Anabolic-androgenic steroids (AAS) are compounds that include testosterone derivatives as well as other derivatives of other androgens such as dihydrotestosterone (DHT). They are synthetically developed and are used to treat some medical conditions, including a number of hormone-related conditions, such as hypogonadism and delayed puberty, as well as some conditions that cause loss of muscle tissue, such as cancer, AIDS and some types of anemia. AAS is safe and effective when used for medical indications and under medical supervision. However, significant adverse effects are associated with the use of AAS, such as hormonal disorder, cardiovascular dysfunction, infertility and mood disorder. Some of these side effects are considered to be minor or short-term effects, while others are considered to be more severe or long-term.
Owing to their effects on increasing muscle growth and strength, increasing bone thickness, and reducing body fat, AAS have become desirable agents for individuals seeking to improve their physical appearance and athletic performance. According to estimates, the global lifetime prevalence of AAS use was 3.3% with higher rates (18.4%) reported in bodybuilders and powerlifters. In a study conducted in Saudi Arabia, it was found that 22% of male gym attendees used AAS. The main sources of AAS were from the coaches (55.06%), The most common oral AAS forms were oxandrolone, followed by stanozolol, and methandienone. While the most commonly used injectable AAS were metenolone enanthate, followed by Deca-Durabolin Sustanon and esterified testosterone. Interestingly, 56.18% of the users recognized the harmful effects of AAS.
AASs are taken in cycles consisting of 6 to 18 weeks of AAS use followed by four weeks to several months off. This cycle aims to allow the body to recover between cycles. Furthermore, AAS are commonly supplemented with other hormones, referred to in AAS user circles as “steroid-accessory drugs”, which may include insulin, growth hormone, or erythropoietin. Additionally, athletes might choose to employ masking agents, such as diuretics, to evade androgen detection or employ what are termed “protective agents”, which can include anti-estrogens, liver protectors, kidney protectors and prostate boosters, aimed at mitigating any adverse effects.
In Saudi Arabia, the increasing number of gyms is testament to an escalating craving to achieve an ideal body appearance. This, along with a paucity of available information regarding the use of exogenous AAS and a lack of awareness regarding their side effects make it necessary to conduct studies highlighting the adverse side effects of AAS abuse. A study conducted in 2019 in Jeddah proposed the establishment of a national awareness programme to reduce the abuse of AAS. Interestingly, this study found a strong correlation between the consumption of AAS and the consumption of energy drinks. Most participants were unaware of the side effects associated with AAS. Participants’ level of knowledge was not related to the use of AAS, gender, physical exercise or energy drink consumption. A 2020 study conducted in Riyadh found that the lifetime prevalence of AAS use among male gym members was high, particularly among those who are single, employed in the private sector, have a low level of education, have friends who use AAS, were offered AAS and use psychoactive medications. Hence, there is a need for health policy reforms aimed at decreasing the prevalence of AAS among young adults and improving education and awareness of the short- and long-term adverse effects of AAS use among gym attendees. A study conducted in Dammam in 2021 aimed to assess the use of AAS among gym members attending gym fitness facilities in the Eastern Province and to determine whether these drugs could have potentially unfavourable effects. The results indicated that more health education and awareness programmes are needed targeting those who attend gyms, as most of the participants were unaware of the potential adverse effects of AAS use.
Blood parameters in athletes, can be influenced by numerous factors, including intense physical activity which may temporarily alter liver function tests and affect thyroid axis function and prolactin levels. However, the direct impact of AAS use on these parameters remains understudied.
A study that includes laboratory blood testing to evaluate the direct effects of AAS agents among users in Saudi Arabia has not been previously undertaken. Therefore, this study aimed to measure the adverse effects of AAS in users by investigating potential changes in their blood parameters and the hormones in their blood after using exogenous AAS. This observational clinical study aimed to investigate the impact of the intake of exogenous AAS by young adults with no medical indication on their health in general and on their blood parameters in particular. To our knowledge, no previous such study has been conducted.
