently more studies
focusing on the effect of stem cells on chronic joint conditions such as osteoar-
thritis of the knees, which affects many people such as someone who is obese
or elderly populations. Currently, the methods of treating osteoarthritis vary
168 Steroids

from physical therapy to surgery to pharmaceutical intervention. Being able to

treat this condition with stem cells would be minimally invasive in comparison
to interventions that use medications for this condition.

UTILIZATION OF STEM CELLS IN CONJUNCTION

WITH STEROIDS
At this time, the stem cell research continues and more discoveries on the
function of stem cells are being made. A recent research came out and pub-
lished by Harvard researchers that a study on stem cells found an interesting
impact of steroids on stem cell. Similarly, to athletic performance steroids also
help amplify the performance of the stem cell. It appears that when stem cell is
mixed with glucocorticosteroid, the stem cells become enhanced and are much
more effective in function. What is interesting here is that stem cells have the
possibility of helping to facilitate the healing process from diseases such as
osteoarthritis as well as various heart conditions. When the stem cells are
mixed with steroids the anti-inflammatory effect significantly increases and
thus may reduce the inflammatory process in the body caused by the disease.
However, the stem cells that are not mixed with steroids do not have such a
strong effect on inflammation. There are also current studies that are trying
to understand the impact of corticosteroids on cancer cells, but many effects
are still not well understood.

THE FUTURE OF STEROIDS

Another interesting point to contemplate is if steroids are becoming virtu-
ally undetectable and evolving quicker than the testing industry then the
whole sport industry may undergo through change in the near future. For
example, with the introduction of new chemicals and molecules in the steroid
formula the detection would seem a bit more complex and require more time,
effort, and resources to uncover. In addition, with the new therapies that are
currently changing the athletic industry, such as neurofeedback, gene therapy,
and various other systems that allow more rapid recovery from training and
injury, the new athlete may become increasingly stronger, faster, more agile,
and mentally enhanced. If such evolution of athletes continues then the base-
line for all athletes will evolve as well. In other words, the more the people in
sports will use these techniques, the better they become, and chances are they
will be more successful in their career and professional goal outcomes, which in
turn can result in more fame, popularity, and demand by the public.
Moreover, since people sponsor sports they would want to see more action
 The Future of Steroids Management 169

and goals accomplished by athletes, which in turn reinforces the usage of new
alternative therapies and demand for more sophisticated enhancements for
athletes.

ALTERNATIVES TO STEROIDS
The Glove
At the University of Stanford, researchers have made a fascinating discovery
regarding the human body and ability to recover at significantly faster rates
post-exercise with utilization of special apparatus known as the glove. This
apparatus was designed according to the theory that as the human organism
achieves high increased temperature, such as during exercise, the muscle per-
formance significantly decreases due to a variety of self-regulating reasons as
well as may cause fatigue in the body. As a result, the body is letting the person
know to stop exercising as a survival mechanism, and the person is almost
forced to stop exercising and goes into a more passive recovery phase. What
the scientists at Stanford also found was that the palm in the body generates
massive amounts of heat during physical activities. Moreover, these scientists
created an invention known as invented “the glove” which primarily acts to
cool down the body through the cooling mechanism of the glove by bringing
the blood to the palm surface through created vacuum and then cooling it.
As the blood is cooled, it eventually comes back to the heart and eventually
cools down the temperature of the body. This invention is brilliant by design
since it acts on body’s natural response to cool down temperatures without
any chemical or pharmaceutical intervention, hence minimizing potential side
effects. What is also impressive about this device is that it allows the athlete to
continue training pass the fatigue and continue exercising where previously he
or she need to stop. In other words, during the experiment with one athlete
who was doing pull ups, the person was able to do as many people in the first
round as in the following rounds as well. Because of this discovery the partici-
pant was cooled almost on every set. And a major discovery occurred in the fol-
lowing six weeks. The participant went from making 180 pull-ups to a more
than 600 as a total number of pull-ups—a significant change in numbers.
The researchers also tested the glove on multiple other sports such as running
and bench press. Also various college sport teams and NFL teams began to uti-
lize this innovation in their daily practices. In addition, what made this inven-
tion so important in comparison to just icing the part of the body is that it has
a fine balance of not too much cooling since that can also affect the body’s
cooling system. The cooling has to be precise and specific enough to let the
whole body cool down instead of just the hand which may occur in the ice
170 Steroids

water. According to these researchers’ temperature may be a major barrier to

performance due to limitations set by the body’s natural self-regulating sys-
tems. However, learning to work with this apparatus the body is able to con-
tinue performing without a need for recovery and avoid the fatigue at the
same time. This concept is very important since many of the users of anabolic
steroids would like obtain better performance and simultaneously faster recov-
ery rate and this invention can certainly help with both.

Neurofeedback
Another powerful futuristic technology that can significantly improve the
performance of an athlete that is completely chemical-free is known as neuro-
feedback. Neurofeedback utilizes digital technology along with sensors that
connected to the person’s head to measure the function of the brain regions.
The computer then compiles the data and measurements and determines the
functionality of each region. Neurofeedback allows the user to see how various
parts of the brain are functioning—some could be low functioning, others
could be in overdrive. Neurofeedback also utilizes games in the form of simu-
lators to retrain the brain so that it is efficient and functioning optimally.
Neurofeedback has also been used by professionals to help with health condi-
tions such as depression and ADHD to retrain the brain and reduce these con-
ditions. However, it appears that neurofeedback has a wider spectrum of use.
In fact, the tools can be used in conjunction with other technologies to give
athletes additional and more specific data about their performance. This digital
technology also gives them an extra digital coach that helps them improve areas
that they are weak in performance through understanding of what is happen-
ing in the brain as well as the body. What is fascinating about this technology
is that it provides a bridge between mind and body, especially in high-
pressured situations such as Olympic events or tournaments where some play-
er’s performance decreases with stress while others thrive under pressure.
During neurofeedback games are utilized as a medium for training the brain
how to respond more optimally. In addition, this data could be extremely use-
ful to someone who is a coach to an athlete and he is able to see what is going
on in athlete’s mind at various points and work on various corrections and
weaknesses accordingly. It’s like going to the medical office that has your chart
information, except this one will focus on the performance of the sport. In fact,
some of these programs are also used by Israeli Air Force to train the staff uti-
lizing flight simulators, which would transfer to actually flying real military
jets. However, these programs also keep track of participant’s movements
and strokes in sports allowing to record data in much more sophisticated
 The Future of Steroids Management 171

way. It can also work with existing commands by the coach and record partic-
ipant’s response and all recorded in the chart data. These types of digitized
training programs are becoming widely available especially in sports such as
tennis. This technology also works with others such as measuring data when
walking on treadmill, the data would show balance and efficiency of the
movement as well as ways to optimize the body so it can be more efficient in
movement and increased performance. Other things these types of programs
can do is also reteach perception of the movement of the ball and being able to
be more perceptive and sensitive of the positions of the ball and patterns of the
participant’s play in total rather than just individual moves. Also some
researchers may attempt to predict the player’s future patterns based on previ-
ously executed moves, which also can possibly give athletes an advantage with
studying their opponents in greater detail. All of these technologies are the
present and future of sports. In addition to steroids that work on physiological
levels of the body, this digitized technology gives them an extra edge by further
enhancing their ability to optimize their mind and body and further make
stronger connection between them.
Stem cells also began to gain popularity especially through sports such as
baseball and football. Athletes from various sports have traveled to different
parts of the world, including Europe, Japan, South Korea, and Russia to have
procedures related to stem cell treatment for ailments such as joint problems
and other sport injuries. In 2012, one of the players by the name of Bartolo
Colon in Major League Baseball has had a stem cell procedure done on his
shoulder and elbow due to problem with his ligaments. The stem cell pro-
cedure involved utilization of individual’s fat along with bone marrow to
extract the stem cells and then having it injected into the joint where the prob-
lem occurs. The purpose of the stem cells is to help facilitate the healing pro-
cess and restore the ligament’s function. The doctor that has performed these
types of procedures has also utilized human growth hormone (hGH) for these
types of procedures but stated that hGH was not used with this MLB player.
Dr. Purita stated that he did this procedure to multiple athletes from both
baseball and football. Bartolo, a famous baseball player, has a strong record
of multiple problems as a result of multiple injuries since 2005, and he was also
left unable to play few months in 2009 and then skipping 2010 altogether due
to injuries. Bartolo was in much pain and tremendous difficulty even throwing
a ball without feeling hurt. The process of stem injection lasted for no longer
than 45 minutes according to Purita. Bartolo began throwing fast speed
pitches again after some time once the procedure was done.
Another example of someone who appeared to benefit from stem cell
therapy was football player Peyton Manning. There are clinics throughout
172 Steroids

