Indian J Urol. 2014 Jan-Mar; 30(1): 27.

Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, Starr 900, New York, NY, USA

Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, Starr 900, New York, NY, USA

Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, Starr 900, New York, NY, USA

Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, Starr 900, New York, NY, USA

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Testosterone replacement therapy (TRT) is a widely used treatment for men with symptomatic hypogonadism. The benefits seen with TRT, such as increased libido and energy level, beneficial effects on bone density, strength and muscle as well as cardioprotective effects, have been well-documented. TRT is contraindicated in men with untreated prostate and breast cancer. Men on TRT should be monitored for side-effects such as polycythemia, peripheral edema, cardiac and hepatic dysfunction.

Keywords: Hypogonadism, side-effects, testosterone replacement therapy

Testosterone has many beneficial effects, including increasing bone strength and density, inducing hematopoiesis, driving sexual function and libido, providing a cardioprotective effect and increasing muscle strength.[1] Testosterone levels are known to decline as men age. The Baltimore Longitudinal Study of Aging reported the incidence of hypogonadism as 20% in men over 60 years of age, 30% in men over 70 years and 50% in men over 80 years of age.[2]

As men age, a decline in testicular production of testosterone are seen, as well as an increase in sex hormone binding globulin, both of which act to decrease bioavailable testosterone.[3] With this gradual decline, the beneficial effects of testosterone could be diminished and negatively affect physical and emotional well-being. Testosterone replacement therapy (TRT) is a reasonable treatment option often discussed for men with low testosterone levels and symptoms of hypogonadism. When replaced, many of the positive effects of testosterone are regained.[4] These positive results have led to a drastic increase in the use of testosterone replacement for men with symptomatic hypogonadism, though long-term data is lacking on the safety.

While the beneficial effects of testosterone are rarely disputed and widely publicized, there is a paucity of the literature on the risks of testosterone use. Any man who has a comorbidity that precludes TRT should be informed of all risks. Factors such as exacerbation of prostate cancer, male breast cancer, worsening benign prostatic hyperplasia (BPH), polycythemia and an increased risk of obstructive sleep apnea (OSA) should be considered when administering TRT to a patient. The goal of this review is to highlight the risks and summarize the current literature on safety of TRT.

One of the major risk factors associated with the administration of testosterone supplementation is its effect on the prostate. We know the prostate to be an androgen-dependent gland and conversely, anti-androgen agents can decrease prostate volume in patients with BPH. As the population continues to age, both the incidence of BPH and late-onset male hypogonadism will continue to rise and practitioners will need to be comfortable with counseling men on the effect of TRT on the prostate.[5]

In a landmark randomized, double-blind, placebo-controlled trial of 44 hypogonadal men, Marks et al. showed that TRT for 6 months improves serum androgen levels, but had little effect on prostate tissue androgen levels, tissue biomarkers and/or gene expression.[6] Testosterone supplementation has been shown to increase prostate size by 12%,[7] but lower urinary tract symptoms (LUTS) and urinary retention do not worsen in men on testosterone therapy.[8,9] Similarly, the presence of hypogonadism in 312 men with reportable LUTS was not predictive of worsening International Prostate Symptom Scores (IPSS) or maximal urinary flow rates.[10]

In fact, some series report an improvement in LUTS after 1 year of TRT.[11,12] In the most recent, randomized controlled trial, 52 men were randomly assigned to receive TRT. At 1 year, the 23 men randomized to 250 mg of testosterone enanthate every 4 weeks reported significant improvements in IPSS and maximal urinary flow rates compared with baseline and controls.[12] At no point in this trial did any patient require additional medication or suffer urinary retention.

While older men on testosterone therapy do have an increase in overall prostate size, this increase in size does not differ from the increase in prostatic hypertrophy seen in elderly men not on testosterone therapy.[13] Taken together, TRT does not appear to grossly worsen LUTS and is not contraindicated in men diagnosed with BPH.

It has been over 60 years since Hodges and Huggins described a relationship between serum testosterone levels and prostate cancer progression.[14] Later in 1982, Fowler and Whitmore reported that exogenous testosterone given to patients with metastatic prostate cancer had worse outcomes.[15] Today androgen deprivation therapy remains a cornerstone of treatment for men with advanced prostate cancer, so it is no surprise that TRT is contraindicated in men with diagnosed prostate cancer, as well as high-risk patients, which includes men with first-degree relatives with prostate cancer and African-Americans who have a prostate-specific antigen (PSA) >3 ng/mL.[4,16]

Recently, there has been a paradigm shift whereby TRT usage has increased despite this potential risk. Many longitudinal studies investigating the relationship of endogenous testosterone levels and subsequent risk of prostate cancer failed to find any association.[17] As such, prostate cancer incidence in men on testosterone therapy is similar to men not on testosterone therapy.[18,19] Similarly, in a 3-year prospective trial, the incidence of prostate cancer was similar among men receiving TRT and controls.[20] In a large meta-analysis of 18 prospective studies that included over 3500 men, there was no association between serum androgen levels and the risk of prostate cancer development.[21] Morgentaler et al. proposed a saturation theory where prostate growth becomes insensitive to changes at normal androgen levels due to saturation of the androgen-receptor; however, there is exponential growth at castrate levels.[22] This theory may explain why testosterone does not directly cause prostate cancer,[23] but it has been shown to accelerate the development of prostate cancer.[24,25]

For premalignancy, prostatic intraepithelial neoplasia (PIN) appears to be a risk factor for developing prostate cancer, however this association has been mostly demonstrated for high-grade disease.[26,27] There is a lack of long-term data on the use of TRT in men with PIN. In one study, 12 months after TRT, only one patient out of 20 men with previous PIN developed overt prostate cancer.[28]

For men who have previously undergone definitive treatment for prostate cancer, the usage of TRT is becoming more accepted. TRT does not appear to increase cancer recurrence in hypogonadal men following radical prostatectomy.[29] In the most recent study by Pastuszak et al., the authors retrospectively reviewed a cohort of 103 men who underwent prior radical prostatectomy and were treated with TRT. Despite a significant increase in PSA in men receiving TRT, there were twice as many cancer recurrences in the control group after 36 months of follow-up.[30]