The study is a cross-sectional observational clinical study with two stages, as follows:
Stage 1 – A questionnaire investigating the occurrence of adverse effects in AAS abusers was designed in Google Forms and was recruited through social media, specifically WhatsApp. The questionnaire link was distributed randomly via various WhatsApp groups and direct messages. These groups included communities of athletes, fitness followers, and bodybuilding forums. This ensured that participants were likely to use or have used AAS. Clear instructions were provided in the questionnaire to assure participants understood the study’s purpose and the value of honesty. To encourage truthful reporting, anonymity was guaranteed. A small group of athletes pilot-tested the questionnaire (n=5), providing feedback on its clarity and relevance. The questionnaire was in Arabic. A condition was given in the questionnaire: an individual is requested to fill out the questionnaire if he is a male athlete who has been using AAS. There are no restrictions on which part of the country the volunteer comes from.
The questionnaire consisted of questions on the (1) sociodemographic characteristics of the participants; (2) overall knowledge, practices and patterns of AAS use (3) prevalence of side effects experienced by users.
Once the questionnaire was submitted, an announcement about participating in further laboratory tests was issued. Individuals who were willing to participate, had to contact the primary investigator via Email or phone call for further inquiries.
Definition of Adverse Effects:
In this study, adverse effects were broadly defined to include:
Stage 2 - Participants who met the inclusion criteria, namely healthy men with no pre-existing conditions, over the age of 18 who used AAS within the past six months, were invited to provide blood samples. Those who had used AAS for medical reasons, or who had ceased using AAS for more than six months, were excluded from the study. Once verbal consent and agreement had been obtained, participants were directed to the laboratory for blood sampling.
In order to minimize methodological or interlaboratory variability, these investigations were conducted in one standardized and validated laboratory in Makkah to ensure consistency of protocols and procedures (Appendix- Supplementary Information1). Blood samples were collected within three weeks of participants agreeing to participate in stage two of the study.
Each participant was assigned an identifiable code to maintain confidentiality, therefore avoiding the necessity of providing personal identification information to the laboratory. These investigations were conducted at no cost to the participants. As soon as the results were available, they were sent to the participants, who were given the option to review and decide whether or not to disclose their results.
Laboratory investigations included tests for testosterone, prostatic antigen, LH, FSH, prolactin, thyroid function, liver function, and complete blood count (CBC). Results of laboratory investigations were collected along with the reference standardized range for each parameter. Al Data are then transferred to an Excel document, where they were sorted, stored, analyzed, and secured.
Given the illicit nature of AASs usage and the inclination of users to conceal their usage, the study faced considerable challenges in collecting a large sample size. As a result, it was imperative to adopt a pragmatic approach and proceed with the sample size available. As part of the recruitment efforts, a multifaceted approach was implemented, taking advantage of online platforms such as social media channels as well as personal outreach to gym trainers and coaches within the community. Announcements and questionnaires were circulated persistently over a duration of three months, aiming to maximize respondent and participant involvement.
The analysis primarily focused on frequency distributions and percentages of responses across various demographics, behaviour and outcome variables.
Participants in the first stage of the study provided informed consent electronically. A consent form was included at the beginning of the online questionnaire, which outlined the purpose of the study, assured confidentiality and explained the voluntary nature of precipitations (Appendix- Supplementary Information 2).
In the subsequent stage, participation was voluntary and required active engagement. Individuals interested in undergoing blood investigations provided verbal and written consent by directly contacting primary investigator. In this interaction, participants were informed of the study objectives, assured of data confidentiality, and assured that they can access their data or withdraw participation at any time.
The Ethics Committee of Umm Al-Qura University approved the research (IRB-HAPO-02-K-012) under the Declaration of Helsinki.
The online questionnaire was completed by 31 individuals, 18 of whom continued to stage 2 and were willing to provide a blood sample to measure changes in their blood parameters. All participants were males, aged 24–45 years. In terms of location of residence, 84% were resident in the Western region, while only 3% were resident in the Eastern region.
The questionnaire included a question about the participants’ purpose in using anabolic hormones. Approximately 94% reported that they were using AASs for nontherapeutic purposes, while only 6% were using AAS for therapeutic purposes. Therapeutic AAS use is medically prescribed and supervised to treat specific medical conditions like delayed puberty, certain types of anemia, while non-therapeutic use is the use of AAS without a valid medical prescription or legitimate medical indication, typically to enhance athletic performance, improve physical appearance (bodybuilding), or for other reasons not medically justified.
Based on our analysis, testosterone accounted for 90% of the ASS used, GHs for 81%, insulin for 2