the world that conduct stem cell procedure for various body parts and injuries
such as tendons, ligaments, muscles, and bone by the use of heavy interven-
tions such as surgeries. In addition, procedures are less invasive as well as allow
significantly quicker recovery time. However, in the United States, these pro-
cedures are still under some restriction due to possible lack of scientific evi-
dence and are considered to be in experimental phases. Due to this lack,
positive reputation insurances are currently not covering anything that has to
do with stem cell procedures. On the other hand, the stem cell research and
application is more popular in other parts of the world and the people that
had these procedures done tend to pay significant money out of pocket as well
as travel to other parts of the world to have them done. Many athletes have
these procedures done due to injuries and wanting to try something that is
quicker and possibly more effective than physical therapy and less invasive
than surgery. Other athletes also had the procedure and some reported great
results where they went back to the games in shorter than if other medical
interventions were used with high functionality in the injured areas. Another
player of NFL had the stem cell procedure on his knees as well as had history
of two unsuccessful knee injuries, which would eventually affect his career in
football. However, three weeks after having the procedure was done, he
resumed his athletic training and played for one more season before retiring
from NFL. There were multiple other examples of such cases where stem cells
and other procedures were used as part of the intervention treatment that
showed great results for athletes and nonathletes alike. However, this technol-
ogy is still in the experimental stages and one need to be mindful that there are
different sides of the same coin.
However, there is also another side of these types of therapies. Many times
the celebrities and athletes themselves would like to try something new to fur-
ther enhance healing and recovery processes if they are going through some
type of ailment where they can utilize nonscientifically confirmed approaches.
However, some researchers found that utilizing steroids may not be as effective
in comparison to other interventions. There are also researchers that believe
that there is an overwhelming amount of hype regarding the stem cell research
in regards to what the cells are capable of and how realistic it is in terms of cure
for any ailments. In addition, when the media discusses the impact of stem
cells in various fields such as sports and what happens to sports athletes then
the perception of any information can be more persuasive and perceived as fac-
tual. What also tends to happen is that the information becomes so stretched
out that it is difficult to distinguish between accurate and reliable solid evi-
dence or media’s message regarding the current situation. Moreover, what
tends to happen frequently is that new approaches to treatment become
 The Future of Steroids Management 173

popular rather than actually be scientifically confirmed through rigorous

research and testing, more and more people spread the message regarding these
approaches, which may create a greater propaganda regarding its effectiveness.
What ends up happening frequently is that some research can indicate the
effectiveness of some type of therapy and in the same time have limitations,
however with the popularity of the approach more propaganda will be placed
on top of the approach making it unrealistic to further extent. For example,
if stem cells work for specific ailments does not it is safe to assume that they
work for all the ailments and with the popular media the message tends to go
in a nonscientific direction of the approach. Some researchers also believe that
the efficiency of stem cell research also shows practicality for limited amount of
approaches and does not scientifically confirm the practicality of others and
what tends to happen is that despite scientific validity these approaches are still
being pushed by media’s attention.
In addition, when individuals in these positions begin to speak for stem cell
research without scientific backup, there are people who truly suffer from these
conditions and are willing to try anything to make it work and as a result
receive false hopes by nonscientific propaganda. For example, upon taking a
closer look at the promotion of stem cell research by popular media, it shows
that majority of advertisement talks about the treatment using stem cells but
has less discussion on the actual evidence behind it. In fact, in situations where
the evidence is lacking, the treatment may still be promoted as if there is evi-
dence backing it. This type of advertisement may send illusive messages to
the public which then creates many myths about the approach of what it can
versus what it actually does. In addition, statistics have been taken in regard
to the number of people who are currently utilizing nonscientifically con-
firmed approaches and the numbers of people utilizing these approaches could
be thousands and a great portion are children. In addition, the profit margins
for these therapies can possibly be in millions.
In order to help solve this problem of propaganda approaches, the scientific
organizations may need to clarify and direct messages to clear up the myths
behind untrue claims. They also need to make the regular listeners more edu-
cated on the truth behind some of the messages sent by the people. Also, the
individual needs to educate themselves regarding the approach through
research that is based on scientific data analysis by understanding scientifically
based information from reliable sources such as National Institute of Health
and PubMed research. It is important for a regular consumer to distinguish
the difference between scientific and nonscientific claims so that the truth be
revealed to them. In addition, the media needs to step up and not promote
messages that are based on a nonscientifically confirmed sources or opinions
174 Steroids

and display them as if it is scientifically based. Everyone starting from the ath-
lete, to media to science community needs to take responsibility since the per-
son and his family is the one that would suffer the consequences.

STEROID USE AMONG TRANSGENDERED INDIVIDUALS

As the technology advances, it makes changes not only to the field of medi-
cine but also to society as a whole in many different spheres. For example,
Wellesley College for women is known academia located west of Boston,
Massachusetts. One of the students there a Junior by the name of Timothy
Boatwright, a transgendered male and picked this school in particular because
he felt more safe than in the co-ed type of environment. There were also other
trans-students such as himself in Wellesley College. Close to twenty-four stu-
dents who are matriculating and half of those who did not identify themselves
as women may have started using testosterone in order to create physical mod-
ifications in their physical appearance. When Timothy was a sophomore he
ran for a high position in student government. However, due to the way the
elections went, other candidates dropped out of the race which put Timothy
in having a great chance to be in the student government. However, as the
news began to travel around the school, Facebook was filled with messages to
abstain from voting which means Timothy would not get the vote he needed
to achieve the position. The message was clear, that out of all diversity in
school, selecting a Caucasian male in leadership does not define diversity as
well as does not emphasize or encourage women to practice leadership.
Moreover, by looking at the history of women, their rights were frequently
sabotaged despite having equal or higher education than males. In addition,
what is currently happening is that women are challenging the traditional view
of womanhood through their own identification such as lesbian, bisexual, or
transgendered. Transgendered students are making changes in schools and as
a result may be creating more neutrality between and within genders them-
selves. In addition, more individuals are identifying themselves by gender
identity they feel is right for them. More trans-students are obtain higher stu-
dent government positions throughout women colleges in the United States.
However, the viewpoint regarding how women view themselves societally is
changing as well. For example, a trans-man would most likely identify himself
as that status and may not identify himself as a woman despite being in all
women college. In fact, one of the students named Kaden Mohamed, a gradu-
ate of Wellesley College, a trans-man felt offended by comments offered by
one of his female peers named Laura. Kaden Mohamed also went through a
process of using testosterone for seven months. Laura discussed how if a man
 The Future of Steroids Management 175

