Anabolic steroids among resistance training practitioners

Objective To compare the use of anabolic steroids (AS), the motivation to use them, their side effects, the source of information and the form in which AS were obtained, the medical follow-up, and the periodic examinations in resistance training practitioners who are either current or former users of AS. Methods A prevalence survey was performed in the gyms of the city of Curitiba, including 719 current and former AS users who self-administered a questionnaire. The chi-square and z of proportions (p <0.05) statistical tests were conducted. Results Esthetics was the main motivation associated with AS intake, leading to satisfactory results. The information about the form in which to use AS was provided by doctors and AS were either purchased at the pharmacy with a prescription or illegally. Current users reported a higher number of cycles and doses, a longer duration of use, as well as larger economical investments into AS. This shows a higher consumption of such drugs, regardless of the medical follow-up and post-cycle therapy. Conclusion Given that a change in the usage pattern was observed when increasing the AS consumption, this should be considered in the elaboration of public policies to inhibit such a trend.

Introduction calculation was performed to determine the number of gyms required in this study (considering p = q = 50%), which resulted to be 100 (given an error of 7.9% and a confidence level of 95%). Successively, the average number of students (over 18 years old) enrolled in these gyms was identified, i.e., 481 practitioners. Thereafter, a new sample calculation was performed, considering an error of 1.25% and a 95% confidence level. The survey was applied out to individuals upon entering each gym. The participants signed a disclaimer that explained informed consent, confidentiality, and anonymity for subjects. A sample of 5884 individuals was obtained. Data were collected between December 2016 and May 2017, in a manner proportional to the number of practitioners present in each gym. Finally, after the exclusion of those individuals who did not use AS, a sample of 719 current and former users of AS resulted.
The questionnaire (S1 and S2 File) was self-administered by participants using the Kobo-Collect application (KoboCollect, Cambridge, Massachusetts, United States) on the Samsung Tablet, Tab 2 model (Samsung, Campinas, Brazil). This questionnaire was developed for this research and validated through the clarity, construct and content indices. The aspects of construction and content were validated by health professionals, while the clarity aspect was validated with individuals of the same class, age and lifestyle of the individuals who would be researched. A pilot study was conducted that the questionnaire could be used with the intended population. The questionnaire briefly, it comprised a first part to be answered by all the resistance training practitioners participating in this research and a second part to be answered only by current and former users of AS. This second part was analyzed in the present study, as it contained questions that addressed the age at AS use onset, the number of cycles performed, the cycle length, the weekly dosage, the type of AS used, the money invested in AS, AS used, the knowledge about the post-cycle therapy (PCT), the motivation to use AS, the satisfaction with the results, the source of information about AS, the form in which AS were obtained, the medical follow-up, the periodic exams and the changes in such exams.
Successively, all the data were transferred from the Kobocollect application (KoboCollect, Cambridge, Massachusetts) to the Excel (Microsoft, Redmond, Washington) and IBM SPSS 20.0 (IBM SPSS, Armonk, New York) software. The exploratory descriptive statistics of the frequency distribution and the percentages were performed using the results presented in the tables. With regards to the inferential analyzes, the chi-square test and the z-test of proportions were conducted, in addition to the student's t-test to compare the means (significant difference at p <0.05).

Results
In the sample studied, 73% of the practitioners were former users of AS, while 27% were current users (men: 77.7%; women: 22.3%). However, when comparing the former and current users, differences between men and women were not observed (p = 0.09). Furthermore, the mean age of the participants was similar between men (30.4 ± 7.0 years) and women (30.8 ± 7.4 years) (p = 0.57), also when considering both former (30.8 ± 7.0 years) and current (29.8 ± 7.2 years) users (p = 0.08).
The majority of the current and former users began to use AS between their 18 and 29 years of age (73.1%), with 6.7% of them starting before their 18 years of age. Specifically, the mean age at onset among the former (24.8 ± 6.0 years) and current (25.0 ± 6.7 years) users was similar (p = 0.79).
