Electronic Supplementary Material Table S2 Outcome Assessment During AAS Use

Electronic Supplementary Material Table S2 Outcome assessment during AAS use

First author
(Year of publication) / N / Medical history and/or clinical examinationa / Hormone changesa / Semenchangesa
Cohort study
Al-Janabi (2011) [45] / 24 / NR / Usersb (n=16)
LH: 1.7 mIu/ml
FSH: 2.5 mIu/ml
T: 3.1 mg/ml
PRL: 17.3 mg/ml
Nonusersb (n=8)
LH: 3.3 mIu/ml
FSH: 3.2 mIu/ml
T: 5.3 mg/ml
PRL: 32.2 mg/ml / Usersc (n=16)
Liquefaction: 31.6±3.4 min
Semen volume: 3.3±0.4 ml
Sperm concentration: 26.4±7.2 million/ml
Total sperm count: 86.6±27.1 million/ejaculate
Sperm motility (categories a+b): 37±5.4%
Normal sperm morphology: 61.9±5.3%
Sperm agglutination: 2.5±0.9%
Round cells: 6.2±0.8 million/ml
The majority of semen samples had normal whitish-opaque color.
1 subject had azoospermia
5 subjects had oligozoospermia ranging between 2 to 7.6x106 sperm/ml
1 subject had mild oligozoospermia (16x106 sperm/ml)
Nonusersc (n=8)
Liquefaction: 32.5±3.3 min
Semen volume: 3.8±0.7 ml
Sperm concentration: 31.8±3.2 million/ml
Total sperm count: 121.1±23.1 million/ejaculate
Sperm motility (categories a+b): 36.8±7.2%
Normal sperm morphology: 71.8±5.1%
Sperm agglutination: 8.5±2.4%
Round cells: 4.9±1.2 million/ml
The majority of semen samples had normal whitish-opaque color.
Garevik (2011)d [41] / 35 / NS / Last day of AAS injection
FSH<0.99 IU/L
LH<1.17 IU/L
FSH<0.1 IU/L in 50% of the subjects (detection limit)
LH<0.7 IU/L in 70% of the subjects
(detection limit) / NS
Bonetti (2008) [37] / 20 / Prostate ultrasound:It was unremarkable and remained normal in all subjects during the study.
Right testicular volume: -6.71%
Left testicular volume: -15.23%
Testes hypotrophy was observed in 16 out of 20 subjects.
Gynecomastia occurred in 5 subjects, painful in 2 cases, but only in one subject it was of clinical relevance. / Baseline (n=20) to 24 months (n=13)
LH: -29.15%
FSH: -13.42%
GH: 0%
IGF1: -28.37%
T: -5.16%
E2: 10.28%
SHBG: -25.48% / Baseline (n=20) to 24 months (n=13)
Sperm count: -23.69%
Semen volume: 13.64%
Sperm motility at 2 hrs: -32.00%
Sperm morphology: -36.56%
TMSC: -62.13%
Two bodybuilders showed azoospermia and 2 others severe oligospermia with consequent impairment of the TMSC.
Karila (2004)[39] / 18 / NS / Minor userse (total cumulative dose≤12,785 mg), n=9
LH: 0.7±0.9 IU/l
FSH: 0.1±0.2 IU/l
T: 24.8±35.0 nmol/l
SHBG: 14±7 nmol/l
Major userse (total cumulative dose12,785 mg), n=9
LH: 0.1±0.2 IU/l
FSH: 0.0±0.1 IU/l
T: 70.7±56.7 nmol/l
SHBG: 13±11 nmol/l / Minor userse (total cumulative dose≤12,785 mg), n=9
Semen volume: 3.4±1.9 ml
Sperm concentration: 39±66x106/ml
Sperm motility (categories a+b): 47±18 %
Normal sperm morphology: 14±12 %
Major userse (total cumulative dose12,785 mg), n=9
Semen volume: 3.2±2.8 ml
Sperm concentration: 27±28 x106/ml
Sperm motility (categories a+b): 40±25 %
Normal sperm morphology: 16±23 %
One subject was diagnosed with azoospermia.
Alen (1987) [36] / 15 / NR / Users (n=7)
LH: -30.88%
FSH: -71.88%
GH: 1008.11%
T: 16.51%
E2: 50%
Cortisol: -7.02%
SHBG: -28.38%
Nonusers (n=8)
LH: 0%
FSH: 0%
T: 0%
E2: 0%
GH: 0%