is going to be a leader in all women college, that may in turn belittle the idea of
having women as leaders. However, these types of scenarios are examples
where society is at present time with self-identification.
Moreover, what it shows is that sexual identity and gender are more convo-
luted than just simply narrowing down the definition of male and female. For
example, trans-men or trans-women may have their own specific preferences
of which gender they are attracted to as well as how they identify themselves
and have their own personal view of identity and environment around them.
On the other hand, those students that were transgendered around him may
not even be able to identify as a male. Another student named Jesse, a trans-
man, has gone through testosterone treatment to become man and identified
himself as a male. In addition, Jesse also went through a top surgery.
However, upon his return to school, he was a completely different person,
his body anatomy was very masculine, and he experienced voice changes as
well as modifications in facial hair were evident. The notion of transgender
began to transform the identity of women. Even student organizations that
were previously labeled as sisterhood have changed their name to siblinghood
and became more welcoming to transgender groups.
However, Jesse was still treated differently than his peers, such as he needed
a female escort to get into friend’s dorm otherwise he could not get in. Also, he
would get stopped by parents and requested why he was there as well as stu-
dents around him who were not familiar with him would ask him questions
as if he was not a student there, especially in places such as bathrooms that
had a label of Wellesley only and non-Wellesley for those that were not stu-
dents in school. Jesse felt like an outsider despite the fact that it was women’s
college. Other factors also began to make a difference such as within the group
of transgender there are multiple views as well regarding how they are viewed
by the LGBT community in itself. On the other hand, another student
trans-male at Wellesley College reported that he began receiving positive
attention from those around him. Accordingly, other members of LGBT
began to perceive him as competition to finding a mate and he had more flex-
ibility in choosing a mate. Moreover, it appears that the views and experiences
of each person vary.

THE IMPACT OF TECHNOLOGY

As the technology evolves, so does the world. Fields such as medicine and
science may shape our everyday lives and perceptions of everything around.
Factors such as fire were utilized into ovens and then microwaves, which make
everything simpler and quicker. On the other hand, as technology and science
176 Steroids

develops the consequences of its use as well as changes that evolve because of
these innovations impact the society as well. For example, with the introduc-
tion of both anabolic and catabolic steroids, medical and sport fields began
to change. Each field had more positives and negatives added to the list.
With the invention of gene doping and stem cells that may eventually make
complete transformations in all fields including how humankind views itself.
With gene identification, alteration as well as utilization of other factors such
as steroids can possibly put science, medicine, and sports in the field of science
fiction. As one dwells into the future, innovation is not only guaranteed but it’s
also making its way in every day of our lives. As the new technology evolves,
they go through rigorous scientific testing and one day it would be available
to everyone as if it was always there. Discoveries such as penicillin not only
transformed the lives of those living at that time but also those of the future
generations to come. The invention also leads to other greater inventions as
well as possible technologies. There is a saying that giants stand on the should-
ers of other giants. Each person in the society that contributes to the society
makes the whole civilization a better place to be, and the changes he or she
makes today will affect the lives of ours and those around us tomorrow.
On the other hand, the challenge of change may bring about new challenges
and problems that we may face as a society, which is also the process of evolu-
tion. However, to continue to innovate the world means the continuance of
the growth process of all mankind globally into the future.
 Directory of Resources

ANABOLIC STEROID CONTROL ACT OF 1990

This act amends the Controlled Substances Act of 1970, which was
intended to regulate certain drugs (for manufacturing, possession, importa-
tion, distribution, and use). This act established criminal penalties for illicit
use of anabolic steroids as well as for coaches and others who might persuade
or induce athletes to take anabolic steroids. For the complete text, see https://
www.congress.gov/bill/101st-congress/house-bill/4658/text.
CENTER FOR DISEASE CONTROL AND PREVENTION (CDC)
CDC increases the health security of our nation. As the nation’s health pro-
tection agency, CDC saves lives and protects people from health threats. To
accomplish its mission, CDC conducts critical science and provides health
information to the national community.
Contact: U.S. Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30329
800-CDC-INFO (800-323-4936)
http://www.cdc.gov/

DESIGNER ANABOLIC STEROID CONTROL ACT

OF 2014 (H.R. 4771)
This legislation classifies steroids as illegal substances and increases criminal
penalties for sale and possession. For the complete text, see https://www
.congress.gov/bill/113th-congress/house-bill/4771/text.
178 Directory of Resources

DRUG ENFORCEMENT AGENCY (DEA)

The DEA is part of the U.S. Department of Justice. It is the major federal
agency responsible for domestic enforcement of U.S. drug policy.
Contact: U.S. Drug Enforcement Agency
800 K Street, NW, Suite 500
Washington, DC 20001
202-305-8500
http://www.dea.gov/
To report illegal drug sales/distribution, call: 877-792-2873

FEDERAL BUREAU OF INVESTIGATION (FBI)

This is the United States’ main crime-fighting and security agency, which
also serves as the primary federal law enforcement agency.
Contact: FBI Headquarters
935 Pennsylvania Avenue, NW
Washington, DC 20535-0001
202-324-3000

FOOD AND DRUG ADMINISTRATION (FDA)

A federal agency of the U.S. Department of Health and Human Services,
one of the U.S. federal executive departments, overseeing the certification of
safe food production and the sale of supplements and drugs, including food.
Contact: U.S. Food and Drug Administration
10903 New Hampshire Avenue
Silver Spring, MD 20993
888-INFO-FDA
888-463-6332

INTERNATIONAL OLYMPIC COMMITTEE (IOC)

This committee oversees the selection of sites for Olympic competitions. It
also controls competition regulations and rules, scoring committees, and safety
and security of athletes.
Chateau de Vidy
Case postale 356
 Directory of Resources 179

1001 Lausanne, Switzerland

+41-21-621-61-11
https://www.olympic.org/about-ioc-institution

MENTAL HEALTH AMERICA (MHA)

Founded in 1909, this is the nation’s leading community-based nonprofit
agency dedicated to addressing the needs of those living with mental illness
and to promoting the overall mental health of all Americans.
Contact: Mental Health America
500 Montgomery Street, Ste. 820
Alexandria, VA 22314
703-684-7722
http://www.mentalhealthamerica.net/

NATIONAL ACADEMY OF SCIENCES (USA)

The National Academy of Sciences (NAS) is a private, nonprofit organiza-
tion of the country’s leading researchers. It was established in 1863 by an act
of Congress, which was signed by President Abraham Lincoln, and its mis-
sion was to provide objective advice to the nation about technology and
science.
Contact: National Academy of Sciences Building
2101 Constitution Avenue, NW
Washington, DC 20001
202-334-2000

NATIONAL ASSOCIATION FOR ALCOHOLISM AND DRUG

ABUSE COUNSELORS (NAADAC)
National organization for addiction counselors providing educational
information on current drug trends, publications, and webinars to educate
consumers.
Contact: NAADAC, the Association for Addiction Professionals
44 Canal Center Plaza, Ste. 301
Alexandria, VA 22314
703-741-7686 or 800-548-0497
http://www.naadac.org/
180 Directory of Resources

NATIONAL CENTER FOR DRUG-FREE SPORT

Provides drug testing and education to major collegiate and professional
sports teams.
Contact: The National Center for Drug Free Sport, Inc.
2537 Madison Avenue
Kansas City, MO 64108
816-474-8655
http://www.drugfreesport.com/

NATIONAL COLLEGIATE ATHLETIC ASSOCIATION (NCAA)

Created to protect the health and safety of student athletes by ensuring that
no athletes utilize drugs to enhance performance.
Contact: The National Collegiate Athletic Association
700 W. Washington Street
P.O. Box 6222
Indianapolis, IN 46206
317-917-6222
http://www.ncaa.org/

NATIONAL INSTITUTE ON DRUG ABUSE (NIDA)

Part of the SAMHSA agency network, the focus of this agency is to advance
science on the causes and consequences of drug use and addiction and to apply
that knowledge to improve individual and public health.
Contact: National Institute on Drug Abuse
Office of Science Policy and Communications, Public Information, and
Liaison Branch
6001 Executive Boulevard
Room 5213, MSC 9561
Bethesda, MD 20892-9561
301-443-1124
https://www.drugabuse.gov/

NATIONAL INSTITUTE OF MENTAL HEALTH (NIMH)

