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A case series on misuse of these agents described severe hypotension, cardiovascular collapse, and death52; combining PDE-5 inhibitors with nitrates is particularly dangerous given the potential for significant decreases in systolic blood pressure and coronary perfusion.53 The primary adverse effects of hCG include potential suppression of the HPT-axis and gynecomastia.2 Human chorionic gonadotropin (hCG) is used to prevent testicular atrophy and preserve some degree of testicular function.27 It is also utilized as PCT to expedite the recovery of testosterone production by Leydig cells.20 Dianabol is particularly suppressive; studies have shown that taking 15mg per day for 8 weeks results in a 69% decrease in average plasma testosterone levels. This structure allows for effective absorption when taken orally but can place a strain on the liver. 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Below is Arnold Schwarzenegger explaining how openly they spoke about the topic of [steroids without working out](https://salestracker.realitytraining.com/node/12087) back then and how it wasn’t taboo like it is today. He accomplished this with Dianabol’s androgenic rating of 60, compared to testosterone’s 100. He frequently served as the test subject for his experiments, consuming the [steroids for working out](http://www.jobteck.co.in/companies/anyone-still-come-across-blue-hearts-dbol-10mg-from-thai-bodybuilding-muscle-fitness-and-health-forum/) himself. Smart users structure cycles with built-in breaks and minimalistic dosing. Most users only react after liver stress starts, but proactive support cuts risk significantly. In rare situations patients have taken high-dose DAs for more than several years, [jobteck.com](http://jobteck.com/companies/dbol-and-test-cycle-sustanon-250-cycle-dosage-side-effects/) a screening TTE is reasonable to exclude valvulopathy. Screening for and treating behavioral disorders are of importance given AAS alone has the potential to cause these issues. Side effects of DAs include headaches, orthostasis, nausea, increased impulsivity, and occasionally cardiac valvular disease in chronic use.74 Initial assessment should include screening candy96.fun for hypertension, hemoglobin a1c, assessment of cardiovascular risk factors, and ensuring patients are up to date with age-appropriate cancer screenings. Growth hormone excess has physiologic sequelae including hypertension, cardiomyopathy, increased malignancy risk, entrapment syndromes, and diabetes mellitus among many others, as is seen in patients with acromegaly.70 Diuretics, such as furosemide and torsemide, are used 1–2 days prior to a physique competition to minimize subcutaneous water retention. But by the early ’80s, doctors were routinely prescribing 20mgs/day to athletes and bodybuilders. 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We have had patients develop cholestatic syndrome, which is when bile flow becomes impaired, resulting in a buildup and causing inflammatory damage to the liver. Our patients sometimes comment that Dianabol reduces their appetite, which is due to the strain on the liver. Thus, the liver will almost certainly become damaged during a cycle of Dianabol. Thus, we often find ALT and AST liver enzymes rising during a Dianabol cycle. Previous randomized control trials of hypogonadal men have shown AI use in men results in decreased sexual function, increased adipose distribution,44 and decreased bone mineral density.44,45 While no cardiovascular event data exists for men using AIs, a retrospective study of over 13,000 female breast cancer patients using AIs showed an increased risk of valvular dysfunction, pericarditis, and dysrhythmia.46 Testosterone levels with gonadotropins may be useful in quantifying the degree of androgen use and HPT-axis suppression, or if AAS use is suspected but uncertain. We suggest prostate stimulating antigen (PSA) screening in this population the same way it is recommended in men receiving testosterone replacement therapy per Endocrine Society guidelines.28 Screening involves assessing PSA in men aged 55–69 years old (or beginning at age 40 if high risk) in those agreeable to prostate cancer screening. Initial screening should include blood pressure assessment, review of family history of cardiovascular disease, lipid profile testing, a comprehensive metabolic panel, and electrocardiogram (ECG) testing. Other notable adverse effects include dose-dependent erythropoiesis and polycythemia,38 thrombosis,16 development of focal segmental glomerular sclerosis (FSGS),39 acute kidney injury (AKI),40 and upper extremity tendon rupture.18 Insulin is used during phases of attempted weight gain due to insulin’s anabolic effects on protein and glycogen synthesis. TSH level with reflexive free T4 and total T3 levels should be obtained in patients using thyroid hormone as a PED. While clenbuterol is primarily used for its fat-burning properties, limited animal data has suggested it may also have an anabolic effect on skeletal muscle.54 DNP is an organic uncoupling agent which allows proton leak across the inner mitochondrial membrane, creating heat as opposed to adenosine triphosphate (ATP). Commonly used compounds to reduce body fat include liothyronine (T3), clenbuterol, ephedrine, and occasionally, dinitrophenol (DNP).27,42 T3 is commonly combined with the potent oral beta-2 agonist, clenbuterol. AIs, such as anastrozole and letrozole, are used during an AAS cycle to minimize the conversion of testosterone to estradiol.