Cortisol: 0%
SHBG: 0% / NS
Alen (1985) [35] / 11 / NS / Users (n=5)
LH: -53.43%
FSH: -89.56%
PRL: 9.56%
T: 132.19%
Ε2: 563.45%
ACTH: -55.43%
Cortisol: 2.82%
Nonusers (n=6)
LH: 58.28%
FSH: -8.91%
PRL: 7.77%
T: -7.53%
Ε2: 2.73%
ACTH: 0.16%
Cortisol: 0.78% / NS
Ruokonen (1985) [44] / 9 / NS / Users (n=4)
Pregnenolone: -29.16%
Progesterone: -29.38%
17-hydroxypregnenolone: -56.41%
17-hydroxyprogesterone: -72.47%
DHEA: -47.69%
Androstenedione: 8.86%
5-androstene-3β,17β-diol: -52.69%
T: 19.37%
5α-dihydrotestosterone: 4.24%
Pregnenolonesulphate: -66.61%
17-hydroxypregnenolone sulphate: -49.68%
DHEAS: -35.48%
5-androstene-3β,17β-diol sulphate: -38.75%
T sulphate: 4.63%
SHBG: -83.52%
CBG: -6.27%
Nonusers (n=5)
Pregnenolone: NR
Progesterone: NR
17-hydroxypregnenolone: NR
17-hydroxyprogesterone: NR
DHEA: NR
Androstenedione: NR
5-androstene-3β,17β-diol: NR
T: NR
5α-dihydrotestosterone: NR
Pregnenolonesulphate: NR
17-hydroxypregnenolone sulphate: NR
DHEAS: NR
5-androstene-3β,17β-diol sulphate: NR
T sulphate: NR
SHBG: -7.69%
CBG: -6.27% / NS
Alen (1984) [47] / 14 / Clinical examination
Testicular sizeb
Month 0: Users= 17.1 ml, Nonusers= 20.8 ml
Month 3: Users= 12.7 ml, Nonusers= 23.9 ml
Month 6: Users= 11.4 ml, Nonusers= 25.1 ml / NS / Sperm count (number of spermatozoa x 106/ml)e
Month 1: Users= 20.5±31.3, Nonusers= 75.6±69.6
Month 3: Users= 0.3±0.8, Nonusers= 108.4±84.4
Month 6: Users= 0±0, Nonusers= 73.3±38.5
Total number of spermatozoa (x 106)e
Month 1: Users= 71.2±113.0, Nonusers= 201.0±180.4
Month 3: Users=0.8±2.0, Nonusers= 230.9±141.2
Month 6: Users=0±0, Nonusers= 191.0±95.0
Acid phosphatase activity (x 106 IU/ml)e
Month 0: Users= 27.7±13.3, Nonusers= 29.9±10.0
Month 3: Users= 24.8±14.2, Nonusers= 31.9±13.6
Month 6: Users= 29.2±14.7, Nonusers= 41.0±15.5
Fructose concentration (mg/ml)e
Month 0: Users= 1.54±0.41, Nonusers= 2.01±0.55
Month 3: Users= 1.92±0.75, Nonusers= 1.94±0.51
Month 6: Users= 1.54±0.66, Nonusers= 1.86±0.67
Ejaculate volume (ml)e
During the investigation: Users: 3.2±0.8, Nonusers: 2.9±0.8
Normal configuration of spermatozoa (%)e
In the beginning of the phase taking AAS: Users: 42.5±7.7, Nonusers: 50.3±7.9
Schurmeyer (1984) [34] / 5 / Weekly interviews:Libido and potency were unaltered.
There were no gynecomastia.
Prostate size did not change.
Testicular volume: -44.83% / LH: -98.92%
FSH: -64.14%
T: -77.11%
PRL: -5.59% / Seminal fructose: 6.85%
Ejaculate volume: 16.32%
Sperm density: decrease
Sperm motility: decrease
% normally formed sperm: decrease
HOP testf: decrease
Azoospermia was first observed in one subject after 7 weeks’ treatment and by week 13 all five men were azoospermic.
Holma (1976)g[24] / 16 / NS / LH: -52.63%
FSH: -47.14%
T: -69.05% / Sperm density: -73.06%
Total number of spermatozoa: -66.25%
Sperm motility: -32.21%
Sperms with normal configuration: -42.58%
Sperms with amorphous heads: 89.54%
Sperms with midpiece anomalies: 71.43%
Sperms with tail anomalies: 160.98%
Sperms with other anomalies: 28.72%
Acid phosphatase: -43.91%
Fructose: 30.29%
Fertility indexh: 764.71%
Three of the subjects became azoospermic and one of them had only 1 million sperms/ml after 2 months use of the drug.