The lead federal agency for research on mental health disorders.
Contact: National Institute of Mental Health
6001 Executive Boulevard
 Directory of Resources 181

Room 6200, MSC 9663

Bethesda, MD 20892-9663
866-615-6464
https://www.nimh.nih.gov/index.shtml

OFFICE OF NATIONAL DRUG CONTROL POLICY (ONDCP)

This agency works directly out of the Executive Office of the President.
It was created by the Drug Abuse Act of 1988. It advises the president on drug
control, activities, and funding across the federal government.
https://www.whitehouse.gov/ondcp

PARTNERSHIP FOR DRUG-FREE KIDS

Provides support and guidance to families that struggle with their son or
daughter’s substance abuse. It has a supportive website and educational materials.
Contact: Partnership for Drug-Free Kids
352 Park Avenue South, 9th Floor
New York, NY 10010
212-922-1560
http://www.drugfree.org/

RECOVERY CONNECTION
Specializes in treatment of addiction by providing quality care to those suf-
fering from drug and alcohol abuse.
Contact: Recovery Connection
1900 Corporate Square Blvd.
Jacksonville, FL 32216
866-811-3235
https://www.recoveryconnection.com/

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES

ADMINISTRATION (SAMHSA)
SAMHSA is part of the U.S. Department of Health and Human Services.
Its primary mission is to improve the availability and quality of substance
abuse prevention, treatment, and mental health services. SAMHSA encom-
passes the Center for Substance Abuse Prevention (CSAP), the Center for
182 Directory of Resources

Substance Abuse Treatment (CSAT), and the Center for Mental Health
Services, as well as its Office of Applied Studies. Collectively, it is the major
federal agency in the United States that supports substance abuse treatment
and prevention and mental health initiatives.
Contact: Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857
1-877-SAMHSA-7
1-877-726-4727

U.S. ANTI-DOPING AGENCY (USADA)

An independent body responsible for ensuring the integrity and commit-
ment of amateur sports associations.
Contact: U.S. Anti-Doping Agency
5555 Tech Center Drive, Ste. 200
Colorado Springs, CO 80919
719-785-2000 or 866-601-2632
http://www.usada.org/

WORLD ANTI-DOPING AGENCY (WADA)

Promotes, coordinates, and monitors at the international level the fight
against doping in sports in all its forms.
Contact: World Anti-Doping Agency
Stock Exchange Tower
800 Place Victoria, Ste. 1700
P.O. Box 120
Montreal, Que. H4Z 1B7
Canada
+1-514-904-9232
https://www.wada-ama.org/
 Glossary

AAS Anabolic-androgenic steroids are synthetically produced varieties of the

male sex hormone testosterone.
Abstinent Going without something voluntarily.
Addiction In pharmacology, the effect that one drug or substance contributes
to the action of another drug or substance.
Addictive The effect that one drug or substance contributes to the action of
another drug.
Adipose tissue Storage of energy in the form of fat.
Adjudicated Make a formal judgment or decision about a problem or
disputed matter.
Albumin A protein soluble in water found in the serum of blood as well as in
egg white and milk. In humans, albumin serves as the main protein for
protein-bound medications.
Amphetamines A central nervous system stimulant.
Anabolic Testosterone or a steroid resembling testosterone.
Anabolic Steroid Control Act of 1990 Amends the Controlled Substances
Act to clarify the definition of anabolic steroids and to provide for research
and education activities relating to steroids and steroid precursors.
Androgenic Causing masculinization.
Androstenedione A steroid hormone that has weak androgenic actions.
It mainly acts as a stepping stone in creating testosterone and estrogen within
the body.
184 Glossary

Anemia A reduction in the number of circulating red blood cells per cubic
millimeter, the amount of hemoglobin per 100 ml, or the volume of packed
red blood cells per 100 ml of blood.
Anorexia It is seen in depression, malaise, commencement of fevers and
illnesses, disorders of the alimentary tract, alcoholism, and drug addiction.
Loss of appetite.
Antibody Antibodies, all of which are immunoglobulins, may combine with
specific antigens to destroy or control them, providing protection against most
common infections.
Anti-inflammatory An agent that counteracts inflammation.
Asthma A respiratory condition characterized by constriction of the bronchi
resulting in difficulty in breathing.
Asymptomatic Without symptoms.
Autoimmune disease A disease in which the body recognizes its own tissues as
foreign and produces antibodies that attach those tissues.
Bronchodilator A drug that expands the bronchial tubes by relaxing bronchial
muscles.
Catabolic The process in which complex substances are converted into sim-
pler ones, usually with the release of energy.
Centers for Disease Control and Prevention (CDC) The CDC works to
protect America from health, safety, and security threats, both foreign and in
the United States. Whether diseases start at home or abroad, are chronic or
acute, curable or preventable, human error or deliberate attack, CDC fights
disease and supports communities and citizens to do the same.
Chronic Of long duration. Opposite of acute.
Chronic Obstructive Pulmonary Disease (COPD) A lung disease marked by
chronic obstruction to lung airflow that disrupts the normal breathing pattern.
Compounded A substance composed of two or more units or parts combined
in definite proportions by weight and having specific properties of its own.
Compounds are formed by all living organisms and are of two types, organic
and inorganic.
Contraindications Any symptom or circumstance indicating the inappropri-
ateness of an otherwise advisable treatment.
Controlled Substances Act (CSA) The Controlled Substances Act (CSA) is
the statute prescribing federal U.S. drug policy under which the manufacture,
importation, possession, use, and distribution of certain substances is
regulated.
 Glossary 185

Corticosteroid Any of several hormonal steroid substances secreted by the

cortex of the adrenal gland. They do not initiate cellular activity but permit
many biochemical reactions to proceed at optimal rates.
Cytokines A number of substances including interleukins, interferons, and
growth factors that are released by the cells of the immune system and are
involved in regulating the immune response.
Designer Anabolic Steroid Control Act of 2014 (H.R. 4771) The Designer
Anabolic Steroid Control Act of 2014 (H.R. 4771) is a bill that expands the
list of anabolic steroids regulated by the Drug Enforcement Administration
(DEA) to include about two dozen new substances and established new crimes
relating to false labeling of steroids. This type of steroid enhances muscles. The
bill established a penalty of up to $500,000 against those found to be falsely
labeling their anabolic steroid products.
Dietary Supplement Safety Act Introduced in Senate (02/04/2010) Dietary
Supplement Safety Act of 2010, it amends the Federal Food, Drug, and
Cosmetic Act (FFDCA) to deem a dietary supplement that is manufactured,
packaged, held, distributed, labeled, or licensed by a dietary supplement
facility that is not registered with the Secretary of Health and Human
Services (HHS) to be adulterated. Requires annual registration of dietary sup-
plement facilities.
Drug Enforcement Agency (DEA) The mission of the Drug Enforcement
Administration (DEA) is to enforce the controlled substances laws and regula-
tions of the United States and bring to the criminal and civil justice system of
the United States, or any other competent jurisdiction, those organizations
and principal members of organizations involved in the growing, manufacture,
or distribution of controlled substances appearing in or destined for illicit traf-
fic in the United States and to recommend and support non-enforcement pro-
grams aimed at reducing the availability of illicit controlled substances on the
domestic and international markets.
Endogenous Growing or originating from within an organism (body).
Endometrium The membrane linking the uterus, which is essential to proper
implantation of the embryo, mainly due to its changes in thickness.
Endothelium A single layer of cells that lines various organs, especially the
heart, blood vessels, and lymph vessels.
Ergogenic Having the ability to increase work, especially to increase the
potential for work output.
Estrogen The primary female sex hormone that is responsible for the develop-
ment and regulation of the female reproductive system.
186 Glossary

Euphoria An exaggerated feeling of well-being.

