How is testosterone therapy different from anabolic steroid abuse?
One reason testosterone therapy is surrounded by controversy is that testosterone can be abused, both in athletic populations and among the general public.1 Scientific evidence is undisputed that testosterone is extremely potent in increasing muscle growth and enhancing physical performance.1-3 The ethical issue of fair play in sports, coupled with the well-documented adverse health effects of supra-physiological doses of testosterone 4 or anabolic steroids 5-15, has given medically legitimate testosterone therapy a bad reputation. This is unfortunately depriving many men suffering from hypogonadism from receiving medically needed testosterone therapy.16
What follows is an overview of the salient differences between use of testosterone therapy that is medically legitimate, and abuse of testosterone and anabolic steroids (which are synthetic derivatives of testosterone), and explain why testosterone therapy - which per definition is medically provided and supervised - has no parallel with abuse of testosterone and anabolic steroids.
What are anabolic steroids?
In order to understand the differences between testosterone therapy and anabolic steroid use, it is important to know what anabolic steroids are.
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.17-22 Testosterone in its 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).23 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 there 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 24,25; including sarcopenia and frailty 26-28, rehabilitation after hip fracture 29,30 and after knee arthroplasty 31-33, treatment of osteoporosis and prevention of fractures 30,34-46, wound healing 47,48, leukemia 49,50, treatment of muscle wasting 51,52 and anemia 53 in dialysis patients, as well as treatment of wasting seen in patients with chronic obstructive pulmonary disease 54 and HIV.55 Note that these benefits are seen in these clinical populations of both men and women.
The fact that testosterone is classified as an anabolic steroid stirs up heated debates about testosterone therapy. However, hypogonadism is a disease that requires medical treatment, as lack of testosterone therapy results in well documented metabolic deterioration and diseases, including obesity, metabolic syndrome, diabetes and heart disease.56
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 explained in “Is testosterone therapy a lifelong treatment?” testosterone therapy is in most cases a lifelong treatment. Not because men with hypogonadism who start testosterone therapy become “addicted” to it, but because it relieves bothersome symptoms caused by low testosterone levels and improves wellbeing, mood and quality of life (as well as objective health status).
Below is a list of several important differences between testosterone therapy and abuse of anabolic steroids, which highlight why they should not be confused.
Testosterone therapy that is prescribed and monitored by a doctor has well-established safety. In contrast, abusers of anabolic steroids use many-fold higher dosages than the recommended clinical doses.13 Doses up to 30 times greater than physiologic replacement doses have been reported.57 This results in supra-physiological blood levels of testosterone, in the range of 3000 – 5000 ng/dL. Compare this to the high end of the healthy physiological testosterone range, which is approx. 1300 ng/dL (depending on the laboratory assay, this value may vary +/- 300).
Continuous vs. cycling use
Testosterone replacement therapy is in most cases a lifelong treatment aimed to replace hypogonadal 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).57-59
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 medical research.8,9,12,15,60-62 In contrast, long-term testosterone treatment is well-documented to be safe, and confers multiple health benefits.56,63,64 For more information on safety and benefits of testosterone therapy, see our Research News section, and the following reports:
Multiple beneficial effects of testosterone replacement therapy in men with testosterone deficiency
Testosterone deficiency and treatment - international expert consensus resolutions
UK policy statements on testosterone deficiency
Long-term testosterone therapy improves cardiometabolic function and reduces risk of cardiovascular disease: real-life results
Testosterone therapy in men with hypogonadism prevents progression from prediabetes to type 2 diabetes
Incidence of prostate cancer after testosterone therapy for up to 17 years
Normalization of testosterone level is associated with reduced incidence of heart attack, stroke and mortality in men
Testosterone therapy and cardiovascular risk - advances and controversies
Stacking: multi-drug combinations
Abusers of testosterone frequently practice ‘‘stacking’’ – i.e. simultaneously use of testosterone combined with multiple synthetic derivatives of testosterone, a practice called polypharmacy.58,65-68 In addition to testosterone and synthetic derivatives of testosterone, high doses of growth hormone and insulin are also commonly added to the mix 67,69, which further increased the health risks.
While polypharmacy may have synergistic effects on muscle growth and physical performance, it also results in more dangerous and potentially lethal consequences.60,70 In contrast, testosterone therapy in men with hypogonadism is done with testosterone (although for men who wish to become fathers in the near future, clomiphene citrate, hCG or aromatase inhibitors are recommended), which is provided in a controlled medical setting in physiological doses that improve health status.
Personal characteristics of users
Abuse of testosterone and anabolic steroids is strongly associated with illicit drug use and substance dependence,66,68,71 and aggressive alcohol use.72 Statements that testosterone therapy – which per definition is medically provided, monitored by physicians and fills important medical needs - supposedly is bad because it carries addiction risk, are unfounded. There is no evidence for testosterone abuse in men who are medically treated with testosterone therapy.73
It is important to keep in mind that just because something can be abused does not mean it has no medically legitimate use. Anything can be abused, even food. 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 their widespread harms in society?