Anabolic steroids, also called anabolic androgenic steroids or AASs, include testosterone and chemically and pharmacologically related drugs (eg, dihydrotestosterone [DHT], dehydroepiandrosterone [DHEA], androstenedione, fluoxymesterone, nandrolone) used to enhance physical performance and promote muscle growth.
AASs are used to increase lean muscle mass and strength; resistance training and a certain diet can enhance these effects. There is no direct evidence that AASs increase endurance or speed, but substantial anecdotal evidence suggests that athletes taking them can perform more frequent high-intensity workouts. When used inappropriately and chronically at high doses and without medical supervision, they can cause erratic and irrational behavior and a wide range of physical adverse effects.
Estimates of lifetime incidence of AAS abuse are approximately 2% in females and 6% in males worldwide in studies involving both adults and adolescents (1). Overall rates and gender differential are similar in studies specific to adolescents in the United states (2, 3, 4).
Medical indications for testosterone include Medical indications for testosterone includemale hypogonadism in adults and in children, delayed puberty, Klinefelter syndrome, and gender dysphoria. Testosterone is widely used though not clearly recommended for treatment of age-related low testosterone; the risks and benefits of this therapeutic indication are discussed in various professional guidelines (5, 6). Some physicians prescribe AASs to patients with wasting related to severe HIV infection or with cancer. However, there are few data to recommend such therapy and little guidance on how supplemental androgens may affect underlying disorders (7, 8). Additionally, because AASs are anticatabolic and improve protein utilization, they are sometimes used to prevent muscle wasting in patients with significant burns, who are bedbound, or are otherwise debilitated. Testosterone has been theorized to benefit wound healing and muscle injury, although few human data support these claims. AASs are not a generally recognized medical treatment for the muscle dysphoria type of body dysmorphic disorder (9).
In the United States, most AASs are regulated by the Controlled Substances Act, and it is illegal to possess them without a prescription.
General references
1. Sagoe D, Molde H, Andreassen CS, Torsheim T, Pallesen S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Ann Epidemiol 2014;24(5):383-398. doi:10.1016/j.annepidem.2014.01.009
2. Pope HG Jr, Kanayama G, Athey A, Ryan E, Hudson JI, Baggish A. The lifetime prevalence of anabolic-androgenic steroid use and dependence in Americans: current best estimates. Am J Addict 2014;23(4):371-377. doi:10.1111/j.1521-0391.2013.12118.x
3. Kersey RD, Elliot DL, Goldberg L, et al. National Athletic Trainers' Association position statement: anabolic-androgenic steroids. J Athl Train 2012;47(5):567-588. doi:10.4085/1062-6050-47.5.08
4. LaBotz M, Griesemer BA; COUNCIL ON SPORTS MEDICINE AND FITNESS. Use of Performance-Enhancing Substances. Pediatrics 2016;138(1):e20161300. doi:10.1542/peds.2016-1300
5. Kanakis GA, Pofi R, Goulis DG, et al. EMAS position statement: Testosterone replacement therapy in older men. Maturitas 2023;178:107854. doi:10.1016/j.maturitas.2023.107854
6. Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and Management of Testosterone Deficiency: AUA Guideline. J Urol 2018;200(2):423-432. doi:10.1016/j.juro.2018.03.115
7. Moyle GJ, Schoelles K, Fahrbach K, et al. Efficacy of selected treatments of HIV wasting: a systematic review and meta-analysis. J Acquir Immune Defic Syndr 2004;37 Suppl 5:S262-S276. doi:10.1097/01.qai.0000144381.09350.5b
8. Roeland EJ, Bohlke K, Baracos VE, et al. Management of Cancer Cachexia: ASCO Guideline. J Clin Oncol 2020;38(21):2438-2453. doi:10.1200/JCO.20.00611
9. Castle D, Beilharz F, Phillips KA, et al. Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. Int Clin Psychopharmacol 2021;36(2):61-75. doi:10.1097/YIC.0000000000000342
Pathophysiology Caused by Anabolic Androgenic Steroid Use
AASs have androgenic effects (eg, changes in hair or in libido, aggressiveness) and anabolic effects (eg, increased protein utilization, increased muscle mass). Androgenic effects cannot be separated from the anabolic, but some AASs are synthesized to minimize the androgenic effects.
Chronic effects
There is limited acute toxicity with a single dose. Adverse effects of AASs vary significantly by dose and drug. There are few adverse effects at physiologic replacement doses (eg, methyltestosterone 10 to 50 mg/day or its equivalent). Athletes may use doses 10 to 50 times this range. At high doses, some effects are clear; others are equivocal (see table There is limited acute toxicity with a single dose. Adverse effects of AASs vary significantly by dose and drug. There are few adverse effects at physiologic replacement doses (eg, methyltestosterone 10 to 50 mg/day or its equivalent). Athletes may use doses 10 to 50 times this range. At high doses, some effects are clear; others are equivocal (see tableAdverse Effects of Exogenous Anabolic Androgenic Steroids). Uncertainties exist because most studies involve individuals using steroids illegally or illicitly, who may not report doses accurately and who also use black market drugs, many of which are counterfeit or contain (despite labeling) varying doses and substances.