Exogenous Growing or originating from outside of an organism.
Fight or flight response An instinctive response to a stressful situation, which
prepares an organism to either resist or run assay; involves a set of physiological
changes such as increased heart rate, blood pressure, and blood glucose.
Gynecomastia The development of female breasts.
Heroin A narcotic derived from morphine.
Hormone A substance originating in an organ, gland, or body part that is con-
veyed through the blood to another body part, chemically stimulating that part
to increase or decrease functional activity or to increase or decrease secretion of
another hormone.
HPA axis (hypothalamus-pituitary-adrenocortical axis) A complex series of
signals and feedback interactions, among three endocrine glands, the hypo-
thalamus, the pituitary gland, and the adrenal gland.
Hydrocortisone Pharmaceutical name for cortisol, an adrenocortical hor-
mone produced by the adrenal cortex.
Immune system The lymphatic tissues, organs, and physiological processes that
identify antigen as abnormal or foreign and prevent it from harming the body.
Immunosuppression A decrease in the activity and protective effects of the
immune system.
Inflammation A localized condition characterized by pain, redness, swelling,
and itching that occurs in response to injury or infection and involves a cascade
of molecules that mediate this process.
Insulin A hormone secreted by the Islets of Langerhans of the pancreas.
Insulin is essential for the use of glucose by cells to produce energy. It lowers
the blood glucose level.
International Narcotics Control Board (INCB). The International Control
Board of Narcotics is an agency that regulates, monitors and enforces rules and
regulations regarding the use of narcotics and psychotropic drugs on a world-
wide basis.
IOC International Olympic Committee.
Leydig cells Cells located in the connective tissue of testicles. They produce
testosterone in the presence of luteinizing hormone (LH).
Libido Interest in sex.
Marijuana The dried flowering tops of Cannabis sativa, the hemp plant.
Metabolism The sum of all physical and chemical changes that take place
within an organism.
 Glossary 187

NIDA The National Institute on Drug Abuse. Its mission is to advance scien-
tific research about the causes and consequences of drug abuse and addiction.
Neurological The branch of medicine that deals with the nervous system and
its diseases.
Neurotoxin A substance that attacks nerve cells.
Obesity Abnormal amount of fat on the body. Usually applied when an indi-
vidual is 20 to 30 percent over average weight for his or her age, sex, and
height.
ONDCP Office of National Drug Control Policy.
Opioid Any synthetic narcotic not derived from opium.
Over the counter (OTC) Available without prescription.
PEDs Performance-enhancing drugs or performance-enhancing substances.
Phototherapy Exposure to sunlight or artificial light for therapeutic purposes.
Precursors Those substances that the body, itself, can convert into steroids.
Prescription Drug Monitoring Programs (PDMPs) Prescription Drug
Monitoring Programs (PDMPs) are state-run electronic databases used to
track the prescribing and dispensing of controlled prescription drugs to
patients. They are designed to monitor this information for suspected abuse
or diversion (i.e., channeling drugs into illegal use) and can give a prescriber
or pharmacist critical information regarding a patient’s controlled substance
prescription history. This information can help prescribers and pharmacists
identify patients at high risk who would benefit from early interventions.
Progesterone A steroid hormone that stimulates the uterus, preparing it for
pregnancy.
Psoriasis A common, chronic disease of the skin consisting of papules that
coalesce to form plaques with distinct borders.
Psychoactive Affecting the mental state, such as a drug that has that action.
Serotonin A chemical present in platelets, gastrointestinal mucosa, mast cells,
and carcinoid tumors. It is a potent vasoconstrictor (causing constriction of the
blood vessels).
Steroids An organic compound of a large group of substances chemically
related to sterols including vitamin D, bile acids, certain hormones, saponins,
and certain carcinogenic substances.
Subcutaneous Beneath the skin.
Substance Abuse and Mental Health Services Administration (SAMHSA)
The Substance Abuse and Mental Health Services Administration
188 Glossary

(SAMHSA) is the agency within the U.S. Department of Health and Human
Services that leads public health efforts to advance the behavioral health of the
nation. SAMHSA’s mission is to reduce the impact of substance abuse and
mental
illness on America’s communities.
Synthetic Artificially prepared. Made by synthesis.
Testosterone A steroid produced by the testicles. It accelerates growth in tis-
sues on which it acts and stimulates blood flow. It promotes the growth of sec-
ondary sexual characteristics and is essential for normal sexual behavior and the
occurrence of erections.
Tetrahydrogestrinone (THG) An anabolic steroid usually taken for the
enhancement of athletic performance.
Therapeutic Having medicinal or healing properties. A healing agent.
Transdermal A route of administration wherein active ingredients are deliv-
ered across the skin for systemic distribution.
United Nations Commission on Narcotic Drugs (CDN) The Commission
on Narcotic Drugs (CND) was established by the Economic and Social
Council (ECOSOC) resolution 9(I) in 1946 to assist the ECOSOC in super-
vising the application of the international drug control treaties.
Urinalysis An analysis of the urine.
U.S. Anti-Doping Agency (USADA) The U.S. Anti-Doping Agency
(USADA) is the national anti-doping organization (NADO) in the United
States for Olympic, Paralympic, Pan American, and Parapan American sport.
The organization is charged with managing the anti-doping program, includ-
ing in-competition and out-of-competition testing, results management pro-
cesses, drug reference resources, and athlete education for all U.S. Olympic
Committee (USOC) recognized sport national governing bodies, their ath-
letes, and events.
U.S. Sentencing Commission The U.S. Sentencing Commission is an inde-
pendent agency in the judicial branch of government. Its principal purposes
are (1) to establish sentencing policies and practices for the federal courts, (2)
to advise and assist Congress and the executive branch in the development of
effective and efficient crime policy, and (3) to collect, analyze, research, and
distribute a broad array of information on federal crime and sentencing issues.
U.S. Food and Drug Administration (FDA) The Food and Drug
Administration is a federal agency of the U.S. Department of Health and
Human Services, one of the U.S. federal executive departments. FDA is respon-
sible for protecting the public health by assuring the safety, efficacy, and security
 Glossary 189

of human and veterinary drugs, biological products, medical devices, our nation’s
food supply, cosmetics, and products that emit radiation.
World Anti-Doping Agency (WADA) The World Anti-Doping Agency was
founded with the aim of bringing consistency to anti-doping policies and
regulations within sport organizations and governments around the world.
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 Index
ACTH-dependent Cushing
syndrome, 89
ACTH-independent Cushing
syndrome, 89
ACTH-secreting tumors, 89
Addison, Thomas, 49
Addisonian crisis, 90
Addison’s disease, 90
Administration: of glucocorticoids, 30;
of steroids, 21, 104–20
Adrenal cortex, 14
Adrenal deficiency, primary, 90
Adrenal diseases, 89–90; Addison’s
disease, 90; Cushing syndrome, 89;
hyperaldosteronism, 89–90
Adrenal glands, 14; experimentations
on, 49–50; overview of, 65
Adrenal insufficiency: chronic, 98–99;
secondary, 90; tertiary, 90
Adrenal medulla, 14
Adrenocorticotropic hormone
(ACTH), 68–69
Advair, 105
Airway hyperresponsiveness, 93
Albumin, 16, 71
Allergic rhinitis, 94
Allergies, seasonal, 94
Alternatives to steroids, 169–74; glove,
169–70; neurofeedback, 170–74
Alzado, Lyle, 60
American Birth Control League, 55
Amgen, 61, 122
Amphetamines, 56–57
Anabolic-androgenic steroids (AAS),
108; abuse of, 108–11; aggressive
behavior and, 112–13; cycling
method, 109; dosage for users, 109;
females, use by, 108–9; method of
administration of, 109; punishment
for using, 111; pyramiding method,
110; side effects from, 108–9;
stacking method, 109; and violent
behavior, 112–13; withdrawal
symptoms, 109
Anabolic-androgenic synthetic steroids,
37–43; anabolic steroid supplements,
39–40; dietary supplements, 40–41;
herbal supplements, 42–43; injectable
preparations, 38; oral preparations,
38; other delivery systems, 39;
testosterone boosters, 42; topical
delivery systems, 38
Anabolic Steroid Control Act
of 1990, 127
208 Index

