How the Liver Works

To understand the impact of orals on the liver, first we need a quick overview of the liver.

The liver is like a processing plant in your body, primarily tasked with making sure that drugs and other substances are safely broken down and prepared for elimination. This is crucial because it helps prevent these substances from sticking around too long and potentially causing harm. The process, known as drug metabolism, involves changing the drugs so they're easier for the kidneys to filter out and remove from your body. The liver accomplishes this through two main phases:

Phase I (Modification): In this initial phase, the liver starts to break down the drugs, making them more water-soluble. This often involves introducing a small chemical change to the substance, which can sometimes deactivate it. However, if the drug isn't fully deactivated, it moves to the next phase.

Phase II (Conjugation): Here, the slightly altered drugs from Phase I are further processed to increase their water solubility. The liver attaches certain chemical groups to the drug, making it even easier for the kidneys to handle and eliminate.

Why Oral Steroids are Toxic to the Liver

Oral anabolic steroids (Anavar, Dianabol, Winstrol, Turnabol, etc.) have a modification in their structure, known as C17 alpha alkylation (C17aa), which allows them to survive the first pass through the liver without being broken down. This modification lets the steroids enter the bloodstream in higher concentrations but also makes them more taxing for the liver to process. Over time, this can stress the liver and cause blockages, which can lead to inflammation and even liver cells being damaged or dying off.

Types of Liver Damage

The damage from these steroids can range from mild to life-threatening and typically falls into several categories:

Hepatotoxicity: The liver tries to break down the steroids, but because of its chemical makeup, this process puts a lot of stress on the liver. Over time, this can lead to liver toxicity, where the liver becomes inflamed and its cells are damaged.

Symptoms might not be immediately obvious, making it a sneaky threat to health but some common ones include:

• Fatigue or feeling unusually tired
• Weakness
• Nausea or vomiting
• Loss of appetite
• Pain or discomfort in the upper right side of the abdomen (where the liver is located)

Cholestasis: One of the most common forms of liver damage due to the use/abuse of oral anabolic steroids. This condition happens when the flow of bile (the digestive fluid produced by the liver) is slowed down or stopped. Since bile helps the body digest fats, a blockage can cause jaundice (yellowing of the skin and eyes), itching, and even more serious liver damage if left untreated.

Common symptoms:

• Jaundice (a yellowing of the skin and whites of the eyes)
• Nausea or vomiting
• Anorexia or loss of appetite
• Itching without a rash
• Dark urine
• Pale-colored stools or unusually light or gray stools
• Upper abdominal pain, particularly on the right side (commonly mistaken for heartburn)

Hepatocellular Jaundice: This type of jaundice is directly related to liver damage from steroids. The liver becomes so inflamed and damaged that it cannot effectively filter toxins from the blood, leading to a buildup of bilirubin, a yellow pigment that causes the skin and whites of the eyes to turn yellow.

As this is a type of jaundice, the symptoms are similar to cholestasis:

• Yellowing of the skin and eyes
• Dark urine
• Pale stools
• Itching
• Fatigue
• Swelling in the abdomen or legs (due to fluid accumulation)

Liver Tumors: Both benign (non-cancerous) and malignant (cancerous) liver tumors have been linked to the use of oral anabolic steroids. These tumors can disrupt the normal functioning of the liver and, in severe cases, lead to liver failure or the need for a liver transplant.

Often asymptomatic in early stages, but symptoms can include:

• Unexplained weight loss
• Loss of appetite
• Feeling very full after a small meal
• Nausea or vomiting
• An enlarged liver, felt as fullness under the ribs on the right side
• Pain in the abdomen or near the right shoulder blade
• Swelling or fluid build-up in the abdomen

Peliosis Hepatis: This rare condition involves the formation of blood-filled cysts within the liver. These cysts can rupture, leading to internal bleeding—a potentially life-threatening situation.

Many cases are asymptomatic and discovered incidentally. When symptoms do occur, they can include:

• Abdominal pain
• Feeling full or bloated
• Jaundice
• Signs of internal bleeding if a cyst ruptures, including low blood pressure, increased heart rate, or weakness

Tests & Diagnostics

Testing is an important process to understanding how well your liver has been affected by the use of steroids.

Blood Tests:

Blood work is usually the first set of tests to assess liver health. These include checking for the following:

• Aspartate transaminase (AST): Although not always a good indicator of liver damage as it is also found in cardiac and skeletal muscles. Reference range: ≤ 35 IU/L
• Alanine transaminase (ALT): Unlike AST, ALT is found predominantly in the liver and requires significant damage to hepatocytes for it to be released into the blood. Reference range: ≤ 45 IU/L
• Alkaline Phosphatase (ALP): An enzyme that is located within hepatic biliary ducts. Elevated levels may be indicative of either cholestasis or biliary obstruction. Reference rage: 30 - 120 IU/L
• Total Bilirubin: High hepatic sources of bilirubin may be indicative of cirrhosis or hepatitis. Reference range: 0.1 - 1.0 mg/dL
• Albumin and Total Protein: These tests measure how well the liver is making proteins that your body needs to fight infections and perform other functions. Low levels can indicate liver damage. Reference Range (Albumin): 3.5 – 5.5 g/dL or 35 – 55 g/L

Imaging Tests:

If blood tests suggest liver damage, doctors may order imaging tests to get a clearer picture of the liver. These can include:

• Ultrasound: A non-invasive test that uses sound waves to create images of the liver, helping to detect signs of inflammation, tumors, or other abnormalities.
• CT Scan or MRI: These are more detailed imaging tests that can provide clearer, more detailed pictures of the liver and surrounding tissues.