Cross-sectional study
Börjesson (2016) [30] / 8 / Self-reported adverse effects (Users, n=5)
Clitoral enlargement: 5/5
Menstrual disorders: 4/5
Reduced breast: 1/5 / NS / NS
Razavi (2014) [56] / 250 / Self-reported questionnaire (Users, n=72)
Changes in libido: 9.7%
Breast enlargement: 1.4% / NS / NS
Coward (2013) [51] / 80 / Self-reported questionnaire
Decreased testicular size: 41.3% (33/80)
Infertility/low sperm count: 11.3% (9/80) / NS / NS
Ip (2010) [32] / 748 / Web-based survey instrument
Clitoral enlargement: 75%
Irregular menses: 50%
Testicular atrophy: 51%
Gynecomastia: 16%
Sexual dysfunction: 14.5% / NS / NS
Taher (2008)[40] / 30 / Self-reported questionnaire
Changes in libido: 40% (6/15) / Userse (n=15)
LH: 1.03±1.09 mIU/mL
FSH: 1.47±0.87 mIU/mL
T: 2.71±1.75 ng/mL
PRL: 21.63±8.88 ng/mL
Nonuserse(n=15)
LH: 3.11±0.94 mIU/mL
FSH: 2.93±1.30 mIU/mL
T: 7.47±1.95 ng/mL
PRL: 14.44±6.19 ng/mL / NS
Perry (2005) [52] / 207 / Self-reported questionnaire
Testicular atrophy: 8% (17/207)
Gynecomastia: 7% (14/207) / NS / NS
Urhausen (2003)[38] / 31 / Nine ex-abusers and 12 abusers indicated that, in the past, they had suffered from gynecomastia at least temporarily; out of them, 5 and 7, respectively, had undergone a subcutaneous mastectomy. / Current usersi(n=17)
LH: 0.21±0.15 (0.06–0.62) IU/l
FSH: 0.45±1.13(0.0–4.76) IU/l
T: 56.9±34.7 (0.3–113) nmol/l
SHBG: 5.2±4.7 (1.0–18.5) nmol/l
E2: 455±335 (0.0–1154) pmol/l
Ex-usersi(n=14)
LH: 3.24±1.34 (0.11–5.39) IU/l
FSH: 5.08±1.86(2.95–8.24) IU/l
T: 14.6±4.2 (6.6-22.2) nmol/l
SHBG: 32±14.8 (17–76.9) nmol/l
E2: 90.3±30.5 (24.2–147) pmol/l / NS
Torres-Calleja (2001)[43] / 30 / NR / Userse (n=15)
LH: 4.1±4.9 mU/ml
FSH: 1.4±3.2 mU/ml
T: 8.9±7.1 ng/ml
DEHA: 245±138 ng/ml
E2: 61.2±73.4 pg/ml
PRL: 5.1±4.9 ng/ml
Nonuserse (n=15)
LH: 5.0±1.9 mU/ml
FSH: 5.0±1.6 mU/ml
T: 5.0±1.8 ng/ml
DEHA: 325±86 ng/ml
E2: 18.7±9.8 pg/ml
PRL: 9.2±4.4 ng/ml / Userse (n=15)
Sperm count: 46.1±96x106/ml
Normal sperm morphology: 17.7±13.6 %
Nonuserse (n=15)
Sperm count: 67.9±48.3x106/ml
Normal sperm morphology: 44.5±7.5 %
Compared with the control group where only one volunteer showed to have severe oligozoospermia (sperm concentration 5x106/ml), sperm concentrations in bodybuilders taking AAS were severely impaired. As a result, three bodybuilders had azoospermia, three others had severe oligozoospermia (sperm concentrations <5x106/ml), five bodybuilders showed moderate oligozoospermia (sperm concentrations between 5 and 20x106/ml) and four others had normal sperm concentrations.
Gruber (2000) [29] / 75 / Clinical examination (clitoromegaly)
Users: 48% (12/25)
Medical history (amenorrhea)
Users: 96% (24/25)
Nonusers: 72% (36/50) / NS / NS
Evans (1997) [50] / 100 / Self-reported questionnaire
Testicular atrophy: 40%
Reduced libido: 33%
Gynecomastia: 34% / NS / NS
Korkia (1997) [33] / 1,669 / Self-reported questionnaire
Males (97 subjects)
Testicular atrophy:56%
Gynecomastia: 32%
Fertility problems: 6%
Females (13 subjects)
Fertility problems: 7%
Menstrual irregularities:61%
Clitoral enlargement: 30.5%
Smaller breasts: 22% / NS / NS
