The recent death of bodybuilder Rich Piana—who collapsed in his home on August 10 and was placed in a medically induced coma shortly after—is raising questions about whether it’s possible to use anabolic steroids in a “healthy” way, as the 46-year-old had previously claimed.
The former Mr. California had spoken openly about his 27-year history of steroid use, stating in a 2016 YouTube video, “If you want to be a professional bodybuilder, guess what—you’re probably going to have to f– –’ do ’em,” People reported Friday.
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Piana’s cause of death has not been publicly released. A police report obtained by TMZ Sports said that 20 bottles of testosterone were found at his home at the time of his collapse. According to TMZ, Piana’s girlfriend also told police that he had previously been diagnosed with an enlarged heart, and that he had “battled opiate addiction in the past but she believed he was clean.”
In a YouTube video from 2014, Piana said that he used—but did not abuse—steroids. He pointed to the fact that he had “a full head of hair,” “no acne scars,” and “a flat waist” as evidence that he was using the drugs properly, and was not damaging his body.
“We want to be doing this in our 60s, 70s, 80s, and 90s,” he said. “I’ll be doing this for the rest of my life. … It’s important for me to live a long life.” He added that he would “never in a million years risk ruining my health or ruining my future due to bodybuilding.”
Piana was right that hair loss, adult acne, and unwanted weight gain can be signs of steroid abuse. But even without those visible symptoms, experts say long-term steroid use can still wreak havoc on a many aspects of a person’s health—and can put him or her in serious danger.
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“With any kind of drug that utilizes something synthetic, there is definitely cumulative effects on the body—some of which are easier to detect than others,” says Tom Hildebrandt, PsyD, associate professor of psychiatry at Ichan School of Medicine at Mount Sinai in New York City.
“In the case of steroids and synthetic androgen, the main risks are to the heart and the brain, and it may take 20-plus years before those manifest and become real.” (Hildebrandt never treated Piana, but he has published several papers on the physical and psychiatric consequences of anabolic-steroid and other performance enhancing–drug use.)
“The heart is a muscle, and one of the most important parts of the health of that muscle is flexibility and its ability to pump enough blood to deliver oxygen to the entire body,” explains Hildebrandt. “But like other muscles, the heart also has androgen receptors—so over time with steroid use, it’s getting bigger and thicker, and it becomes less flexible and less efficient at pushing blood throughout the body. That puts you at greater risk for a whole host of heart-related defects, including heart failure.”
A recent study in the journal Circulation adds to the evidence that anabolic steroid use makes it harder for the heart to function properly. About 70% of steroid users in the study had low heart-pumping capacities; they were also more likely to have elevated blood pressure, clogged arteries, and high cholesterol.
As for brain-related dangers, some of the more well-known side effects of taking steroids include depression, mood swings, and so-called ’roid rage. But Hildebrandt says long-term use also appears to speed up age-related cognitive decline. “At least in some percentage of chronic users, it leads to a greater deterioration in brain function for otherwise-healthy, aging men,” he says.
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Steroid use has been linked to other health risks as well. Research presented last year at the annual meeting of the European Association for the Study of Diabetes in Munich found that steroid abuse among weightlifters is associated with insulin resistance, a condition that can lead to type 2 diabetes.
In men, long-term steroid use has also been linked to shrinking testicles, an increased risk of prostate cancer, decreased sperm count, and the development of breasts. In women, it can cause the growth of facial hair, a deepened voice, and menstrual-cycle changes.
In October 2016, the Food and Drug Administration issued a warning that testosterone supplements and related anabolic-androgenic steroids (AAS) can cause heart attacks, personality changes, and infertility. “Abuse of testosterone, usually at doses higher than those typically prescribed and usually in conjunction with other AAS, is associated with serious safety risks affecting the heart, brain, liver, mental health, and endocrine system,” the agency said in a statement.
Despite warnings about the side effects and health risks of steroid pills and injections, an estimated 2.9 million to 4 million Americans still use them. About 1 million are dependent on them.
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Hildebrandt points out that the vast majority of people who use anabolic steroids won’t experience health problems right away—or will decide that the benefits (like more lean muscle mass, an improved physique, and increased strength) outweigh any short-term side effects that do occur. For many people, he says, the cognitive and cardiovascular risks may not be evident for years or even decades.
“Anyone who’s thinking about using these drugs or has been using them for any significant period of time needs to question whether this really has to be a lifestyle for them,” says Hildebrandt. “Because the longer they continue, the more likely they are to experience side effects and risks later in life.”