For men with untreated prostate cancer on active surveillance, TRT remains controversial. However, several studies have shown that TRT is not associated with progression of prostate cancer as evidenced by either PSA progression or gleason grade upstaging on repeat biopsy.[31,32] In the most recent study by Morgentaler et al., 13 men with symptomatic hypogonadism and untreated prostate cancer received TRT for a median of 2.5 years and no local prostate cancer progression or distant disease was observed.[33]

While there have been reports of metastatic prostate cancer in older men who are on testosterone therapy,[20] these are mostly anecdotal. Because of this potential risk, practitioners are often reluctant to administer testosterone in patients they believe may be at high risk for prostate cancer or whom they suspect may have the low-grade disease. Men on TRT should have frequent PSA monitoring; any major change in PSA (>1 ng/mL) within the first 3-6 months may reflect the presence of a pre-existing cancer and warrants cessation of therapy.[34] Current guidelines on the frequency of PSA monitoring and role of pre-treatment transrectal ultrasound guided prostate biopsy are lacking.[35] Taken together, there has been consistent rejection that TRT causes development of prostate cancer in men, however administration of TRT for hypogonadal men previously treated for high-risk prostate cancer should be taken with caution.

While there is no known physiologic link of testosterone directly to the development of breast cancer, it has been suggested that high levels of testosterone may lead to increased aromatization to an active derivative of estrogen, which ultimately may stimulate breast tissue receptors and increase the risk of male breast cancer.[36]

The role of testosterone in breast cancer development is yet to be fully understood.[37] Currently, several case reports exist[38] and one retrospective review sites an incidence 11% in 45 men on long term TRT over 10 years.[39] Future prospective studies with longer follow-up will determine if such association between TRT and male breast cancer truly exists.

Testosterone leads to an increase in hemoglobin by as much as 5-7%[1,25] through its effect on the production of erythropoietin, which can dramatically improve symptoms of anemia in men.[40,41]

Studies looking at the occurrence of polycythemia as a negative side-effect in men on testosterone therapy are rare. Despite this, polycythemia is an accepted side-effect of TRT. While testosterone exerts a positive effect in men with baseline anemia, it can lead to polycythemia in over 20% of men treated on TRT.[42] Polycythemia may lead to an increased incidence of vascular events, including stroke, myocardial infarction and deep vein thrombosis with possible pulmonary embolus.[42] While these complications are all possible with polycythemia, their theoretical occurrence has not been demonstrated to occur in men on TRT.[43]

Because of this risk of polycythemia, men undergoing TRT should not only have their complete blood count (CBC) monitored during their therapy, but should also have a baseline CBC drawn before testosterone therapy is initiated. While on testosterone therapy, if the hematocrit (HCT) rises greater than 54%, testosterone therapy should be held until the HCT normalizes. If it is restarted after normalization, it should be performed so at a lower dose with continued careful monitoring.[16]

OSA is a risk associated with TRT in men, but its etiology is not particularly well understood. While some studies suggested that there is no association between OSA and TRT,[44] others have demonstrated that that OSA occurs in men undergoing TRT and when supplementation is stopped, the OSA resolves.[45]

While no clear link has been established, men on TRT should be counseled on the risk of potential OSA when therapy is started. They should be monitored for increased symptoms, such as snoring while sleeping or fatigue. If patients starting TRT already carry a diagnosis of OSA, physicians should counsel these patients that TRT may worsen their symptoms. While, OSA remains to be a relative contraindication to initiation of TRT, more research needs to be completed on this association in order to gain a better understanding of its etiology if there is one at all.

The systemic effects of TRT may be exacerbated in men with limited cardiovascular reserve. Previous dogma held that androgens could have atherogenic potential. In a randomized, placebo-controlled trial, Basaria et al. reported an increased risk of cardiovascular events in men randomized to TRT; however, this small cohort had a high prevalence of chronic disease.[46] Today, current literature suggests that TRT has a neutral to beneficial effect on reported cardiovascular events.[47,48] Because some men may have a limited cardiovascular capacity, clinicians prescribing TRT must be cautious with respect to its ability to cause edema.[49] Until date, no longitudinal studies examine the impact of TRT on the cardiovascular system, however some studies suggest that TRT may serve as an adjunct rehabilitative therapy in patients with congestive heart failure (CHF).[50,51,52]

While topical testosterone delivery systems avoid first-pass hepatic metabolism, there remains concern regarding TRT in patients with chronic liver disease. The majority of reports of liver toxicity and jaundice are limited to orally-administered alkylated forms of testosterone.[53] However, a small prospective study representing a cohort of cirrhotic patients demonstrated topical gels to be safe and efficacious.[54] It has also been shown that TRT may improve hepatic function in patients with end-stage liver disease.[55] Because of these mixed results, clinicians should be aware of the possible risks associated with TRT in men with hepatic dysfunction and counsel these men accordingly.

Because TRT is known to cause water retention, caution with testosterone use in patients with chronic renal insufficiency is often advised. In patients with end-stage renal disease (ESRD) on dialysis, fluid shifts are less of a concern in patients on TRT since the fluid retention can be handled with dialysis. While polycythemia may be an adverse side-effect, this is a potential benefit in patients with chronic renal failure and anemia.[56] Furthermore, the half-life of testosterone elimination after withdrawal appears similar between patients with and without ESRD.[56] Few studies have assessed the effects of TRT in patients with chronic kidney disease; however, small studies have suggested that TRT has anabolic effects among ESRD patients, even in the absence of hypogonadism. Aside from frequent monitoring of congestive symptoms and peripheral edema in this select population, TRT appears to be safe for patients with chronic kidney disease without dose adjustment.[57]

When testosterone reaches supra-therapeutic levels, aggressive behavior and increased rates of suicide among adolescent users have been reported;[58] however, no study has documented a negative impact on cognition in men patients receiving TRT. In fact, studies have shown that testosterone replacement to eugonadal levels may improve or stabilize cognitive function.[59,60,61] Lower levels of testosterone have a negative impact on spatial and verbal abilities, as well as cognitive function; therefore, it is no surprise that normalizing testosterone levels results in cognitive improvements.[62,63]

With exogenous testosterone supplementation, the pulsatile release of gonadotropin-releasing hormone is blunted and the release of follicle-stimulating hormone and luteinizing hormone are depressed. As such, a decrease in spermatogenesis is seen.[64] While this effect may not be of importance to many men who have completed their families, physicians prescribing TRT need to be aware.

