Many oral anabolic-androgenic steroids (or injectable forms of oral steroids) are toxic to the liver (hepatotoxic). These compounds can cause severe, life-threatening damage when abused, and occasionally even under therapeutic conditions. Drugs commonly associated with clinical hepatotoxicity include (but are not limited to) fluoxymesterone, methyltestosterone, methandrostenolone, methyltestosterone, oxymetholone, and stanozolol.

 These steroids are all C-17 alpha-alkylated at the carbon-17 position with an ethyl or methyl group. All C-17 alpha-alkylated anabolic-androgenic steroids have some degree of hepatotoxicity. Elevated liver enzyme levels, which indicate liver strain, have also been reported for non-alkylated injectable steroids, including nandrolone decanoate and testosterone enanthate. These steroids have never been associated with severe liver damage and are not considered hepatotoxic.

Monitoring Liver Function

Before physical symptoms or dysfunction develop, early signs of hepatotoxicity can often be seen in blood test results for liver function. This is most likely to include elevated levels of aminotransferases AST and ALT, also known as serum glutamic-oxaloacetic transaminase (SGOT) and serum glutamic-pyruvic transaminase (SGPT). Cholestatic enzymes alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) may also be elevated along with other markers. Screening for abnormalities in liver markers is considered the most effective way to prevent liver damage from steroid use. If asymptomatic toxicity is not noticed and drug intake remains unchanged, more severe liver stress, liver damage, or liver dysfunction may develop. It is recommended to immediately discontinue anabolic-androgenic steroids and conduct a comprehensive evaluation of liver and overall health.

Cholestasis

The most common form of actual liver dysfunction caused by oral anabolic-androgenic steroids is cholestasis. This is a condition characterized by reduced bile flow, usually due to obstruction of small bile ducts in the liver (intrahepatic). This leads to the accumulation of bile salts and bilirubin in the liver and blood instead of normal excretion through the digestive tract. Inflammation (hepatitis) may also be present. Symptoms of cholestasis include anorexia, discomfort, nausea, vomiting, upper abdominal pain, or itching. Due to reduced bile excretion, stools may become clay-colored (alcholic stool), and urine may turn amber-colored. Cholestatic jaundice may develop, characterized by yellowing of the skin, eyes, and mucous membranes due to high bilirubin levels in the blood (hyperbilirubinemia). Intrahepatic cholestasis may also lead to necrotic lesions in liver cells (liver tissue death).

Intrahepatic cholestasis typically resolves on its own within a few weeks of discontinuing all hepatotoxic steroids without medical intervention and without causing serious damage. In more severe cases, it may take several months for liver enzyme levels and function to return to normal. Liver lesions may also heal over time. In some cases, doctors have begun using ursodeoxycholic acid (ursodiol) for supportive treatment, a secondary bile salt known to have hepatoprotective and anti-cholestatic effects. However, the exact value of using this drug to treat steroid-induced cholestatic jaundice remains unknown. The liver is highly resilient, and intrahepatic cholestasis is unlikely to continue to degrade after stopping the drug unless other pathologies are present.

Severe Liver Complications

More severe liver complications are rare but include hepatic peliosis (blood-filled cysts in the liver), portal hypertension and variceal bleeding (bleeding associated with elevated portal blood pressure and obstructed blood flow), hepatocellular adenomas (benign liver tumors), hepatocellular carcinoma (malignant liver tumors), and angiosarcoma (an aggressive malignant tumor of the blood vessel lining in the liver). Sometimes these conditions are very insidious, developing rapidly without clear early symptoms. Although many of these potentially life-threatening side effects are often attributed to patients receiving steroid medications, there are increasing case reports of otherwise healthy young bodybuilders abusing these drugs. Additionally, there are at least two reported cases of previously healthy bodybuilders who developed liver cancer after taking high doses of oral anabolic-androgenic steroids, with one confirmed death.