The highest percentage of the former users consumed AS for a period of time longer than one year (66.3%): 19.2, 17.5, 29.6, 14.5, and 19.2% used it for more than five and three years, one year, and six and three months, respectively. Table 1 compares the current and former users of AS. While a higher percentage of former users only performed one cycle of AS, six cycles or more were reported by current users. In addition, a shorter duration of one to two months per cycle was mainly observed in former users, whereas cycles with a duration longer than five months were mostly found among current users. Moreover, while a dosage of 100 mg per week was commonly reported by former users, dosages higher than 301 mg per week were described by current users. In addition, injectable AS were mostly employed by current users. Furthermore, a higher percentage of former users invested up to US$ 134 for buying AS, whereas values over US$ 134 were described by current users. However, the use of AS related to esthetic reasons and curiosity was higher among former users. Specifically, of those who were curious, 60.1% only performed one cycle (p = 0.029). In contrast, the use of AS for bodybuilding was greater in current users. Of the satisfied individuals, there was a higher percentage of current users. Winstrol1 (stanozolol) was the most commonly used AS by both current and former users. However, a greater diversity of AS was consumed by current users, including Durates-ton1 (phenylpropionate, isocaproate, propionate and decanoate testosterone), Landerlan1 (oxandrolone), Deca-Durabolin1 (nandrolone decanoate), Dianabol1 (methandrostenolone), Deposteron1 testosterone), Parabolan1 (trenbolone), Boldenone1 (boldenone undecylated), Masteron1 (drostanolone propionate), and Hemogenin1 (oximethalone). Table 2 shows the presence of collateral symptoms in both current and former users, as well as their disappearance after the end of the cycle. A higher percentage of the following symptoms was observed among current users: increased libido, acne appearance, irritability/aggressiveness, hypertension, depression, and dependence. Table 3 illustrates that a higher percentage of current users obtained the information related to AS from doctors and nutritionists. In addition, a higher percentage of current users received AS either through a prescription in the pharmacy or in other ways, including the black market or imports. Furthermore, a higher percentage of current users reported medical follow-ups and periodic exams (e.g., total testosterone dosage) given their usage of AS. Moreover, changes in the results of such tests were identified, mainly among the current users. Finally, a higher percentage of current users was aware of the PCT and performed it similarly to previous users.

Discussion
One of the strengths of the present study relies on its large sample size, i.e., 719 weight training practitioners who are either current or former users of AS. Our results reveal differences between these groups, which were mainly related to the form of use: the number and duration of the AS cycles, the amount of money invested in them, the type of AS, the dosage used, and their motivation to consume them. Furthermore, differences were observed in the source of information related to the drugs, the way in which AS were obtained and the conduction of medical follow-ups.
In the current study, a higher number of former rather than current users of AS was observed, in accordance with previous literature [22,23]. While Silva & Moreau (2003) [22] and Leifman et al., (2011) [23] separated current (17 and 5, respectively) from former (23 and 62, respectively) users into two categories, all the other surveys grouped them into a single category, making their comparison not possible. Furthermore, a larger number of current and former male users was here found, in accordance with previous literature [24,13,25,26].
Practitioners' mean age was similar between men and women, as well as between current and former users. However, although our averages are above the age ranges described in other studies [27,10,9], the mean corroborates with the values seen in the literature if the age at onset of AS use is considered. It is also worth mentioning that 6.7% of the individuals started the use of AS at an age younger than 18 years old, as evidenced in other studies [28][29][30][31]. Our results identified that a higher percentage of former, as opposed to current, users only conducted one AS cycle, with a shorter duration (1 to 2 months) and smaller dosages (100 mg). This strengthens the hypothesis of a curiosity-driven AS use, given that the percentage of former users who reported such a reason was also higher. In contrast, the opposite was observed in current users, who performed six or more cycles, with longer durations (5 months or more) and higher dosages (301 mg or more) than former users. While the satisfaction associated with the results can be one of the motivating hypotheses behind the regular use of AS, the practice of bodybuilding may also be an explanation to this phenomenon, since the motivation to consume AS was also greater in current users.