When serum levels of testosterone are increased, a concurrent increase in the secretion of sebum occurs, which can lead to acne. Despite this known association, this effect is typically minimal.[65] Case reports regarding testosterone supplementation leading to changes in hair patterns have been documented; however no randomized, placebo-controlled trials exist. Various topical and intramuscular injectable forms of testosterone are associated with a variety of skin reactions, mainly erythema and pruritus in up to 60% of users.[20]

TRT is associated with external, physical changes in the men. Exogenous testosterone is known to cause an imbalance in the hypothalamic-pituitary axis. As such, testosterone can be converted to estrogen by aromatization. Excess estrogens may lead to gynecomastia and/or breast pain, both of which may be seen in 10-25% of men on TRT.[66] The ratio of estradiol to androgens is the key factor in the development of gynecomastia rather than absolute increases in androgens themselves.[66] Clinicians must be aware of non-iatrogenic causes of gynecomastia and therefore the appropriate work-up should be sought out to rule out other pathology, especially if there is any breast tenderness or unilateral gynecomastia. Only a few case-reports describe a relationship between male breast cancer and TRT.[38,39]

In addition, excess estrogens may cause an increase in visceral obesity. With vigilant monitoring of serum estrogen levels, TRT has been shown to promote weight loss.[67] Well-known to many prescribers of TRT is a risk of water retention and/or edema. The etiology of this association remains unclear to date.[68] The degree of retention is generally mild. As mentioned above, men on TRT with a history of CHF should follow closely[69].

TRT has numerous benefits that can great enhance a patient's quality-of-life. Before prescribing TRT, one must be conscientious of its adverse effects. Data on the safety of TRT specific to our aging population is not currently available; however TRT has been linked to prostate cancer, BPH, polycythemia and OSA. A full assessment of the morbidity of TRT would require a large-scale, randomized, controlled trial. To date, physicians remain in a quandary about the best approach to care for men with symptoms of hypogonadism. TRT, when given to appropriately selected patients with vigilant monitoring as outlined in this review and in , can bring improvements in quality-of-life, energy level, libido, muscle mass, cognition and bone density.

Potential risks of TRT and associated monitoring strategies

Source of Support: Nil

Conflict of Interest: None declared.

Read this article:
Risks of testosterone replacement therapy in men

We are pretty sure that you've heard about legal steroids and read unbelievable Crazy bulk reviews. These amazing health supplements have transformed the way natural bodybuilders look and feel.

In other words, they have bridged the massive void that existed between anabolic steroids and run of the mill health supplements like protein powder.

In case you were unaware, CrazyBulk is the company that pioneered Legal Steroids.

The brand has managed to single handedly spearhead the safe and clean bodybuilding movement by making it possible for natty bodybuilders to stand toe to toe with chemically enhanced bodybuilders.

But we've got to tell you this. We don't blame you at all if you were skeptical about Crazy bulk.

Some of the transformations made possible with their steroids are bound to draw suspicion. Moreover, there are no clear Crazy bulk reviews on the internet that explain how these supplements work and whether or not, they are safe for long term use.

That's why we have created this Crazy Bulk review. Today, we will analyze Crazy bulk from head to toe for you and try to shine more light on steroids than what other Crazybulk reviews tell you.

Click Here to Visit Crazybulk Official Website

Crazybulk USA Supplements is a brand of health supplements that is dedicated to men who want nothing short of enhanced bodybuilding performance. In other words, the company specializes in steroids.

As far as we know, they were the ones who came up with the term steroids. Until then, legal steroids were a catchall phrase used to describe prohormones, peptides, and other chemicals that were in essence, anabolic steroids. But were modified to an extent that they could fly under the radar without being detected.

But if you are a natty bodybuilder, the only difference that these bought to the table, was that they were legal. Other than that, it was as good as using steroids.

They had all the side effects. Sometimes, even worse than using AAS because users expected these to be a free ride and then would be caught unaware with severe liver stress and hair loss.

Crazybulk USA Supplements came up with their own brand of steroids that were not only legal but were completely natural and safe. These were legitimate performance enhancement compounds with no male hormones derivatives.

They mimic the effect of the anabolic agent without causing any of the side effects associated with them. For example, Trenbolone is the most powerful steroid there is. It's an extremely potent androgen receptor agonist that can boost nitrogen retention, protein synthesis, and red blood cells count.

But Trenbolone is also the most toxic steroid of them all. It can cause severe cardiovascular issues, is a bronchoconstrictor, & has long term mental health issues too. In comparison, Crazybulk offers Trenorol, a legal alternative to Trenbolone that mimics the result of Trenbolone without any of the side effects.

Click here for Best Price on Crazybulk Official Website

Crazy Bulk Supplements is owned by Wolfson Berg, one of the world's leading producers of health supplements. The company is based in Los Angeles, California, and has been around since 2009.

Wolfson Berg has a flawless reputation in the industry in over 11-years of business. That has been made possible due to few things.

Click here for Best Price on Crazybulk Official Website

Crazybulk USA Supplements work by achieving anabolic synergy. This means that their products are more than the sum of their parts because they work in conjunction with each other to elicit enhanced metabolic responses.

Each one of their bodybuilding supplements is designed to produce results like their anabolic counterparts and hence, produce a different result when combined together.

For example, D-BAL is a legal alternative to Dianabol which helps in increasing strength and massive muscle gains. But if you combine it along with Anadrole (a legal steroid alternative to Anadrol) then the synergy divines exponentially, giving you greater results than just adding up the two separate products together.

Some of their steroids work by increasing the levels of endogenous testosterone. But others increase the levels of endogenous HGH and IGF-1, both of which are potent muscle building hormones.