Adverse Effects of Exogenous Anabolic Androgenic Steroids
Probable or Proven | Not Well Shown |
|---|---|
Dermatologic effects : Acne, alopecia, virilization, voice changes, and hirsutism in females, Cardiovascular: Hypertension, left ventricular hypertrophy, impaired ventricular function (systolic and diastolic), dyslipidemia (decreased HDL, increased LDL) Endocrine: Male gonadal suppressionn (decreased sperm count, testicular atrophy, subfertility/infertility), gynecomastia, abnormal menstrual cycle Hematologic: Erythrocytosis, thromboembolism Hepatic: Peliosis hepatitis, adenoma Musculoskeletal: Premature closure of epiphyses, tendon/ligament ruptures Neuropsychiatric: (at high doses) manic or hypomanic behavior, aggressiveness, irritability, decreased sexual drive Renal: Proteinuria, decreased glomerular filtration rate, fluid retention | Cardiovascular: Increased risk of sudden death in athletes Genitourinary: Testicular cancer, prostate cancer, prostatic hypertrophy Hepatic: Hepatic carcinoma Endocrine: Decreased glucose tolerance, thyroid dysfunction Neuropsychiatric: Cognitive deficits, significant mood disorder at low doses |
HDL = high-density lipoprotein; LDL = low-density lipoprotein;. | |
Data from Bond P, Smit DL, de Ronde W. Anabolic-androgenic steroids: How do they work and what are the risks? Front Endocrinol (Lausanne). 2022;13:1059473. doi:10.3389/fendo.2022.1059473; Kersey RD, Elliot DL, Goldberg L, et al. National Athletic Trainers' Association position statement: anabolic-androgenic steroids. J Athl Train 2012;47(5):567-588. doi:10.4085/1062-6050-47.5.08; Mingxing L, Yanfei Y. Adverse Effects of Anabolic Androgenic Steroid Abuse in Athletes and Physically Active Individuals: A Systematic Review and Meta-Analysis. Subst Use Misuse. Published online February 13, 2025. doi:10.1080/10826084.2025.2460986; Nieschlag E, Vorona E. Doping with anabolic androgenic steroids (AAS): Adverse effects on non-reproductive organs and functions. Rev Endocr Metab Disord 2015;16(3):199-211. doi:10.1007/s11154-015-9320-5; and Smit DL, Buijs MM, de Hon O, den Heijer M, de Ronde W. Positive and negative side effects of androgen abuse. The HAARLEM study: A one-year prospective cohort study in 100 men. Scand J Med Sci Sports 2021;31(2):427-438. doi:10.1111/sms.13843 | |
Athletes may take a fixed dose of one or multiple kinds of AASs for a certain period, stop, then start again (cycling) several times a year. Stopping the drugs in particular is believed to allow endogenous testosterone levels, sperm count, and the hypothalamic-pituitary-gonadal axis to return to normal and to decrease harmful effects and the need for increasing drug doses to attain the desired effect. However, multiple studies demonstrate the persistence of adverse effects while cycling (1,2, 3).
Athletes frequently use multiple kinds of AASs simultaneously (a practice called stacking). They may use different routes of administration (oral, IM, or transdermal) simultaneously. Starting from a small dose and increasing the dose gradually, and tapering the dose of the same AAS to zero is referred to as pyramiding. Stacking and pyramiding are intended to increase receptor binding and minimize adverse effects. To avoid positive anti-doping tests, athletes may stop using long-lasting AASs and replace them with shorter-acting formulations (bridging).
Pathophysiology references
1. Christou MA, Christou PA, Markozannes G, Tsatsoulis A, Mastorakos G, Tigas S. Effects of Anabolic Androgenic Steroids on the Reproductive System of Athletes and Recreational Users: A Systematic Review and Meta-Analysis. Sports Med 2017;47(9):1869-1883. doi:10.1007/s40279-017-0709-z
2. Hammoud S, van den Bemt BJF, Jaber A, Kurdi M. Chronic anabolic androgenic steroid administration reduces global longitudinal strain among off-cycle bodybuilders. Int J Cardiol 2023;381:153-160. doi:10.1016/j.ijcard.2023.03.057
3. Smit DL, Buijs MM, de Hon O, den Heijer M, de Ronde W. Positive and negative side effects of androgen abuse. The HAARLEM study: A one-year prospective cohort study in 100 men. Scand J Med Sci Sports 2021;31(2):427-438. doi:10.1111/sms.13843
Symptoms and Signs of Anabolic Androgenic Steroid Use
The most characteristic sign of anabolic androgenic steroid (AAS) use is a rapid increase in muscle mass. The rate and extent of increase are directly related to the doses taken. Patients taking physiologic doses have slow and often unnoticeable growth; those taking megadoses may increase lean body weight by several pounds per month. Increases in energy level and libido (in men) occur but are more difficult to quantify.