Pope (1994) [49] / 156 / Testicular lengthe
Users
Total users: 44.4±6.2 mm
Past users: 46.1±5.5 mm
Current users: 42.1±6.5 mm
Nonusers
49.5±6.3 mm
Gynecomastia
Users
Total users: 28% (25/88)
Past users: 31% (16/51)
Current users: 24% (9/37)
Nonusers
3% (2/68) / NS / NS
Malarkey (1991) [31] / 16 / The women who stated they were using three or more steroid preparations, noted an increase in clitoral size. / Usersc
FSH: 7.4±1.5 IU/L
LH: 5.2±1.4 IU/L
Estradiol: 190.9±27.2 pmol/L
DHEAS: 3.6±0.81 nmol/L
SHBG: 22.4±3.8 nmol/L
Testosterone: 47.9±14.2 nmol/L
Nonusersc
FSH: 12.3±1.1
LH: 6.7±1.1 IU/L
Estradiol: 133±26.1 IU/L pmol/L
DHEAS: 4.2±0.4 nmol/L
SHBG: 52.5±6.4 nmol/L
Testosterone: 1.2±0.1 nmol/L / NS
Knuth (1989) [42] / 82 / No side effects were reported and only one man revealed gynecomastia during the physical examination. / Athletes still taking AASc(n=19)
LH: 1.9±0.3 U/L
FSH: 1.4±0.2 U/L
T: 25.3±5.9 nmol/L
Dihydrotestosterone: 2.7±0.3 nmol/L
E2: 274±21 pmol/L
Nonusers (n=41)
LH: NR
FSH: NR
T: NR
Dihydrotestosterone: NR / Usersc (athletes still taking AAS, athletes with a drug-free interval of <3 months, athletes with a drug-free interval of >4 months), n=41
Semen volume: 3.9±0.2 ml
Athletes still taking AAS (n=19)
7 men were azoospermic
2 men had only single sperm per high-power field in the sediments of their ejaculates
5 men were severely oligospermic
2 men showed moderately impaired sperm concentrations
2 men had normal sperm concentrations (41.8 and 71x106/ml)
Reduced sperm motility (compared to nonusers)
Reduced normal sperm morphology (compared to nonusers)
Nonusersc(n=41)
Semen volume: 3.8±0.3 ml
Yesalis (1988) [55] / 45 / Self-reported questionnaire (Users, n=15)
Increased sex drive: 60% (9/15)
Decreased sex drive: 13% (2/15)
Gynecomastia: 7% (1/15)
Enlarged prostate: 7% (1/15) / NS / NS
Strauss (1985) [28] / 10 / Self-reported questionnaire
Enlarged clitoris: 80% (8/10)
Decreased libido: 10% (1/10)
Diminished or stopped menstruation: 70% (7/10) / NS / NS
Strauss (1983) [54] / 39 / Gynecomastia
Current users: 4/20
Other subjects: 1/19
Subjects who had used AAS
Increase in libido during AAS use: 48%
No change in libido: 32%
Decrease in libido: 19% / NS / NS
RCT
Remes (1977) [26] / 12 / NS / Methandienone experiment (n=12)
5 mg methandienone
LH: -34.67%
FSH: 7.32%
T: -66.03%
10 mg methandienone
LH: 9.36%
FSH: 2.63%
T: -73.01%
DHEAS experiment (n=16)
20 mg DHEAS
LH: -18.42%
FSH: 6.58%
T: 1.27%
40 mg DHEAS
LH: 3.98%
FSH: -9.72%
T: -40.88% / NS
Hervey (1976) [27] / 11 / No changes of consequence in general health. / Plasma LH: -14.92%
Plasma FSH: -20.69%
Plasma T: -58.67%
Plasma GH: 17.81%
Plasma cortisol: 38.28%
Urine cortisol: 82.26% / NS
Aakvaag (1974) [23] / 21 / NS / Users (n=10)
LH: -24.90%
FSH: 6.07%
Total T: -32.69%
Bound/free T: -41.98%
Free T: 10.81%
Nonusers (n=11)
LH: -4.56%
FSH: 11.86%
Total T: NR
Bound/free T: -4.67%
Free T: 0.42% / NS
Non-randomized parallel clinical trial
Johnson (1972) [48] / 31 / Interview regarding sexual drive
One subject noticed an increase in sexual drive and one a decrease. The rest reported no change. / NS / No significant changes occurred in sperm count.