Some of their bodybuilding supplements are designed to increase metabolism (the body's internal temperature), so they help you build muscle and burn fat, at the same time.

Others are more geared towards preventing fat gain or water retention while parting dietary nutrients making them more adept for muscle growth.

Crazy Bulk became a rage in the health and fitness industry after they launched D-Bal, the legal alternative to Dianabol.

Almost overnight, natural athletes and sportsmen realized that they had a legitimate dietary supplement that could produce dramatic gains as fast as anabolic steroids do, that too without the fear of side effects or being busted for doping.

D-Bal sold out weeks in advance and the demand was so strong for bulking steroids that Crazy bulk decided to launch several more anabolic compound clones designed especially for bulking.

If you are looking to bulk with Crazy bulk steroids, these are your best options.

D-Bal is the first bulking legal steroid to have gained so much traction. It is a dietary supplement that has been designed to mimic the effects of Dianabol, or Methandrostenolone, the most (in)famous bulking, oral steroid of all times.

Dianabol was a favorite amongst golden era bodybuilders because of its uncanny ability to increase lean muscle mass in the shortest time possible.

In fact, it was so popular that it is estimated to have been taken by over half a million Americans during this era.

However, there were two major problems with Dianabol -

1) It caused extreme side effects

2) It was difficult to control the dosages and it nearly always led to excess dosages.

D-Bal solves both these problems for you, making it the number one bulking steroid alternative in Crazybulk USA's stable of steroids. It stimulates protein synthesisto produce increased muscle mass.

It not only produces huge muscle gains but also has serious cutting properties because it increases nitrogen retention, which in turn helps build muscle mass while burning fat.

When you take D-Bal, you can get up to 10 pounds of muscle growth in a month and the best part is that it only costs $69.99 for a month's supply.

Click here for D-Bal Best Price at Official Website

2- Testo-Max - The Legal Testosterone Clone

If there is any legal steroid after D-Bal that is equally popular, then it has to be Testo-Max. Millions of men around the world are testosterone deficient. While Testosterone replacement therapy is a solution, not everyone is ready for it.

Many people choose to skip TRT because they fear being enslaved by a lifetime of injections. Besides, TRT is a lengthy and expensive process. For weeks and months, you will be struggling to dial down your hormonal baseline.

Testo-Max offers you the same end results with none of the hassles. It's an oral capsule that boosts testosterone levels by up to 72% thanks to ingredients like d aspartic acid. When your serum and free testosterone levels increase, you will get all the benefits associated with it.

Your body builds muscle mass much quicker. You have increased blood flow to the muscle tissue, which enables faster repair. Your sex life skyrockets as your libido and energy levels increase.

Testo-Max is the ultimate mass builder that will also bring about a marked improvement in your quality of life.

Click here for Testo-Max Best Price at Official Website

Decaduro is the bulking steroid alternative that you can take over a longer period of time without worrying about the hassle of managing your hormonal levels.

While its effects are not as pronounced as D-Bal or Testo-Max, Decaduro will help you gain muscle consistently. It is the legal alternative to Deca-Durabolin, one of the oldest and most effective bulking steroids ever made.

Think slow but a steady way to gain muscle. Also, it's not watery, mind you. You get thick slabs of muscle mass with very little, to no water retention or fat gain.

Decaduro is also advantageous for sportsmen because it increases collagen synthesis, thereby promoting recovery and reducing pain caused due to joint health issues. In fact, we know of many sportsmen who use Deca duro year round purely for this.

Deca provides an essential balance to D-Bal's extreme nature. It is for this reason that when you take all three products together in a cycle, you can expect much faster results than when you use them separately.

Click here for Decaduro Best Price at Official Website

Anadrole is the legal alternative to Anadrol, the bulking steroid that charged a generation of men into a new era of epic gains. Anadrol is often considered the twin to Dianabol.

The difference between the two is the kind of muscle tissue that each one produces. Dianabol produces a very wet mass while Anadrol produces a slow and steady increase in both strength and muscle mass.

Anadrole is the legal steroid that produces a similar 'kind' of muscle tissue as Anadrol does. It will help you get bigger and stronger by increasingred blood cells countand thus improving nutrient delivery to your muscles. It offers all the benefits of an intense bulking cycle without any risks.

For instance, Anadrol is notorious for causing debilitating muscle cramps. So much so, that you have to often supplement with Taurine to just make it bearable. It can also increase red blood cells to an extent that it thickens your blood. But Anadrole does not cause these problems. You get the pumps for sure. But without the pain. Your red blood cells increase, but only enough to support anabolism.

Click here for Anadrole Best Price at Official Website

When bulking steroids became a rage, it was obvious that users started to demand a solution for the fat loss phase of their workout.

Crazy bulk responded by launching two products that help you lose weight, - Clenbutrol and Winsol, both legal steroid alternatives to Clenbuterol and Winstrol respectively. Both are extremely effective for any fitness goal that demands that you lose weight.

But cutting is not always about just losing fat. Sometimes, it is also about preserving muscle and even gaining dry muscle tissue. That's why Crazy bulk announced the launch of two more amazing cutting agents, completing a well-rounded portfolio of steroids.

Here's a look at the best cutting steroids from the brand.

Clenbuterol, the sympathomimetic nervous system stimulant is the most popular fat burner used by pros. But even pros generally limit the usage to a few weeks because of howtoxic Clenbuterol is.

That's why Crazy bulk came up with Clenbutrol. Don't miss the missing 'E'. Clenbutrol is the legal alternative to synthetic Clenbuterol. It is an all-natural, potent cutting steroid that mimics the lipolysis effect of clen, without the stimulation and hence, the side effects.

Clenbutrol is a remarkable legal steroid. Its obvious use is in a cutting phase. But most people are unaware of how amazing this legal steroid is while trying to retain lean muscle. For this reason, your cuts become more effective.

You don't end up looking skinny and unhealthy on Clen. Also, it is a terrific legal steroid to stack with bulking compounds. You peel away stubborn body fat and retain the muscle mass.

