Hormone Advice from a Doc Who Lifts: An Interview with Dr. Karl Nadolsky
by Bryan Krahn on March 13, 2015
At some point every bodybuilder contemplates taking steroids.
Maybe it’s to break out of a lengthy training slump, or to better compete with the rest of the guys on stage? Perhaps it’s just to scratch that “anabolic itch” and see what their body is truly capable of.
Today more guys than ever are taking the anabolic steroid (AAS) plunge – or at least considering it — and while there’s plenty of information available online, much of it is outdated, antiquated, or so full of shit that it would be better used to fertilize the lawn.
That leaves consulting with real-life doctors. But many GP’s just aren’t well versed in steroids for athletic purposes, or have much interest. Even the supposed hormone specialists, the endocrinologists, can be a crap-shoot.
After all, you’re taking up their time asking about drugs for “vanity purposes” when they have patients waiting to see them who are sick and dying. Sorry bro, now don’t let the door hit your ass on the way out.
Plus, let’s face it – most of these docs don’t even lift. And to a bodybuilder, that means something.
Karl Nadolsky is not one of those docs. A board certified internist and osteopath, Dr. Karl is finishing specialty training in endocrinology in Bethesda, MD.
He’s also a diplomate of the American Board of Obesity Medicine and member of the American Association of Clinical Endocrinologists, Endocrine Society, American Thyroid Association, American Society of Bariatric Physicians, The Obesity Society, and the National Lipid Association.
And as you can see, he definitely lifts.
Dr. Nadolsky wrestled throughout college at Michigan State and competed in a couple natural competitions prior to entering medical school. He later tried his hand (as a natural) in a non-tested NPC show where he was, in his words, “smoked.”
Still, Dr. Karl has maintained and continues to refine his exceptional physique through hard training and proper nutrition — or simply “Leaner Living.” In other words, Dr. Nadolsky is a very much a modern-day bodybuilder.
Dr. Karl’s physique and credentials get him a lot of attention from aspiring bodybuilders, especially younger lifters considering steroids. We asked him to answer a few questions for The Mountain Dog and hopefully separate a little fact from fiction.
Q. Let’s get the bro’ness out of the way — you look great dude. But you’re basically a hormone doc. No gear, ever?
Karl Nadolsky: Thanks, and yeah, a lot of people assume that I must have dabbled at some point in my athletic or medical training. But that’s just not so. I’ve always trained hard and had great coaching, and I guess I have above average genetics.
But let me also say, my physique hasn’t changed much in over 10 years. In terms of muscle mass, this is probably it. All I’ve done the past decade is refine/maintain it.
Q: Really? You’re tapped out, muscle-wise?
KN: Most of my muscle mass was built during adolescence and in college, with about ten pounds (muscle/fat) added the couple of years after I was done wrestling daily and cutting weight.
So my physique hasn’t changed in 12 years no matter how hard I work. I’m just at or near my natural genetic limit. Though to be fair, I don’t eat to “bulk” for health reasons — I promote cardio-metabolic wellness via “living lean.”
I may not be able to gain much more muscle naturally or compete in professional bodybuilding — or even come close to having average sized calves — but I’m fine with that. Now I just want to be an example that working hard and consistently from a young age through adolescence and into adulthood can result in a powerful and healthy physique.
Q. We’ll get back to your “slump” later. What things should a bodybuilder consider before starting steroids?
KN: Let’s start with the disclaimer — as a former scholar-athlete and now an endocrinologist, I would never advocate anyone take any form of hormone unless he/she is clinically deficient and the discussion on risks/benefits favors benefits.
That said, I’m also not here to “scare anyone straight,” but being educated is wise. Doctors should never “shame” bodybuilders, just like we shouldn’t shame patients with obesity or drug, cigarette, alcohol use.
Anyway, first you should consider legality, in addition to health implications and costs. While some of the injectable testosterone (T) we prescribe for replacement therapy is reasonably priced, many of the new products are very expensive.
Let’s not forget, the amount of T required for muscle mass varies widely between men. So really educate yourself on the potential risks and if the benefits are worth it to you.
Q; Fair enough. So let’s say a guy wants his doc on board with his AAS plans. Better yet, he wants his doc to prescribe for him. Should he ask his doctor for a testosterone test? How should guys talk to their doctor?
KN: Doctors won’t (at least shouldn’t) prescribe TRT without a legitimate diagnosis of hypogonadism. So males should know the legitimate symptoms of “low T” — decreased sexual thoughts, erectile dysfunction, loss of muscle mass, decreased hair growth (chest, legs, etc), decreased energy/fatigue, headaches, gynecomastia, nipple discharge.
Saying “I wanna get jacked” likely won’t get a favorable response, though trouble building muscle is a legitimate symptom.
But when you go this road, understand that when discussing hypogonadism, there are many potentially reversible or treatable causes beyond just testosterone.
It can be primary (testicular problems) or secondary (hypothalamus/pituitary). Sometimes there can be tumors in the brain (generally the pituitary) which can cause other hormone excess or just cause the LH/FSH (gonadotropins) to be low. Those can often improve with medications or surgery. Obesity and diabetes can also be a factor, not to mention hypothyroidism, which is quite prevalent and needs to be screened for.
Regardless of how you get the treatment, most docs will want to help you stay healthy and advise against steroids if not needed — though should still monitor for adverse effects if using.
Q. So an informed doc is going to rule out a lot of other things before he starts writing you a script for cypionate. Should all bodybuilders get bloodwork before starting on anabolic steroids (AAS)?
KN: Yes. There are many potential adverse effects of testosterone treatment for which we monitor while on TRT. And these effects would be expected to be even worse for those taking exogenous T to get levels to supraphysiologic ranges.