Psychologic effects (usually only with very high doses) are often noticed by family members:
Wide and erratic mood swings
Irrational behavior
Increased aggressiveness (“roid rage”)
Irritability
Increased libido
Depression
Increased acne is common in both sexes; libido may increase or, less commonly, decrease; aggressiveness and appetite may increase. Gynecomastia, testicular atrophy, and decreased fertility may occur in males. Virilizing effects (eg, alopecia, enlarged clitoris, hirsutism, deepened voice) are common among females. Also, breast size may decrease; vaginal mucosa may atrophy; and menstruation may change or stop. Virilization and gynecomastia may be irreversible.
Diagnosis of Anabolic Androgenic Steroid Use
Usually a clinical diagnosis
Sometimes urine testing
Although elite athletes are tested for AAS use by anti-doping agencies, there is no practical diagnostic test to evaluate for surreptitious AAS use in the general patient population. When a patient presents with signs and symptoms of chronic AAS use, it is important to include AAS use in differential diagnoses. It might be useful to measure serum testosterone, follicle-stimulating hormone, and luteinizing hormone levels, since they are more commonly available tests. Exogenous testosterone and AASs decrease gonadotropin levels.
When testing to detect AASs is done, urine analysis is by gas chromatography-mass spectrophotometry.
Testosterone taken exogenously is indistinguishable from endogenous Testosterone taken exogenously is indistinguishable from endogenoustestosterone by gas chromatography-mass spectrophotometry. However, if high levels of testosterone are detected, the ratio between testosterone and epitestosterone (an endogenous steroid that chemically is nearly identical to testosterone) is measured. A testosterone:epitestosterone ratio > 6:1 is suggestive of exogenous testosterone use.
Treatment of Anabolic Androgenic Steroid Use
Cessation of use
Use of medications to restore fertility
The main treatment for users of anabolic androgenic steroids (AASs) is cessation of use. Although physical dependence does not occur, psychologic dependence, particularly in competitive bodybuilders and athletes, may exist. Gynecomastia may require surgical reduction. A person who uses injectable formulations should be updated on tetanus vaccination.
A well-known complication of AAS use is infertility, due to the suppression of the hypothalamic-pituitary-gonadal (HPG) axis and subsequent suppression of spermatogenesis in the testes. Cessation of AAS use can restore spermatogenesis, but recovery can take several months to years (1). Many of these patients are in their prime reproductive years, and depending on factors such as the age of the female partner and number of children desired, there may be a strong need to restore fertility as soon as possible. In these patients, medications such as selective estrogen receptor modulators (eg, clomiphene, enclomiphene), aromatase inhibitors (eg, anastrozole, letrozole), and gonadotropins (human chorionic gonadotropin and follicle stimulating hormone) can be used to restore the HPG axis and spermatogenesis (receptor modulators (eg, clomiphene, enclomiphene), aromatase inhibitors (eg, anastrozole, letrozole), and gonadotropins (human chorionic gonadotropin and follicle stimulating hormone) can be used to restore the HPG axis and spermatogenesis (1, 2). However, even with medical therapy, a substantial proportion of patients can continue to have subfertile semen parameters and ultimately require assisted reproduction (3).
Treatment references
1. McBride JA, Coward RM. Recovery of spermatogenesis following testosterone replacement therapy or anabolic-androgenic steroid use. Asian J Androl 2016;18(3):373-380. doi:10.4103/1008-682X.173938
2. Tatem AJ, Beilan J, Kovac JR, Lipshultz LI. Management of Anabolic Steroid-Induced Infertility: Novel Strategies for Fertility Maintenance and Recovery. World J Mens Health 2020;38(2):141-150. doi:10.5534/wjmh.190002
3. Ledesma BR, Weber A, Venigalla G, et al. Fertility outcomes in men with prior history of anabolic steroid use. Fertil Steril 2023;120(6):1203-1209. doi:10.1016/j.fertnstert.2023.09.016
Prevention of Anabolic Androgenic Steroid Use
Physicians caring for both adults and adolescents should be alert to the signs of AAS abuse and teach patients about its risks. Education about AASs should start by the beginning of middle school, using programs that teach alternative, healthy ways to increase muscle size and improve performance through good nutrition and weight training techniques. Presenting both risks and benefits of AAS use seems to be a more effective way to educate adolescents about the negative effects of illicit steroid use.
Drugs Mentioned In This Article