Click here for Clenbutrol Best Price at Official Website

Anvarol is not exactly a cutting steroid. It is powerful enough to promote muscle gains too. But it has such a strong lipolytic effect that it helps people get rid of stubborn fat while retaining muscle growth.

Anvarol is the legal alternative to Anavar, by the way. Anavar is the steroid of choice for thousands of fitness models and female bodybuilders. The big draw is that it produces very dry and lean muscle tissue, with excellent vascularity.

But any oral C17 AA steroid is metabolized by the liver and hence, can be extremely liver toxic. Anvarol, however, is a completely natural steroid that mimics the positive effects of Anavar without any negative side effects.

You can retain lean muscle, it will help with stripping body fat, gain strength and look ribbed with Anvarol, without worrying about your cholesterol levels.

Click here for Anvarol Best Price at Official Website

Winsol is the legal alternative to Winstrol or Stanozolol. This powerful steroid is often preferred to other C17-AA oral steroids because it provides muscle gains, offers great increment in strength, and does not lead to bloating or water retention.

However, Winstrol can only be used for short bursts of time because it can damage your liver severely if abused. Winsol, on the other hand, has no side effects at all. It does not aromatize or convert to DHT, which means that it won't have any negative impact on your sex drive either.

Winsol is the perfect replica of Winstrol. It is the steroid of choice if you are looking for an aesthetic physique, muscle gains, with very little water retention, great pumps, amazing strength gains, and excellent vascularity.

It is also the perfect product for athletes who need to stay under a certain weight limit, or anyone looking for that hard core workout without looking bulked up.

Click here for Winsol Best Price at Official Website

Last but not the least, we have Trenorol, the legal replica of Trenbolone. We are sure that you have heard great things about Tren. It has attained legendary status in the world of bodybuilding.

But what you do not hear is how toxic and serious the side effects of Tren can be. Trenbolone is a potent drug, and should not be taken by recreational lifters. Period.

However, if you want to get the results of Trenbolone, without going bonkers, then you should consider taking Trenorol instead. It has all the benefits of Tren with zero risks.

Your endogenous levels of Testosterone will peak, changing the way your body produces and repairs lean muscle tissue. You will make great muscle growth, simultaneously with a metabolism boost, which leads to accelerated body fat loss as well. This means that you can take Trenorol for cutting too.

Your lifts will increase in number and weight. You also get amazing muscle pumps during the workout.

Click here for Trenorol Best Price at Official Website

Steroids are a shortcut to muscle gains. But what if you want to cut short the time it takes to build your dream physique, even with steroids?

That's where Crazy bulk's stacks come into the picture.

Steroid stacks are a combination of different steroids that are tailored to provide different effects for specific fitness goals. For instance, the Growth hormone stack combines strong endogenous hormone boosters.

While you can stack any number of Crazy bulk steroids since they work in synergy, here are the two most popular ones for your consideration.

Some legal steroid users have used single runs of the bulking legal steroids mentioned above and hit a plateau. Well, we are talking about natural supplements here and there's only so much it can offer.

If that describes you, then stacks will help you blast through the plateau. The bulking stack contains four of the most potent mass building steroids of all time.

That's the most explosive combination of steroids you can ever use. Don't think that you will only gain mass with this. You will also gain strength, cut body fat, and look ribbed. It's a whole body transformation.

2- The CrazyBulk Cutting Stack

The Crazy Bulk cutting stack is a combination of four potent legal cutting steroids. Just like the bulking stack, the cutting stack is a versatile blend that can do so much more than mere fat loss.

Here are the supplements included in this stack.

If you are looking for a shortcut that will help you get in prime shape in a span of weeks, this is it. The Cutting Stack is the ultimate way to get peeled and beach-ready without jumping through hoops.

Does Crazy bulk only offer steroids?

No. They also offer a variety of other supplements including Whey protein powder. It's just that steroids are the most popular.

Here are some others that might interest you, other than the steroids and the cutting stack.

HGH-X2 is an all natural human growth hormone (HGH) booster. Crazy bulk's expertise in endogenous hormone optimization comes through in HGH-X2 as well. It is very difficult to come across legitimate GH booster folks. HGH-X2 is one of the best legal human growth hormone (HGH) boosters on the market.

It produces a sustained increase in your GH pulses and works by stimulating your pituitary gland. The best part is that HGH-X2 does not come with some of the adverse side effects associated with synthetic HGH. You will notice a marked improvement in recovery, muscle mass gain, fat burn, and the appearance of wrinkles.

HGH-X2 is also the perfect steroid to stack with other steroids, to create a growth hormone stack.

A lot of people get gynecomastia or enlarged male breast tissue due to increased levels of estrogen in their bodies. This typically happens when you hit puberty, but it can also result due to the use of steroids like Testosterone. Gynectrol is specially designed to remove this stubborn layer of chest fat from your breast tissue.

Continue reading here:
CrazyBulk Reviews 2022: How Good Is the Legal Steroids Brand? - Cleveland Scene

Following the initial devastation of the coronavirus pandemic, the U.S. economy has so far engineered an impressive recovery. Although not every metric is perfectly aligned, we can say this much: the early (and understandable) prognostications of doom and gloom did not materialize. However, with so many unknowns heading into 2022, investors may want to adjust their capitalization strategy. Here, were going to discuss ideas for best small-cap stocks to buy.

Why downsize your investment opportunities? First of all, many people have long operated under the thesis of the small-cap effect or the tendency for smaller publicly traded companies to outperform their large-cap counterparts over time. Early this year, the Wall Street Journal provided some contextual evidence for this phenomenon, noting that the best small-cap stocks within the S&P 500 index did indeed outperform their larger rivals.

Another reason to consider downsizing is what Id term the George W. Bush effect of lower expectations. Heading into his presidential debate with former Vice President Al Gore, Bushs team attempted to raise expectations so high for Gore while downplaying them for Bush. A similar situation is going on with large caps as many want to see even more robust growth from them. That might not happen, though, boosting the best small-cap stocks.

