Anabolic Steroids

Earn CME/CE in your profession:


Continuing Education Activity

Anabolic steroids are synthetic derivatives of testosterone that have both medical applications and a high potential for misuse. These agents play a critical role in managing conditions such as primary hypogonadism, delayed male puberty, hypogonadotropic and idiopathic hypogonadism, Kallman syndrome, luteinizing hormone-releasing hormone deficiency, and dysfunction of the pituitary-hypothalamic axis. Despite their therapeutic benefits, anabolic steroids are frequently misused due to their ability to enhance muscle size and strength, which can lead to significant adverse effects and long-term health risks.

This activity provides healthcare professionals with essential knowledge about the appropriate diagnostic workup, dosing schedules, and monitoring strategies for anabolic steroid use. Key topics include the mechanism of action, pharmacodynamics, pharmacokinetics, adverse event profiles, and potential interactions. Guidance is also provided on recognizing signs of misuse and managing withdrawal symptoms effectively. By addressing these aspects, this activity supports the interprofessional team in ensuring the safe and appropriate use of anabolic steroids while mitigating risks associated with misuse and abuse.

Objectives:

  • Identify the approved indications for anabolic steroid therapy.

  • Assess the general mechanism of action of the anabolic steroid class of drugs.

  • Identify the potential adverse effects and indicate appropriate monitoring for adverse events when using anabolic steroids.

  • Implement collaborative interprofessional team strategies for improving care coordination and communication to advance appropriate clinical outcomes with anabolic steroid therapy and improve outcomes, as well as measures to prevent misuse.

Indications

Anabolic steroids (also known as androgenic steroids) are synthetic derivatives of testosterone. The legal, as well as illegal, use of anabolic steroids is increasing. According to the National Household Survey on Drug Abuse, it is estimated that there are at least about one million current or former illegal users of anabolic steroids in the US, of which over 300,000 are current users.[1] About 3% of all young males in the US have used anabolic steroids, including over 500,000 students still in high school.[2][3]

There are 2 types of anabolic steroids: 17-α-alkyl derivatives (eg, oxandrolone, oxymetholone, and fluoxymesterone) and 17-β-ester derivatives (eg, testosterone cypionate, testosterone enanthate, testosterone heptylate, testosterone propionate, nandrolone decanoate, nandrolone phenpropionate, and dromostanolone). Nandrolone phenpropionate is a C18 androgenic anabolic steroid and was one of the first anabolic steroids to be used as a doping agent by professional athletes in the 1960s. This drug was banned from the Olympics by the IOC in 1974. All anabolic steroids are DEA schedule III drugs.[4][5][6]

FDA-Approved Indications 

These include primary hypogonadism, delayed puberty in boys, hypogonadotropic hypogonadism, luteinizing hormone-releasing hormone deficiency, pituitary-hypothalamic axis dysfunction from various tumors, injury, and radiation. Other indications for the use of testosterone include primary testicular failure in patients with cryptorchidism, orchitis, testicular torsion, vanishing testis syndrome, previous history of orchiectomy, Klinefelter syndrome, Kallman syndrome, chemotherapeutic agents, and toxic damage from alcohol use or heavy metal exposure. Proper dosing of anabolic steroids for verified medical indications is best described in the companion StatPearls' reference review on Androgen Replacement at www.statpearls.com/point-of-care/17525.[7]

Off-Label Uses 

These include bone marrow stimulation in leukemia, aplastic anemia, kidney disease, growth failure, loss of appetite, and loss of muscle mass in malignancy and acquired immunodeficiency syndrome. Anabolic steroids are illegally used by athletes at all levels in sports, such as bodybuilding, weightlifting, baseball, football, cycling, wrestling, and many others, to improve their performance.

Anabolic Steroid Abuse 

The lifetime prevalence of anabolic steroid abuse in men is estimated at 6.4% and is increasing.[8] Recent data suggests that the current average user of anabolic steroids for unauthorized non-medical reasons is highly educated, White, has an above-average income, is approximately 30 years old, and does not participate in sports.[9] They use anabolic steroids to "feel better" and increase muscle mass.[9] There is an even higher incidence of anabolic steroid abuse reported among weight lifters, bodybuilders, active duty military, law enforcement personnel, strongman competitions, practitioners in martial arts (especially kickboxing and mixed martial arts), and prison populations.[10] While most bodybuilding competitions officially have a drug-free policy, it is rarely enforced, so anabolic steroid abuse is widespread in the sport, especially at the highest levels of competition.[11] Among senior weightlifters, the incidence is reported to be 44%.[12]

A noticeable increase in strength and muscle mass can be seen in as little as 6 weeks in younger men on anabolic steroids who exercise.[13] Similar results in older men may require higher testosterone dosages and longer durations.[13] Unfortunately, anabolic steroids are inexpensive and readily available in gyms and fitness centers and online despite more stringent DEA safeguards and regulations designed to limit illegal access.[14] When strength-based athletes who used unauthorized anabolic steroids were compared to similar athletes who did not use supplemental hormones, the anabolic steroid abusers demonstrated a higher level of cardiovascular risk, more coronary artery disease, and concentric myocardial hypertrophy.[15]

Illegal anabolic steroid use is thought to frequently start in teenagers due to social and peer pressure, as it is believed to help with depression, improve athletic performance, increase muscle mass, and enhance body self-image.[16] Compared to the general population, anabolic steroid abusers are more likely to have been involved in school sports and have a history of other illicit drug use. Over half of all anabolic steroid abusers reported recent use of illicit recreational drugs (eg, amphetamines, cannabis, cocaine, etc).[17] One-third will have friends or relatives who abuse anabolic steroids.[11]