Q. What’s a safe age to start taking T?
KN: The question is, are you deficient? Any age is safe if replacing testosterone when deficient. That said, AAS would certainly be more detrimental prior to ending puberty/adolescence
Q: Would it be prudent for guys who may hope to start families one day to freeze a sperm sample?
KN: Interesting question. There are methods for preserving fertility (sperm cryopreservation), which are typically incorporated for those being treated with chemotherapy for a variety of cancers which cause hypogonadism. Though guys can often “re-start spermatogenesis via clomiphene and/or HCG, freezing sperm is likely good insurance.
Q. Back to you now – you’re 35: what are your own T levels like?
KN: Currently my T levels are very normal, actually on the “lower end” of normal. And yes, they were likely higher (naturally) when I was younger and building my physique. But they remain very much in the normal range now.
Q: That doesn’t concern you?
KN: Why would it? I’m asymptomatic and look and feel fine. So my normal is my normal.
I think guys are too concerned with some arbitrary T number, like going from 400 ng/dl to 700 is going to make a huge difference in the gym. Such an increase may be statistically very significant but likely won’t pay huge dividends in terms of adding muscle mass.
There are also changes in binding proteins so actually the “free T” calculated is a better correlate of effective levels.
That said, going from 100 to 500, however, could offer dramatic benefits to the patient, both in terms of health and cognitive well being.
And certainly, there’s also the whole concept of treating the symptoms, not the numbers. So if they’re symptomatic, treatment should be explored.
Q: Are guys too hung up on estradiol (e2) levels?
KN: Yes! There was evidence presented last year that showed body composition is actually related to “healthy” e2 levels, suggesting that unless it is pathologically elevated, it’s a healthy part of a male hormone profile.
Obviously the difference may be in those taking androgens have increased aromatase activity leading to higher than desirable e2 levels.
Interestingly, a common referral to endocrinology is for young guys taking testosterone supplements, or even adrenal prohormones, which then easily aromatize to e2 and they now have gynecomastia. Some try using aromatase blockers or anti-estrogens, but they still manage to get gynecomastia.
Q: With e2 levels, we hear of guys taking aromatase inhibitors like Arimidex and Aromasin, and we also hear about guys taking estrogen antagonists such as Tamoxifen. From a clinical perspective, what drives the decision on which one is right for a patient?
KN: Clinically we would discuss the risks/benefits of each medication and consider the context. A patient with gynecomastia secondary to AAS may benefit from something like Tamoxifen though often it requires surgery in addition to stopping the androgen use.
Some advocate the use of aromatase inhibitors in obese patients with mildly elevated estrogen due to increased aromatase in adipose tissue, but as I previously noted, there’s evidence that having healthy aromatase activity and estradiol levels may be beneficial for body composition specifically.
Q: It’s become vogue to use very small doses of HCG while on a steroid cycle — 200-300 IU doses daily — what are your thought on this? Will it really send the signal to your testes and keep them working at that dose?
KN: HCG is used as an LH analog to stimulate testicular testosterone production and spermatogenesis in secondary hypogonadism, which can certainly be due to AAS use.
I’m not sure there’s enough data to say it will work the way you ask, however, it is recommended concominantly to help those using AAS to get off of them.
That said, I would warn that it does increase risk of aromatization and gynecomastia though.
Q: Speaking of coming off, how effective is clomid in restoring natural HPTA function?
KN: The evidence in the literature in addition to clinical experience for clomiphene and enclomiphene along with other SERMs is pretty reasonable for men without pathology but have secondary hypogonadism due to obesity, diabetes, and perhaps AAS use.
Of course that doesn’t mean it’s a permanent solution and these meds have their own risks which must be understood.
Q: So I’m on a cycle. What should I get my doc to monitor?
KN: For anyone on TRT we monitor a few things, and it certainly would be beneficial to monitor if taking higher doses, which could worsen these parameters.
• PSA (prostate)
• Hematocrit
• Blood Pressure
• Gynecomastia
• Complete Blood Count
• Obstructive Sleep Apnea
• Cardio metabolic profile (HDL/LDL) Correcting low T actually improves lipids while supraphysiologic doses seem to raise LDL and lower HDL.
Q: What are some of the absolute dumbest things steroid-using bodybuilders do or believe?
KN: Certainly insulin is number one that I’ve heard of, just for the acute risks. You’re not likely going to die from a steroid injection, whereas that risk is real for an insulin user. I’m actually surprised we don’t hear of more tragedies.
Other things that would worry me include albuterol and other stimulants. And even hGH, which is likely healthy when correcting a deficiency, is a question mark in terms of long term effects especially at high doses. In fact, we treat acromegaly because of severe consequences.
Q: Bodybuilding and steroids are obviously closely associated. Since users gonna use, what would be the most important advice you could give?
KN: Back to understanding risks versus the potential benefits. One of the most disturbing things I read online are these bodybuilders talking like they have all the answers when it comes to AAS, especially in supraphysiological doses.
I’m here to tell you, they don’t. Cause we don’t. It is basically a massive crap shoot, especially in long term health outcomes.
My colleagues and I work with these drugs every day and we’re still constantly learning and discovering new things, and altering our practices based on the most recent data. How a guy can think he has it all down just because he’s done a lot of cycles is kind of dangerous.
So in the end, understand risk. Be informed. Error on the side of caution. Don’t try to “push” it – that could exacerbate the potential risks.
And above all, mitigate the risks by working with your doctor whenever possible. They’re not there to call you a juice monkey or throw you out (though they might dismiss if you go completely against their advice). Above all, they’re just concerned about your health and well being.
Q: Great advice. Where we can learn more about you?
KN: www.DocsWhoLift.com & www.leanerliving.com
Facebook: www.facebook.com/DrKarlNadolsky
Twitter & Instagram: @DrKarlNadolsky