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How is anabolic steroid use different from testosterone replacement therapy?

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    Question How is anabolic steroid use different from testosterone replacement therapy?


    One main reason testosterone replacement therapy (aka testosterone treatment) is surrounded by controversy is that testosterone can be abused, both in athletic populations and the general public.[1] Scientific evidence is undisputed that testosterone y potently enhances physical performance and increases muscle growth.[1-3]

    The ethical issue of fair play in sports, coupled with the well-known adverse health effects of supra-physiological doses of anabolic steroids [4-14], has given medically legit testosterone replacement therapy (aka TRT, testosterone therapy or testosterone treatment) a bad reputation and is depriving many suffering men with testosterone deficiency from receiving medically needed testosterone treatment.[15]

    In this article I will point out the salient differences between use testosterone replacement therapy – a.k.a. testosterone therapy or testosterone treatment - and abuse of anabolic steroids, and explain why testosterone treatment - which per definition is medically provided and supervised - has no parallel with abuse of anabolic steroids.

    What are anabolic steroids?
    In order to understand the differences between testosterone treatment and anabolic steroid use, let’s first define what are anabolic steroids?

    Anabolic-androgenic steroids (AAS), popularly known as “anabolic steroids”, “anabolics” or “steroids”, include synthetic derivatives of testosterone, which were originally developed in the late 1930s.[16-21] Testosterone in its natural unmodified form is also classified as an anabolic steroid, and listed among its synthetic derivatives as a banned substance by the World Anti-Doping Agency (WADA).[22] Natural testosterone and anabolic steroids are legally classified as Schedule III controlled substances, and thus require a doctor’s prescription when used for medical purposes.

    Are they any medical indications for use of anabolic steroids?
    It may come as a surprise to most people that there are actually several medical indications for the use anabolic steroids [23, 24]; including sarcopenia and frailty [25-27], rehabilitation after hip fracture [28, 29] and after knee arthroplasty [30-32], treatment of osteoporosis and prevention of fractures [29, 33-45], wound healing [46, 47], leukemia [48, 49], treatment of muscle wasting [50, 51] and anemia [52] in dialysis patients, as well as treatment of wasting seen in patients with chronic obstructive pulmonary disease [53] and HIV.[54] Note that these benefits are seen in clinical populations of both men and women.

    The fact that testosterone is classified as an anabolic steroid stirs up the already heated debates about testosterone therapy. However, testosterone deficiency is a syndrome that merits medical treatment, as lack of treatment results in well documented metabolic deterioration and illness.[55]

    New FDA warning on abuse and dependence of testosterone
    The war on testosterone continues. On October 25th 2016 the FDA issued a class-wide labeling change for all prescription testosterone products, adding a warning about the abuse potential of testosterone products. This created media headlines touting that testosterone therapy is bad because it carries addiction risk.

    As I explained in a previous article “Is Testosterone Replacement Therapy a Lifelong Treatment?”, testosterone therapy is in most cases a lifelong treatment. Not because hypogondal men who start testosterone therapy become “addicted” to it, but because it relieves symptoms caused by testosterone deficiency and thus improves wellbeing (as well as health status).

    Salient differences between anabolic steroid abuse and testosterone therapy
    Below I list a couple of important differences between testosterone therapy and abuse of anabolic steroids, to highlight why they should not be confused.

    Testosterone therapy that is prescribed and monitored by a doctor has well-established safety (see my other numerous articles on the topic), abusers of anabolic steroids use many-fold higher dosages than the recommended clinical doses.[12] Doses up to 30 times greater than physiologic replacement doses have been reported.[56]

    This results in supra-physiological blood levels. In the case of testosterone, typical blood levels are in the range of 3000 – 5000 ng/dL. Compare this to the high end of the healthy physiological range, which is approx. 1300 ng/dL (depending on what laboratory assay that is used, this value may vary +/- 200).

    Continuous vs. Cycling
    Testosterone replacement therapy is in most cases a lifelong treatment aimed to replace dwindling testosterone levels associated with aging and aging-related morbidities. In contrast, users of anabolic steroids cycle their use of preparations. Use of anabolic steroids often occurs in repeated cycles of around 12 weeks, followed by periods of non-use (breaks).[56-58]

    However, it is becoming more and more common for anabolic steroid users to use anabolic steroids continuously - known as “cruising” - and on top of that add periodic cycles of other anabolic agents and/or increasing dosages – known as “blasting”.

    Risks vs. Benefits
    The side effects of anabolic steroid use in high doses are well established in the medical research.[7, 8, 11, 14, 59-61] It is not hard to imagine the long-term negative health effects of cruising and blasting…

    Stacking: multi-drug combinations
    Users of anabolic steroids frequently ‘‘stack’’ – i.e. simultaneously abuse – multiple synthetic derivatives of testosterone, a practice called polypharmacy.[57, 64-67] In addition to synthetic derivatives of testosterone, growth hormone and insulin are also commonly used.[66, 68] While polypharmacy may have synergistic effects on muscle growth and physical performance, it also results is worse and more dangerous side effects.[59, 69]

    Personal characteristics of users
    Abuse of anabolic steroids is strongly associated illicit drug use and substance dependence [65, 67, 70] and aggressive alcohol use.[71] Statements that that testosterone therapy – which per definition is medically provided and supervised - is bad because it carries addiction risk, is absurd.

    Bottom Line
    As I stated in a previous article “Testosterone Replacement Therapy - why is it so controversial?", just because something can be abused does not mean it has no medically legitimate use. Anything can be abused, even food! And if somebody has the urge to abuse something, that person will do so regardless of legal classification of the object of abuse.

    When considering the tremendous health benefits of testosterone therapy in hypogonadal men, the controversial discussions about testosterone therapy are moot if put in perspective. For example, one may question how come tobacco and alcohol – two highly addictive and widely available substances of abuse with no medical indications whatsoever - are legal, despite the well documented harms?

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