Anabolic steroids, 1–6, 101, 108, 111, Bronchodilators, 93

119–20, 128; androgens, 18; Brown-Séquard, Charles-Edouard,
estrogens, 18–19; gestagens, 18–19; 49–50
placental hormones, 19–20 B type I (SR-BI), 67
Anabolic steroid supplements, 39–40 Budesonide, 96–97
Anabolism, 15 Budesonide (Rhinocort Allergy), 94
Androderm, 38 “Buffalo hump,” 89
AndroGel, 38 Butenandt, Adolf, 52
Androgens, 18
Androstanes, 18 Carbohydrate metabolism: and natural
Androstenedione, 19 glucocorticoids, 82
Androstenetrione, 40 Cardioactive steroids (CASs), 74–75
Androstenone, 52 Cardiovascular system: and natural
Angiotensin-converting enzyme glucocorticoids, 80–81
(ACE), 69 Case studies: anabolic steroids, 1–6;
Angiotensin I, 69 psoriasis and topical steroid cream,
Angiotensin II, 69 7–12; steriods use in cancer
Anti-Drug Abuse Act of 1988, 133 treatment, 62–64
Armstrong, Lance, 130, 143 Catabolic steroids, 15–17, 101, 119;
Arthritis: psoriatic, 8; rheumatoid, 92, glucocorticoids, 15–17;
102–3 mineralocorticoids, 17; and steroids
Attention deficit Hyperactivity Disorder management, 167–68. See also
(ADHD), 153 Medical steroids
Autoimmune disorders, 91–92 Catabolism, 15
Catecholamines, 65
Barbiturates, 128 CBS News, 41
Bath salts, 159 Center for Disease Control (CDC)
Bay Area Laboratory Co-Operative Survey, 134
(BALCO), 125, 131 Centers for Disease Control and
Baycadron, 25 Prevention (CDC), 143, 147, 150
Benzoic acid, 44 Chenodeoxycholic acid (CDCA), 73
Berlin Wall, 117 Cholecalciferol, 74
Berthold, Arnold Adolph, 48–49 Cholestanes, 43–44
Betamethasone, 25–26, 103 Cholesterol, 66–67; non-selective
Bile acids, 73 pathway, 67; transportation
Birth control remedies, 54 to cells, 67
Bisexuality, 51 Cholesterol esters, 67
“Blood doping,” 122 Cholesterol structure, 14
Boatwright, Timothy, 174 Cholic acid, 73
Bonds, Barry, 131 Chronic adrenal insufficiency, 98–99
Bordo, Susan, 110 Chronic obstructive pulmonary disease
Brain, and natural glucocorticoids, (COPD), 93
78–80 Chylomicrons, 66–67
Brave New World (Huxley), 55 Ciba Pharmaceuticals, 53
 Index 209

Clobetasol, 107 Designer steroids, 37, 125

Clobetasol propionate spray, 95 Dexamethasone, 25, 98, 103
Clomid, 40 Dianabol, 53
Cocaine, 115 Dietary Supplement Safety Act, 125
Colon, Bartolo, 171 Digoxin, 74
Combination oral contraceptives, 99 Dihydrotestosterone (DHT), 71
Compliance Act of 1971, 124 Dionne, 147–48
Comstock Law, 55 Diseases: adrenal, 89–90;
Contraception, 34–37, 99–100; gastrointestinal, 96–97; ocular, 96
contraceptive preparations, 35–37; Disorders of the skin, 94–95
history of, 54–55; oral contraceptives, Distribution, of steroids, 124–26
35; role of Gregory Pincus, 56 Drostanolone, 112
Controlled Substances Act, Drug Enforcement Agency (DEA), 39,
124, 126, 134 124–25, 131
Corticosteroids, 93 Dry powder inhalers (DPIs), 33
Corticosteroid therapy, 96 Durabolin, 125
Corticosterone, 17
Corticotropin-releasing hormone, 89 Ecchymoses, 89
Cortisol, 16 Ecstasy, 159. See also Molly
Cortisol-binding globulin, 69 11β-hydroxysteroid dehydrogenase
Cortisone, 16, 22–23; discovery of, 53 type 2 (11β-HSD2), 70
Counterfeit topical steroids, 107 Emotional eating, 79
Creams, 27 Endocrine system, and natural
Creatine ethyl ester (CEE), 42 glucocorticoids, 83–84
Creuzfeldt Jacob Disease (CJD), 58, Endosomes, 67
122–23 Eoetin alfa, 61
Crocodile, 160 Epogen (EPO), 61, 122–23
Cushing, Harvey, 89 Equipoise, 125
Cushing disease, 89 Erythropoietin (EPO), 165
Cushing syndrome, 89; ACTH- Estradiol, 18, 20
dependent, 89; ACTH- Estradiol valerate, 35
independent, 89 Estranes, 18
Cycling method, 109 Estrogen receptor α (EPα), 72
Estrogen receptor β (EPβ), 72
Danazol, 39 Estrogens, 18–19; and gonadal
Dbol, 53 steroids, 87
Decadron, 103 Eunuchs, 47
Deca-Durabolin, 125 European Union, 132
Dehydroepiandrosterone (DHEA), 19, Europol, 132
41, 99, 126
Deoxycorticosterone, 17 FDA Office of Criminal
Dermatitis herpetiformis, 94 Investigations, 131
Designer Anabolic Steroid Control Act Federal Bureau of Investigation
of 2014, 134 (FBI), 131
210 Index

Fentanyl, 159 Half vasectomy, 51

Flavonoids, 43 Hematologic disorders, 97
Fludrocortisones, 24 Hematologic effects and natural
Fluocinolone (Retisert), 96 glucocorticoids, 85
Fluticasone, 105 Hench, Philip, 53
Fluticasone propionate (Flonase Herbal supplements, 42–43
Allergy), 94 Heroin, 109
Foams, 27 High-density lipoproteins (HDLs), 66
Follicle-stimulating hormone (FSH), High Intensity Drug Trafficking Areas
70–72 (HIDTA) program, 133
Food and Drug Administration (FDA), Hoagland, Hudson, 55
42, 53, 113–14, 122–23, 161 Hoffman, Philip Seymour, 159
Fortesta, 38 Hooton, Don, 148–50
“4-hydroxy-testosterone,” 124, 125 Hooton, Taylor, 145–48
Foxglove, 74 Hormonal contraceptives, 99
Freud, Sigmund, 51 Hormonal steroids: chemical structures
of, 68; glucocorticoids, 68–69;
Gastrointestinal diseases, 96–97 gonadal steroids, 70–73;
Gastrointestinal system and natural mineralocorticoids, 69–70;
glucocorticoids, 84–85 synthesis of, 67–68
Gels, 27 Hormones: defined, 13; and
Genentech, 58, 122 steroids, 13
Genetic doping: experimentation of, Human growth hormones (hGH), 122
164; and its possibilities, 164–66 Humira, 103
Gestagens, 18–19 Huxley, Aldous, 55
Ghrelin, 79 Hydrocortisone, 22–23, 122
Giambi, Jason, 131 Hydroquinone, 107
Glove, 169–70 Hydroxymethylbutyrate (HMB),
Glucocorticoid nasal sprays, 94 40–41
Glucocorticoid receptor (GR), 69 Hyperaldosteronism, 89–90;
Glucocorticoids, 14, 15–17, 68–69, 90, secondary, 90
91. See also Natural glucocorticoids Hypogonadism, 104
physiological effects
Glycoprotein hormone, 122 Immigration and Customs Enforcement
Glycosides, 43 (ICE), 131
Gonadal steroids, 70–73; and estrogens, Immune system and natural
87; and progestogens, 87; and glucocorticoids, 80–82
testosterone, 87 Inflammation: described, 103; and
Gonadotropin-releasing hormone glucocorticoids, 16–17
(GnRH), 70–71 Inflammatory bowel disease (IBD), 96
Great Depression, 55 Inhaled corticosteroids: dry powder
Growth hormone disorder (GHD), 59 inhalers (DPIs), 33; metered dose
Growth hormones (GHs), 57–60 inhalers (MDIs), 30–33; nebulizers,
Gynecomastia, 115 33; potencies of, 31–32
 Index 211