Injectable AS were mostly used, mainly among current users. To the best of our knowledge, this is the first study identifying the frequency of AS administration forms in this population. With regards to injectable AS, a lack of proper asepsis care during the application increases the risk of infections. As a consequence, this may lead to hospitalizations given the practitioners' progression to abscesses, which may turn into more severe conditions, such as muscular necrosis or sepsis [32]. With regards to oral AS, high hepatoxicity is expected [33,16].
In accordance with the literature, testosterone and stanozolol were the most commonly used AS [22,34,35]. Although a previous study cited testosterone as commonly used AS [33], oxandrolone, which had a high prevalence in this study, was not widely assessed in other studies.
Stanozolol was the most used AS among both groups, in accordance with Silva and Moreau (2003) [22], possibly given its popular brands that can be found both in the oral and injectable forms [36]. Similarly, nandrolone decanoate was also commonly consumed in other studies [9,11,22,35,37], possibly considering its higher accessibility (i.e., lower cost in trade) and greater disclosure [36]. Both stanozolol and nandrolone decanoate are frequently used for muscle growth, given their higher anabolic characteristics compared to androgenic AS [36]. Although more than one AS is usually used during a cycle [8], veterinary drugs, such as boldenone undecylation and trenbolone, have also been consumed [12]. A report of fulminant Table 3 heart attack due to the use of boldenone in humans was reported [38]. In contrast, trenbolone may affect the liver, causing cholestatic hepatitis [39,40] and may be associated with the proliferation of tumor cells in prostate cancers [41]. In addition, it can result in dermatitis, including severe inflammatory acne with pustules and hemorrhagic ulcerations [42]. Collateral symptoms were reported by both current and former users, as widely reported in previous literature [5,8,16]. However, while most symptoms disappeared after the end of the cycle, given their acuity, the chronic symptoms observed may cause slow and irreversible changes [8].

. Comparison of the source of information related to AS, the way in which the AS was obtained, the medical follow-up and exams, alterations in such exams, and the knowledge and conduction of the PCT between former and current users of AS
In accordance with previous studies, increased libido, acne, and irritability/aggressiveness were the main collateral symptoms reported by both current and former users [22,9]. Increased libido may be classified as an acute side effect, given that it again decreases after the cycle [15], and it is associated with high serum levels of testosterone resulting from the use of supraphysiological dosages [5]. In contrast, considering that acne usually occurs during puberty and not in adulthood, the use of AS increases the activity of the sebaceous glands, which leads to higher oil concentrations present in the skin [8]. Furthermore, irritability/aggressiveness are often associated with the AS use [8].Although increased aggression may lead to heightened violence, such a hypothesis was not previously proven, given that the individuals involved in cases of violence also used other drugs, alcohol or had personality tendencies [24].
Transient hypertension, an acute symptom, was more frequent in current users [16]. However, this acute symptom may become chronic, since the use of AS for long periods is associated with cardiovascular diseases, including hypertension, heart attack, and stroke. The most commonly used oral AS alter the levels of lipoproteins that carry the cholesterol in the blood, increase the level of low-density lipoprotein (LDL), and decrease the high-density lipoprotein (HDL) instead [8].Therefore, their assessment is important for controlling health-related risks [22].Moreover, current users were noticed to be more cautious compared to former users, possibly because they underwent more medical follow-ups.
Dependency was also more frequent in current users. The use of AS for long periods of time may eventually affect the brain as other addictive illicit drugs, acting primarily on the dopamine, serotonin, and opioid systems [8].However, dependency may also be associated with the presence of body image disorders, such as "muscular dysmorphism", where excessive preoccupation is laid onto the musculature [24]. Moreover, the stories of success disseminated by the means of communication related to image alteration and muscular bodies motivates such body transformations [12].