Further, everyone thats following the market knows that initial public offerings became, well, endemic in 2021. From traditional offerings to direct listings to special purpose acquisition companies (SPACs), weve seen it all and then some. However, the record year for IPOs may produce an unintended consequence. Mainstream investors are overwhelmed with flashy opportunities, while the best small-cap stocks are flying under the radar, waiting for their turn to shine.

Finally, smaller companies may be able to respond quickly and adapt to shifting market conditions. On the other hand, large-cap firms must answer to powerful stakeholders who may hinder necessary change. Therefore, as we greet the new year, dont forget to consider these ideas for best small-cap stocks to buy.

Of course, nothing in the market is without risk. While the best small-cap stocks may outperform blue chips over time, when circumstances turn volatile, smaller tends to be a liability. Primarily, this is because they lack the resources of larger enterprises. Thus, due diligence is always critical.

Typically, analysts regard small caps as companies that feature a market cap between $300 million to $2 billion. In that context, Im cheating a tad bit with CommVault Systems, which at time of writing runs a hair over $3 billion. Nevertheless, CommVault is listed on many articles of best small-cap stocks, including exchange-traded funds (ETFs) focusing on this subsegment.

But thats not the main reason Im including it here. Rather, the company, which specializes in data protection and data management solutions, is incredibly relevant. For instance, lost data from cyberattacks can cost enterprises millions. Further, smaller organizations that participated in last years grand telecommuting experiment may be at higher risk if their employees dont practice proper security measures.

As well, even the biggest firms can suffer significant damage due to outages and other unforeseen incidents. Therefore, with so much valuable assets transmitting across digital lines, its more imperative than ever for corporations of any size to protect themselves. This dynamic makes CVLT one of the best small-cap stocks to buy, regardless of whatevers lying around the corner in 2022.

More of a traditional small-cap firm with a time-of-writing market value of $557.5 million, ANI Pharmaceuticals specializes in the development, manufacturing and marketing of high-quality branded and prescription generic drugs. Obviously, the pharmaceutical space enjoyed significant attention mostly due to the Covid-19 treatment and vaccination race. With much of that fervor fading, though, ANI can shine in a post-pandemic environment.

Should omicrons higher transmissibility (but less severe symptoms) profile be indicative of the twilight of the Covid period, resources will again shift back toward non-pandemic-related healthcare needs. Further, prescription generics should play an important role in the post-pandemic era. If theres anything that we can rely on, its that healthcare costs seemingly have an exclusive directional trajectory, up.

Moreover, I like companies where the insiders believe in their business, enough so that theyre buying up additional equity. No, insider buying isnt the be-all, end-all for best small-cap stocks. However, its an encouraging sign that since 2020, the transactions that have occurred are buys, not sells. So, if youre the practice-what-you-preach type, you might want to consider ANIP.

Let me caveat the idea of including Endo International on your radar of best small-cap stocks to buy with a warning: This is not going to be any easy opportunity. On a year-to-date basis, ENDP stock has shed 42%.

On the positive side, the red ink means that the market cap for Endo is $1.09 billion, which means its no longer on the borderline of what would be considered a small-cap firm.

But is it one of the best small-cap stocks to buy? As the top holding of the Invesco S&P SmallCap 600 Equal Weight ETF (NYSEARCA:EWSC), plenty of folks at a much higher paygrade than me certainly think so. And as I mentioned earlier with ANI Pharmaceuticals, as the Covid-19 period fades into the rearview mirror, Endos specialty in generics and specialty-branded pharmaceuticals should help lift ENDP stock.

But heres something uniquely intriguing. One of Endos products is Testopel, a testosterone replacement therapy. According to a report published on ScienceDaily, a study of patients hospitalized due to COVID-19 suggests that the disease might deteriorate mens testosterone levels.

Further, many male Covid patients reported loss of libido. Cynically, then, ENDP should rise to the occasion.

As a recent uplisting from the over-the-counter market to the Nasdaq exchange, I consider Ranger Oil Corp a spiritual IPO. True, on paper, an IPO represents the first time a company distributes its equity shares to the public. On the other hand, an uplisting from the pink sheets to a proper exchange is more of an introduction to a wider audience.

But isnt that one of the main points about an IPO? After all, privately held enterprises can raise funds through venture capitalists and other means. However, going public allows firms to reach the widest audience possible, netting the largest raises possible (all other things being equal). So with Ranger Oil being a Nasdaq play, I have higher expectations for it in 2022.

Still, some might question its inclusion on a list of best small-cap stocks to buy considering that the oil and gas business is losing sentiment against renewable energy firms. In recent years, renewables have become much more economically viable due to rising technology and lower costs.

However, the high energy density of fossil fuels means they could be surprisingly relevant for many, many years to come. Therefore, if youve got some loose change, you might want to put it to work with Ranger Oil.

Customers Bancorp is a perplexing idea among best small-cap stocks and not just because Im again playing a little loose with the definition of small. At a few ticks under $2 billion, Customers Bancorp may be poised to enter the mid-cap range fairly soon.

And that notion isnt out of the question. CUBI stock has been a high-flyer in 2021, gaining almost 218% since the January opener. Since Im not the biggest fan of buying into strength after a particularly robust rally, Im personally a bit hesitant on the opportunity.

Nevertheless, some folks might be encouraged with the outsized performance. Certainly, the companys fundamentals justify the premium. For instance, in the first three quarters of this year, Customers Bancorp has already rung up $548.9 million on the top line, exceeding 2020s results by 9.3%.

To be clear, 2020 wasnt a down year for the company, which saw total revenue increase nearly 41% over 2019s result. So, the firm is on a tear.

Whats interesting about Customers Bancorp is that one of its subsidiaries is building a cryptocurrency infrastructure to better serve its clients. Thats the kind of smart, innovative thinking that will make CUBI possibly more relevant than the competition.

Another high-momentum play among the best small-cap stocks to buy, Ill leave it to you whether you want to acquire shares of Arlo Technologies a wireless smart home security system provider into strength or hold out for a better price. Over the past six months, ARLO gained 31% while in the trailing month, its up 16.5%. Most of those gains occurred in the prior five days, up nearly 13%.