Intermediate-density lipoproteins McCormick, Katherine, 55–56

(IDLs), 66–67 Medical marijuana, 134–35
Internal Revenue Service (IRS), 131 Medical steroids: and the future of
International Narcotics Control Board medicine, 161–64. See also Catabolic
(INCB), 133 steroids
International Olympic Committee Medical uses of steroids, 101–4
(IOC), 57, 118, 123, 129, 151 Medicine, medical steroids and future
Internet and steroids, 158 of, 161–64
Messenger RNA (mRNA), 69
Jensen, Knut, 56 Mestranol, 35
Jones, Marion, 131 Metabolism, 15
Justino, Cris “Cyborg,” 113 Metered dose inhalers (MDIs), 30–33
Methandrostenolone, 53
Kendall, Edward, 53 “The Method of Brown-Séquard,” 50
Keto group, 20 Methylprednisolone, 24–25
Koppenhaver, Jon, 112. See also Methylprednisolone acetate, 24
“War Machine” Methyltestosterone, 38
Krieger, Andreas, 118 Min-Cheuh Chang, 56
Krieger, Heidi, 118 Mineralocorticoids, 17, 69–70, 90;
physiological effects, 86–87
Lashmanova, Elena, 152 Mixed Martial Arts (MMA), 112–13
Lee, Se-Jin, 163 Mohamed, Kaden, 174
Leptin, 20 Molly, 159. See also Ecstasy
Lipid metabolism, and natural Motivation, 144–47
glucocorticoids, 85 Musculoskeletal system: and natural
Lipoproteins, 66 glucocorticoids, 82–83
Lotions, 27
Low-density lipoproteins (LDLs), National Basketball Association
66–67 (NBA), 130
Luteal phase, 73 National Drug Control Strategy, 133
Lynn, Loretta, 56 National Drug Intelligence Center
Lysergic acid diethylamide (LSD), 128 (NDIC), 131
National Institute of Health, 173
Mack, Christy, 112 National Pituitary Agency (NPA), 58
Major League Baseball, 106, 149–50 Natural glucocorticoids physiological
The Male Body: A New Look at Men in effects, 78–86; brain, 78–80;
Public and in Private (Bordo), 110 carbohydrate and protein
Male characteristics, 47–48 metabolism, 82; cardiovascular
Male hypogonadism, 52 system, 80–81; endocrine system,
Male sexuality, 49–50; and 83–84; gastrointestinal system,
testosterone, 50 84–85; hematologic effects, 85;
Manning, Peyton, 171 immune system, 80–82; lipid
Mass Xtreme, 114 metabolism, 85; musculoskeletal
McCain, John, 125 system, 82–83; permissive action, 78
212 Index

Natural steroid groups: anabolic “The Pill,” 56

steroids, 18–20; catabolic steroids, Pincus, Gregory, 55–56
15–17 Pitts, Joseph, 134
Natural steroids, 90 Placental hormones, 19–20
Natural steroid synthesis: and adrenal Planned Parenthood, 55
glands, 14; cholesterol structure, 14; Pneumocystis jiroveci, 97
and physiological functions, 14–15 Pneumocystis jiroveci pneumonia
Nebulizers, 33 (PCP), 97–98
Neurofeedback, 170–74 Polycystic ovary syndrome (PCOS), 57
New York Times, 41, 106–7 Popular Mechanics, 39
New York Yankees, 111 Prednisolone, 23–24, 54
Non-hormonal steroids, 43–45; bile Prednisone, 23–24, 54, 97–98, 103
acids, 73; cardioactive steroids Pregnanes, 18
(CASs), 74–75; cholanes (cholic Prelone, 103
acids), 44; cholestanes, 43–44; Prescription-based topical steroids, 107
vitamin D, 73–74 Prescription Drug Monitoring
Non-selective pathway, 67 Programs (PDMP), 124
Norbolethone, 125 Primary adrenal deficiency, 90
Nutropin, 122–23 Primobolan, 39
Production, of steroids, 122–24
Ocular diseases, 96 Progesterone, 18, 19–20, 72–73
Office of National Drug Control Policy Progesterone receptor A (PRA), 72
(ONDCP), 132, 133 Progesterone receptor B (PRB), 72
Ointments, 26 Progestogens, and gonadal steroids, 87
“1-testosterone,” 124, 125 Prolactin, 20
Operation Cyber Juice, 132 Protein metabolism, and natural
Operation Raw Deal, 131 glucocorticoids, 82
Ophthalmic corticosteroids, 33–34 Protropin, 58
Oral corticosteroids, 93–94 Psoriasis, 94; and topical steroid
Oral-Turinabol (O-T), 117 cream, 7–12
Organotherapy, 50 PubMed, 173
Organ transplantation, 95 “Pulse therapy,” 92
Oxandrolone, 39, 118 Pyramiding method, 110
OxyContin, 115
Quercitrin, 43
Paraneoplastic pemphigus, 94
Parathyroid hormone (PTH), 74 Regulation, of steroids, 126–34
Pemphigus vulgaris, 94 Renin-angiotensin-aldosterone system
Performance enhancement drugs (RAAS), 69
(PEDs), 121, 129 Replacement therapy, 34
Permissive action, and Respiratory disorders, 92–94
glucocorticoids, 78 Rheumatoid arthritis, 92
Physiological functions, and natural Risks of steroids, 104–20
steroid synthesis, 14–15 Rock, John, 56
 Index 213