A higher percentage of current users obtained information about AS from doctors. In fact, the emergence of anti-aging treatments increases the number of doctors who encourage AS therapies [43]. However, attention is drawn to the fact that doctors are prescribing such therapies to youngsters, who fail in conducting a medical follow-up, representing a big issue [13]. Therefore, the increased number of doctors prescribing the use of AS may be stimulating its use. In fact, the acquisition of such drugs in the pharmacy with a prescription was high, as described in previous literature [22,33]. Moreover, friends, coaches, and nutritionists also influence the use of AS [44,9]. In fact, coaches encourage their clients to consume AS for better results in the shortest time possible to improve their reputation in the academy [27].
This study did not find a definite protocol for the use of AS. Various combination, dosages, durations, and cycles were in fact used by practitioners. An empirical culture on how to best use AS according to the final objective exists, which can either be obtained from manuals or transmitted orally between users (based on their own experiences) [22]. Furthermore, this information, as well as the AS products, are widely found on the internet.
In accordance to previous studies, in addition to pharmacies, AS were found to be also illegally marketed (black market) and easy to access [33,45,9]. In fact, AS are marketed freely on the internet and in the gyms themselves [36]. About 1/3 of the illicitly imported products derive from Paraguay, according to the federal police of Brazil. It should be noted that these products are not regulated and that they may be falsified [46], leading to possible serious health damages.
Although most of the individuals do not conduct a medical follow-up, a higher percentage of current users performed monitoring and tests to control for the risks associated with the use of AS, including changes in vital organs (e.g., heart and liver) and dosage of testosterone. However, performing these tests does not eliminate health risks [22].
Although a great knowledge about PCT exists, a small number of individuals actually perform such a therapy. Briefly, PCT involves the use of certain medications aimed at reversing the suppression of endogenous production of testosterone at least temporarily. Its abrupt interruption, without returning to the endogenous production, can lead to a state of hypogonadism characterized by a substantial loss of muscle mass, reduced energy levels, depression, and loss of libido. However, a higher percentage of current users are performing PCT, which may be a result of the increased number of medical follow-ups conducted in this group 7 . In the present study, the following drugs used during PCT were identified: tamoxifen, human chorionic gonadotropin hormone (CGH), Clomiphene, Anastrozole, Saw Palmetto, Legalon, and Proviron. These drugs were prescribed for such a therapy in previous literature [7].
The limitations of the current study will now be highlighted. Firstly, a response bias may have affected our results, considering that the answers provided in the self-administered questionnaire depended on the participant's honesty and that confirming their veracity was not possible. In addition, as some of the information refer to a period in the past (even years before the current investigation), especially with regards to former users, uncertainties regarding the information provided may be present.

Conclusions
Most current users performed between two to five and up to six or more cycles of AS, with a duration of five months or more and a dosage higher than 301 mg per week. They consumed the injectable type of AS, invested an amount of money higher than US$ 134 and used stanozolol. Esthetics was found to be the main reason associated with the use of such drugs and individuals were satisfied with the obtained results. Although they presented side-effects during the period of use (mainly increased libido, irritability/aggressiveness, and acne appearance), such symptoms disappeared after the use. The information related to the use of AS was mainly obtained through doctors and the drugs were purchased either through friends or at a pharmacy with a prescription. Individuals conducted medical follow-ups, had a knowledge of PCT and performed it. In contrast, most former users only conducted one cycle of AS, for a duration of one to two months, with dosages lower than 100 mg per week. They invested less than US$ 134 in AS, did not conduct medical follow-ups and did not perform PCT.
Overall, we noticed some changes in the pattern of use between former and current users of AS. Specifically, the latter reported a higher number of cycles of AS, a longer duration, increased dosage and money invested in AS, and a consequent higher and diverse consumption of AS. However, the presence of collateral symptoms does not inhibit such a consumption, possibly due to the safety provided by the medical follow-ups, which were conducted by a high number of current users. Finally, an increase in both the number of doctors providing such services and the acquisition of AS in pharmacies with a prescription was observed. This implies the need for public policies ensuring both improved information, given the symptoms and risks presented, and better control, considering that the abuse of such drugs is associated with a number of health risks.