However, like other names among the best small-cap stocks, Arlo justifies its momentum through strong financial performances. During the first three quarters of this year, the company generated revenue of $292.3 million. Considering that 2020 sales amounted to $357.2 million, Arlo only needs a modest tally in the fourth quarter to beat out the prior years result.

Heck, a modest tally should be enough to eclipse 2019 sales, which was $370 million.

Most importantly, though, the outside fundamentals are cynically supportive of ARLO stock. For instance, weve been hearing news reports about San Franciscos brazen property crime spree. Apparently, tolerance for such behaviors is dimming, playing into Arlos hands.

My riskiest and most audacious name among best small-cap stocks, Im going to urge you to perform your own due diligence with KAR Auction Services. Believe me, my feelings will not be hurt if you think this idea is garbage. As the corporate brand entails, KAR Auction provides vehicle auctions and related vehicle remarketing services. Thus, the obvious question is, why?

After all, weve seen an absolutely bonkers season for used car prices. Out of nowhere, buying a car any car during the pre-pandemic period was now a great investment. As you know, this runs counter to the common logic (actually fact) that unless youre buying a truly distinct vehicle, mass-produced vehicles almost always lose their value.

However, as much as people would like to think that car prices are on the cusp of falling, so far, theyve been rising. Indeed, a recent Fortune article bemoaned that rates in the secondhand market keep going higher. Surely, the madness will end in 2022?

Well, maybe not. You see, the computer chips that go into vehicles are of a cheaper, lower-margin variety. Therefore, semiconductor firms would much rather prioritize the consumer-electronics industry, which are much more lucrative.

As much as I hate to say it, KAR could very well be one of the best small-cap stocks to buy for 2022.

On the date of publication, Josh Enomoto did not have (either directly or indirectly) any positions in the securities mentioned in this article.The opinions expressed in this article are those of the writer, subject to the InvestorPlace.comPublishing Guidelines.

A former senior business analyst for Sony Electronics, Josh Enomoto has helped broker major contracts with Fortune Global 500 companies. Over the past several years, he has delivered unique, critical insights for the investment markets, as well as various other industries including legal, construction management, and healthcare.

More:
7 of the Best Small-Cap Stocks to Buy Before 2022 - InvestorPlace

It is funny how times change. The Guardian has obtained a letter, written in 2003 by Dr Richard Budgett, in which he discusses the consequences of trans women competing in womens sport. Responding to a government inquiry, Budgett, then at the British Olympic Association, states: The effect of allowing male transsexuals to compete as women would be to make competition unfair and potentially dangerous in some sports and would undermine womens sports.

This would have been an interesting answer at the time. It is even more so now. Society has shifted. Language has changed. Budgett is now medical and scientific director at the International Olympic Committee. And his views, according to IOC sources, have evolved particularly when it comes to finding ways to balance the need for inclusion and fairness in sport. A controversial new IOC framework, drawn up in part by Budgett, adopts a strikingly different stance. While stressing that mens and womens competition should be fair and safe, it also tells sports that, until evidence determines otherwise, trans athletes should not be deemed to have an unfair or disproportionate competitive advantage.

Yet the ink had barely dried on that framework document when the US college swimmer Lia Thomas caused a fresh splash in the debate. For her first three years at the University of Pennsylvania the 22yearold swam as a male competitor, making six Ivy League swimming finals though not setting the world alight. But in the past month, competing as a trans woman after taking hormone replacement therapy to lower her testosterone, she has swum the fastest 200- and 500yard times in the US this year.

That, though, tells only half the story. Thomass 200yard time of 1:41:93 ranks as the 17th fastest of all time less than three seconds off the fivetime Olympic medallist Missy Franklins US record of 1:39:10. Meanwhile her 500yard time of 4:34:06 puts her 21st in history and within striking distance of a record set by Katie Ledecky, who is widely regarded as the greatest female swimmer in the sports history.

All roads now lead to the NCAA championships in March, where Thomas could become swimmings first transgender All-American champion. It will be a significant moment for sport and for Thomas, who last week stressed how important it was for her to swim as her authentic self and praised the IOC for promoting inclusivity while keeping competition integrity going.

Others, though, are less happy. According to reports, Thomass teammates were in tears with one explaining: They feel so discouraged because no matter how much work they put in it, theyre going to lose. Meanwhile Swimming World magazines John Lohn said he was uneasy that Ledeckys record was under threat. Simply, she is an icon who changed what was perceived to be attainable, he wrote. The fact that Thomas could break the record of such a onceinageneration athlete confirms the biological advantages she possesses, and their power,.

Thomass surge to the top of the rankings also poses questions of the IOC and NCAA. Remember the female category exists because the performance gap between elite men and elite women is so stark. It starts at around 10%-13% for running and swimming and rises thereafter. That is why most sports require trans women to suppress their testosterone to compete in the female category.

Recent studies, though, suggest that significant strength and muscular advantages remain even after hormone therapy. Thomass performances appear to back that up. Before transitioning, she was not a serious challenge to male records but is now swimming only 2.6% slower than the current 200yard female record. It means, as the developmental biologist Dr Emma Hilton points out, Thomas has gained a significant ranking advantage from switching category.

Is this unfair? In 2003 Budgett thought so. As he put it in his letter: The BOA believes the effect of allowing transsexuals to compete in their acquired sex would be to make competition unfair for women. The physique determined by two or more decades of life as a male would not be significantly changed (in the case of male to female transsexuals) which would eradicate the concept of a level playing field.

Some will argue that sport is never truly fair, that Michael Phelpss big wingspan gave him genetic advantages too. But male puberty provides such a categorical advantage in terms of muscle mass, strength, lean body mass and bone density that it far exceeds the advantage of a few centimetres in arm length.

No magic bullet, no one-size-fits-all policy can satisfy all sides. The issue involves competing rights and strong emotions. Worryingly a recent UK Sports Councils Equality Group report also found that women in sport were told to keep quiet by their national governing bodies and feared abuse on social media if they voiced their opinions.