Rodriguez, Alex, 39–40, 111, “Steinach operation,” 51

116, 143 “Steinach vasoligature,” 51
Romanowski, Bill, 131 Stem cells, 168
Ronicol, 56 Steroid abuse, beginning of, 140–44
Ruzicka, Leopold, 52–53 Steroid acute regulatory (StAR)
protein, 71
Salk Institute for Biological Steroid hormones, 13
Studies, 164 Steroids: administration and risks,
Salmeterol, 105 104–20; allergic rhinitis and seasonal
Sanger, Margaret, 54–55 allergies, 94; alternatives to, 169–74;
Saponins, 44 applications in clinical practice,
Schedule I drugs, 127, 128 90–100; autoimmune disorders,
Schedule II drugs, 128 91–92; chronic adrenal insufficiency,
Schedule III drugs, 127, 128 98–99; contraception, 99–100;
Schedule IV drugs, 128 defined, 13; disorders of the skin,
Schedule V drugs, 128 94–95; distribution of, 124–26; future
Schwarzenegger, Arnold, 163 of, 168–69; gastrointestinal diseases,
Searle, 56 96–97; hematologic disorders, 97; and
Seasonal allergies, 94 hormones, 13; Internet and, 158;
Secondary adrenal insufficiency, 90 legalization and decriminalization,
Secondary hyperaldosteronism, 90 134–35; medical uses and side effects,
Secosteroids, 44 101–4; non-hormonal, 43–45; ocular
Septic shock, 97 diseases, 96; organ transplantation, 95;
Sex hormone-binding globulin pneumocystis jiroveci pneumonia
(SHBG), 71 (PCP), 97–98; production of, 122–24;
Sex steroids. See Androgens regulation of, 126–34; respiratory
Side effects of steroids, 101–4 disorders, 92–94; septic shock, 97;
Skin, disorders of, 94–95 summary of clinical uses of, 91;
Slow-twitch fibers, 83 therapeutic effects of, 90–100;
Social impact of steroid use: decreasing utilization of stem cells in
steroid use, 147–54; motivation, conjunction with, 168
144–47; prevention, 139; steroid Steroids management: alternatives to
abuse beginning of, 140–44 steroids, 169–74; future of, 157–76;
Solutions, 27 future of medicine, 161–64; future of
Somatotropin, 57 steroids, 168–69; genetic doping and
Sosa, Sammy, 106 possibilities, 164–66; impact of
Spiritual beliefs, 48 technology, 175–76; medical steroids,
Spiriva, 105 161–64; steroid use among
Sports Illustrated, 39 transgendered individuals, 174–75;
Stacking method, 109 technology and steroids, 158;
Stanozolol, 111 utilization of catabolic steroids,
Starling, Edward, 52 167–68; utilization of stem
Star Trek, 161 cells in conjunction with
Steinach, Eugen, 50–51 steroids, 168
214 Index
Steroid use: among transgendered
individuals, 174–75; decreasing,
147–54
Sterols, 44
Stinging nettle (urtica dioica), 42
Stress ulcer, 84
Striae, 89
Strikeforce, 113
Substance Abuse and Mental Health
Services Administration, 134
Sweeney, Lee, 164–65
Syntex, 56
Synthetic estrogens, 35
Synthetic hormones, 99
Synthetic steroids: anabolic-androgenic,
37–43; contraception, 34–37;
defined, 13; inhaled corticosteroids,
30–33; ophthalmic corticosteroids,
33–34; replacement therapy, 34;
steroid bases, 21–26; systemic
corticosteroids, 21–26; therapeutic
purposes, 20; topical corticosteroids,
26–30
Systemic corticosteroids, 21–26;
betamethasone, 25–26; cortisone,
22–23; dexamethasone, 25;
fludrocortisones, 24; hydrocortisone,
22–23; methylprednisolone, 24–25;
prednisolone, 23–24; prednisone,
23–24; triamcinolone, 25
Systemic lupus erythematosus, 92
Systemic steroids, 95
Technology, and steroids management,
175–76
Tertiary adrenal insufficiency, 90
Testim, 38
Testosterone, 104; and gonadal
steroids, 87; and male
sexuality, 50; primary activity
of, 18; replacement, 37;
synthesization in females, 19
Testosterone boosters, 42
Testosterone cypionate, 38
Testosterone undecanoate, 38
Tetrahydrogestrinone (THG), 126
Therapeutic use exemptions (TUE), 130
Thyroid-stimulating hormone
(TSH), 83–84
Thyrotropin-releasing hormone
(TRH), 83
Titus, Craig, 110
Topical corticosteroids, 26–30, 95;
creams, 27; foams, 27; gels, 27;
lotions, 27; ointments, 26; solutions,
27; wet dressings, 27–28
Tour de France, 130, 143
Transgendered individuals: steroid use
among, 174–75
Tren-Xtreme, 114
Triamcinolone, 25, 94
Triamcinolone acetonide, 25
Tribulus terrestris, 43
Tryptophan, 44
TT-40-Xtreme, 114
2,6,17-androstenetrione, 126
Ultimate Fighting Championship
(UFC), 112–13
UN Commission on Narcotic Drugs
(CND), 133
United States Anti-Doping Agency
(USADA), 129–30
University of Stanford, 169
U.S. Anti-Doping Agency, 165
U.S. Congress, 124
U.S. Department of Agriculture, 123
U.S. Department of Justice, 134
U.S. Olympic Committee, 129
U.S. Postal Inspection Service, 131
Vasculitis, 92
Very-low-density lipoproteins (VLDLs),
66–67
 Index 215

Vitacost, 42 World Anti-Doping Agency (WADA),

Vitamin D, 73–74 39, 129–30, 149, 165
Voronoff, Serge, 51
Yeats, William Butler, 51
Wall, Donnie Keith, 128
“War Machine,” 112. See also Ziegler, John, 53
Koppenhaver, Jon ZMA, 42
Wellesley College, 174–75 Zona fasciculate, 65
Wet dressings, 27–28 Zona glomerulosa, 65
Winstrol, 125 Zona reticularis, 65
About the Authors and Contributor

JOAN STANDORA, PhD, LADC, CASAC, CADC, is an associate professor at

Kingsborough Community College in Brooklyn, New York. She received her
PhD in psychology with a specialization in addiction from Capella University.
She holds a license in substance abuse counseling from Connecticut and counsel-
ing credentials from both New York and Pennsylvania. Dr. Standora was honored
as an Advocate for Action in 2014 at the White House Office of National Drug
Control Policy for her work in the addiction treatment and education fields.
She has directed several treatment programs, primarily focused on women and
children, as well as working in criminal justice problem solving courts.
Currently, Dr. Standora is the program director of the addiction counseling pro-
gram at the college and maintains a small private practice in Pennsylvania.

ALEX BOGOMOLNIK, LMSW, CASAC, is an adjunct professor at

Kingsborough Community College in Brooklyn, New York. He received his
Master’s degree in social work from New York University as well as his under-
graduate degree in psychology from Baruch College. Mr. Bogomolnik
also holds a New York State credential in substance abuse counseling. He is
currently working as a chemical dependency counselor in Staten Island
University Hospital and a social worker in New York Guardianship Services,
serving primarily the elderly population. He has also worked with adolescents,
adults, and the elderly population in addiction treatment centers, outpatient
clinics, nursing homes, and various other settings.
218 About the Authors

MALGORZATA SLUGOCKI is an assistant professor of Pharmacy Practice

at Fairleigh Dickinson University School of Pharmacy in Florham Park, NJ.
She received her Doctor of Pharmacy degree from Long Island University
College of Pharmacy. Malgorzata Slugocki also holds national certificates in
Medication Therapy Management, Diabetes Care, and Immunization
Delivery. She currently teaches courses in endocrine disorders and infectious
diseases, as well as provides certificate training to students and pharmacists.
Prior to joining FDU, Dr. Slugocki enjoyed a career as a home infusion phar-
macist, managing various types of intravenous home therapies, including anti-
biotics, steroids, chemotherapy, immune-globulins, total parenteral nutrition,
and pain management.

TAE EUN PARK, PhD, is an assistant professor of Pharmacy Practice at

Touro College of Pharmacy in New York. Her practice site is at the State
University of New York (SUNY) Downstate Medical Center in Brooklyn,
New York, where she serves as the post-graduate year-two (PGY2) Infectious
Diseases Pharmacy Residency Program Director. Dr. Park holds a doctorate in
pharmacy from Ernest Mario School of Pharmacy, Rutgers, the State
University of New Jersey in Piscataway. She completed her PGY1 Pharmacy
Practice Residency training from the Hospital of Saint Raphael (currently known
as Yale-New Haven Hospital–Saint Raphael) in New Haven, Connecticut, and
PGY2 Infectious Diseases Pharmacy Residency training from the SUNY
Downstate Medical Center in Brooklyn, New York. Before joining Touro
College of Pharmacy, she was a faculty member at Fairleigh Dickinson
University School of Pharmacy in Florham Park, New Jersey. She is a board cer-
tified pharmacotherapy specialist. Her published peer-reviewed articles include
“Use of Aspirin and Statins for the Primary Prevention of Myocardial
Infarction and Stroke in Patients with Human Immunodeficiency Virus
Infection” in International Journal of STD & AIDS; “Review of Integrase Strand
Transfer Inhibitors for the Treatment of Human Immunodeficiency Virus
Infection” in Expert Review of Anti-Infective Therapy; “Ceftazidime-Avibactam:
A Novel Cephalosporin/B-Lactamase Inhibitor Combination for the
Treatment of Resistant Gram-Negative Organisms” in Clinical Therapeutics;
and “Use of Raltegravir in HIV-Infected Pregnant Women” in New Jersey
Journal of Pharmacy.