Liver Biopsy:

In some cases, a liver biopsy might be necessary to determine the extent of liver damage. This involves taking a small sample of liver tissue with a needle. The sample is then examined under a microscope to look for signs of inflammation, scarring, or other liver issues.

Specialized Tests:

Depending on the suspected cause of liver damage, doctors may order additional tests to check for specific conditions, such as viral hepatitis or autoimmune liver diseases.

Can Damage Be Reversed?

The question of whether liver damage caused by steroids can be reversed is nuanced and depends on several factors, including the severity of the damage and the actions taken after the damage is identified.

Potential for Reversal:

Early-stage Damage: For milder forms of liver damage, such as elevated liver enzymes indicating inflammation or stress on the liver, ceasing the use of oral anabolic steroids can lead to a reversal of damage. The liver has a remarkable capacity to regenerate and repair itself if the source of damage is removed early enough. Lifestyle changes, such as adopting a healthy diet and avoiding alcohol, can support liver recovery.

Advanced-stage Damage: In cases of more serious damage, such as the development of liver tumors (benign or malignant) or severe cholestasis, complete reversal may not be possible. While stopping steroid use is still crucial, treatment focuses on managing symptoms and preventing further damage. Advanced liver damage like cirrhosis, where the liver is extensively scarred, significantly impairs the liver's ability to regenerate, and in such cases, the damage is often irreversible.

Steps Towards Recovery:

1. Immediate Cessation: The first step in addressing liver damage from oral anabolic steroids is to stop using them immediately. Continuing to use these substances will only exacerbate the damage.
2. Medical Evaluation: Consultation with a healthcare professional for a thorough evaluation is critical. Blood tests, imaging studies, and sometimes liver biopsies can assess the extent of liver damage and guide treatment options.
3. Lifestyle Adjustments: Supporting liver health through diet, exercise, and avoiding harmful substances like alcohol can aid in recovery. Nutritional support, including certain supplements, may be recommended by healthcare providers.
4. Monitoring and Management: Regular follow-up with a healthcare provider to monitor liver function and assess recovery is essential. This may include ongoing blood tests and imaging studies.

Liver Support & Protection

Certain supplements have been studied for their potential to support liver health and protect it from damage, including that caused by the use of oral anabolic steroids. While no supplement can entirely negate the risk of liver damage from steroid use, some may offer protective effects when used responsibly and under the guidance of a healthcare professional. Here are a few supplements commonly associated with liver health:

• TUDCA (Tauroursodeoxycholic acid) & UDCA (Ursodeoxycholic acid): A bile acid naturally occurring in small quantities in the human body, TUDCA has been used to treat cholestasis (bile acid build-up). It helps protect and rehabilitate liver cells, potentially offering protection against steroid-induced liver damage.
• Milk Thistle (Silymarin): Milk thistle contains silymarin, a group of compounds said to have antioxidant and anti-inflammatory properties that may protect liver cells. Silymarin is believed to stimulate the regeneration of liver cells and protect them from toxins. It has been used traditionally for treating liver disorders, although scientific studies offer mixed results.
• N-acetylcysteine (NAC): NAC is a precursor to glutathione, one of the body's most potent antioxidants. It plays a crucial role in detoxifying harmful substances in the liver. NAC has been shown to help replenish glutathione levels, potentially aiding in the protection against liver damage.
• Omega-3 Fatty Acids: Found in fish oil and certain plant oils, omega-3 fatty acids have anti-inflammatory properties that might help reduce the risk of liver fat accumulation and inflammation, common issues in liver damage.
• Vitamin E: An antioxidant, Vitamin E may provide protection against liver damage by reducing oxidative stress within the liver. It's particularly been studied for its effects on non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH), but its protective benefits might extend to damage from steroids.
• Turmeric/Curcumin: Turmeric and its active component curcumin have strong anti-inflammatory and antioxidant properties. Some studies suggest curcumin may help protect the liver by reducing inflammation and combating oxidative stress.

While these supplements can offer some level of protection, they should not be seen as a way to continue the unsafe use of anabolic steroids. The best way to protect the liver is to avoid or minimize the use of substances that can cause damage.

For individuals who decide to use oral anabolic steroids, proactive health monitoring through regular blood tests is essential. Liver damage often doesn't show immediate symptoms, making early detection and timely medical intervention key to potentially reversing the harm inflicted on this vital organ.

Disclaimer: This blog post is intended for educational purposes only and should not be taken as medical advice. Always consult your healthcare provider for personal health concerns.