Yet perhaps times are changing. At the Sport Resolutions dispute resolution service last week several experts were able to discuss openly and courteously what sports should do next. It made for fascinating listening. For David Grevemberg, of the Centre for Sport and Human Rights, inclusion mattered most. And if sport had to radically change, then it should. Are there ways, that are not infringing on human rights, to create a level playing field? he asked. Are there other conditions that we can create for example staggered starts in the 100m? Or delayed starts?

Thank you for your feedback.

Meanwhile Joanna Harper, a visiting fellow at Loughborough University and a trans woman, argued for a similar approach to the IOCs 2015 guidance but with trans women required to reduce their testosterone to below five nmol/L for at least 12 months. She said the advantages were small enough that trans women and cis women can have equitable and meaningful sport.

However, for Dr Nicola Williams, a spokeswoman for Fair Play For Women, the best solution would be for men to budge up and be more inclusive by allowing trans women and trans men into an open or universal category, with a separate category exclusively preserved for natal females.

Whatever your view, one thing is clear: this issue is not going away. And Thomass groundbreaking performances have only made that clearer to Richard Budgett, the IOC and the rest of us.

Here is the original post:
Sports trans issue is here to stay. But at last, the debate is starting to change - The Guardian

Go here for Part One.

Content Warning: This post contains discussions of medical and sexual abuse of children. Please read with caution.

Dr. John Money was a psychologist and researcher at Johns Hopkins. He did a lot of research into gender and sex, both medically and sociologically, and invented a number of terms and ideas we now associate with both. However, his reputation is not, as the saying goes, great. He was involved with a number of experiments in performing gender-related surgeries on infants, the most infamous being the case of David Reimer.

David Reimer, date unknown

Reimer was born in 1965, one of a pair of twin boys. A botched circumcision destroyed his penis as an infant. Money spent decades championing the idea that gender identity is primarily learned. He persuaded Reimers parents that it would be better for him to receive further surgeries and be raised as a girl (Brenda). They did so. And Moneys involvement didnt stop there. During subsequent appointments with the twins, he forced them to strip for genital inspections (sometimes taking pictures) and to engage in sexual play, claiming that such childhood rehearsals were essential to develop a healthy adult gender identity.1 He trumpeted what he called the John/Joan case as proof positive of his theories about gender being more a result of nurture than nature.

Unfortunately for the victims of this disgusting quack, he was wrong. By age eleven, Brenda had a strong sense he was not a girl, despite regular estrogen injections and female puberty. Finally, in 1980, the Reimers told Brenda the truth. He promptly took on a male identity (including the name David) and began to receive testosterone injections and masculinizing surgeries. No amount of female socialization or hormone replacement therapy had been able to efface his inner sense of who he was.2

Now, I expect a lot of anti-trans readers (Catholic or not) will be nodding along sagely to all of this. You cant fight nature. You cant just decide to be a different gender. Try, and it will take a terrible toll, perhaps a deadly one. This is why all this gender ideology stuff is so dangerous.

But is that really the lesson here? Because if it were that simple, gender transition should produce far greater misery than the dysphoria its meant to treat. But thats not what the evidence shows: on the contrary, transition is the only recognized treatment for adult dysphoria in modern medicine.3 Opponents of gender ideology love to cite detransitioners (people who transitioned to another gender and later changed their minds) as evidence that transition is bad and dangerous, but if anything, they prove the opposite.4 Only a tiny percentage of people whove transitioned pursue detransition, and of those, an even smaller fraction claim to do so out of regret. Most cite factors like prohibitive medical expenses and family rejectionnot a keen inner sense that they were and remain their old gender.

The actual experiences of trans people line up far more with David Reimers than with the lives of cisgender5 people. Theyre usually raised and socialized according to their birth sex; most experience all the normal hormonal changes of puberty. Yet none of this effaces the sense, which they often have from an even earlier age than Reimer, that their gender is not the same as their physical sex. Could any serious person claim that these peoples minds have been changed by a fad? When both nurture and nature have been working to settle them since infancy?

And whats even more ridiculous about all this is, we just did this. We spent the 1980s, 1990s, and 2000s trying out the whole ex-gay narrative. And in 2013, the largest ex-gay organization in the world shut its doors and its leader issued a public apology for the harm hed done.

Does it follow that transgender issues are just like homosexuality? No. But can we at least not rush to make all the same assumptionsthat being trans is a psychological disorder, that its the parents fault for not nurturing the child right, that its curable with the right therapy, that people are doing it for attentionthat just gave us such a colossal series of embarrassing disasters? Can we please stop for five damn minutes and actually look at the research thats been done about this, instead of pretending we must have the answers already because the Church is infallible?

Its no insult to the Church to suggest that she hasnt yet answered a question that simply hadnt been raised before. And its no compliment to suppose that she is incapable of handling new questions. The modern concept of being transgender has antecedents in cultures all over the world, yes. But as far as I can tell, it hasnt been posed in exactly this form before, or with the same scientific resources to help answer it we have today.

Worse still, were not even done with Money. Because he didnt start his career of experimenting on the bodies of helpless infants in 1965. His career goes further back, and gets into the correction of the bodies of intersex people.

And whats intersexuality? I am, both sarcastically and sincerely, glad you asked.

Part Three to come.

1I expect it will come as no surprise to anyone that, while allowing that it could be sadistic, Dr. Money considered affectional pedophilia to be perfectly healthy as well.

2Reimers life, I am sorry to say, remained tragic. He continued to struggle with mental problems throughout his life, as did his brother, who died of an overdose in 2002. In 2004, at age 38, Reimer took his own life. The twins parents consider Dr. Money responsible for both deaths; he himself died in 2006.

3I specify adult here, because gender dysphoria in children does seem to weaken or fade completely at puberty in some cases. However, the research on this is stillno pun intendedin its infancy. It is also true that some adults choose to manage dysphoria, rather than treating it through transition; this doesnt change the fact that managing a condition isnt the same as treating it.

4More realistically, they prove neither: studies of detransition are few as yet, and many have small sample sizes that limit their usefulness.

5Cisgender means a person who identifies with the gender of their birth sex.

Read more here:
With My Body, I Thee Worship: Part Two - Patheos