Abbreviations

RCT: randomized controlled trial, AAS: anabolic androgenic steroids, N: total number of participants, n: number of participants in group,NR: not reported, NS: not assessed, T: testosterone, DHEA: dehydroepiandrosterone, DHEAS: dehydroepiandrosteronesulphate, Ε2: estradiol, GH: growth hormone, PRL: prolactin, SHBG: sex hormone-binding globulin, CBG: cortisol binding globulin, TMSC: total motility sperm count, IGF1: insulin-like growth factor 1, SD: standard deviation, SEM: standard error of mean.

Footnotes

aChangesrepresent the percent change from baseline and have been assessed using the following formula: [(mean at the end of AAS use-mean at the start of AAS use)/mean at the start of AAS use]x100%.

bValues are expressed as mean.

cValues are expressed as mean±SEM.

dValues refer to 21 individuals who tested positive for nandrolone.

eValues are expressed as mean±SD.

fHOP test: % eggs penetrated.

gHormone changes refer to 16 subjects of the study Holma and Adlercreutz [24], whereas semen changes refer to 15 subjects of the study Holma [25].

hThe “fertility index” gradation is based on the logarithmic system and is presented by Eliasson[1]. The following scores have been used for estimating semen quality with reference to volume, spermatozoa, agglutination and viscosity: 0=fully normal, 1=questionable, 3=decreased and 10=pathological. The sum of the scores has been used for the following classification: 0-1=normal, 2-4=doubtful, 5-9=pathological and ≥10=severely pathological.

i Values are expressed as mean±SD (minimum-maximum).

Conversion to International System of Units (SI)

• Testosterone, DHEA: multiply ng/ml with 3.47 to convert to nmol/L.
• Estradiol: multiply pg/ml with 3.67 to convert to pmol/L.
• Prolactin: multiply ng/ml with 0.04 to convert to nmol/l.

References

1.Eliasson R. Standards for investigation of human semen Untersuchungsstandards für das menschliche Sperma La standardisation de l'analyse du sperme humain. Andrologia. 1971;3(2):49-64.