Muscle-building, performance-enhancing dietary supplements are heavily marketed to boys, teenagers, and young men (especially those participating in sports) as safe nutritional aids, taking advantage of the intense social and peer pressure to increase muscle mass to look and feel good.[18][19][20] These dietary aids often contain high levels of stimulants, steroids, and various other toxic substances that are not even listed as ingredients due to inadequate regulation of nutritional supplements in the US.[18][20][21] These unregulated but heavily promoted nutritional supplements serve as an effective gateway to early anabolic steroid abuse.[2][18]

While the benefits of anabolic steroid use to increase athletic performance are undeniable, they also pose a serious health risk, which is why sports organizations universally ban them. Anabolic steroid abuse can inappropriately activate signaling proteins like mTOR, disrupt normal protein synthesis, modify cell cycle metabolism, increase oxidative stress, and cause cellular apoptosis. Clinically, this results in cardiovascular disorders such as hypertension, dyslipidemia, coronary artery arteriosclerosis, and left ventricular hypertrophy, leading to eventual heart failure as well as acne, altered brain GABA receptors, Achilles tendon rupture, early sudden death, gynecomastia, hypercoagulability, infertility, neuropsychiatric disorders, testicular dysfunction, and atrophy of the testes.[15][22][23][24][25] Supraphysiological dosages have also been associated with early dementia.[26] The estimated overall risk of death among chronic anabolic steroid abusers is roughly double or triple that of the age-adjusted male control population.[27][28][29]

Laboratory findings of anabolic steroid abuse include decreased levels of sex hormone-binding globulin, high-density lipoprotein, and cholesterol due to the effect of chronic exogenous androgen abuse on the liver.[11] Testosterone levels are likely to be above the normal range if sampled during a treatment period.[11] Urine, blood, and hair samples can be tested for anabolic steroid abuse using liquid and gas chromatography as well as mass spectrometry.[30][31][32][33]

For more information on Anabolic Steroid Toxicity and Anabolic Steroid Use Disorder, see the respective companion StatPearls' reference reviews at www.statpearls.com/point-of-care/291 and www.statpearls.com/point-of-care/17498.[24][34]

Mechanism of Action

Endogenous androgen is responsible for the growth and development of the sex organs in men and for maintaining secondary male sex characteristics. The enzyme aromatase converts testosterone to estradiol, and 5α-reductase converts testosterone to the more potent dihydrotestosterone.[11] Endogenous anabolic steroids such as testosterone and dihydrotestosterone, as well as synthetic anabolic steroids, mediate their effects by binding to and activating androgen receptors.[35]

In skeletal muscle, anabolic steroids regulate the transcription of target genes that control the accumulation of DNA in skeletal muscle required for muscle growth.[6][35][36][37] Anabolic steroids increase muscle satellite cell proliferation and promote the formation of new myotubules and myonuclei.[24][38] They also regulate lipolysis, which affects catecholamine signal transduction, and block the differentiation of adipocyte precursor cells.[24][39] Exogenous high-dose anabolic steroids also affect G-protein-coupled plasma membrane receptors, which ultimately increase the phosphorylation of transcription factors by increasing the Ca2+ concentration and activating ERK1/2 kinases.[24]

Anabolic steroids also upregulate and increase the number of androgen receptors, thus enabling increased training intensity and indirectly contributing to increased muscle size and strength. They also have a stimulatory effect on the brain through their diverse effects on various central nervous system neurotransmitters, antagonism of glucocorticoids, and stimulation of the growth hormone-insulin-like growth factor-1 axis.

Nandrolone decanoate and phenpropionate are associated with an increased ratio of anabolic activity versus androgenic activity. Nandrolone decanoate is designed to increase muscle mass. This slow-acting steroid promotes nitrogen retention in muscles, increases muscle size, and relieves joint pain by promoting collagen synthesis and enhancing bone mineralization. Nandrolone phenpropionate also increases muscle growth, improves appetite, and stimulates red blood cell production, which may sometimes result in polycythemia.

Dromostanolone is a synthetic anabolic steroid with anti-estrogenic properties and is 5 times more potent than methyltestosterone, which is often used illegally by bodybuilders to prepare for competition. Dromostanolone increases the retention of nitrogen, phosphorus, and potassium, resulting in increased protein anabolism and a decrease in the catabolism of amino acids, leading to an increase in the density and hardness of muscle.

In some cases of symptomatic hypogonadism, clomiphene can be used to increase testosterone levels to normal without directly using anabolic steroids and without affecting fertility.[7][40][41] Clomiphene is not effective in patients with elevated LH levels.[7][40][41]

Administration

Available Dosage Forms

Anabolic steroids may be administered via oral pills, injections, topical creams or gels, or skin patches.

Adult Dosing

  • Testosterone cypionate and enanthate are given as 50 to 400 mg intramuscularly once to 4 times a month for primary hypogonadism and hypogonadotropic hypogonadism. The recommended initial regimen is 100 mg IM weekly to minimize peaks and valleys while avoiding supernormal levels. The use of gels and creams can also alleviate dosage variations.
  • Testosterone undecanoate dosing starts with an initial dose of 750 mg, then 750 mg 4 weeks after the first dose, and 750 mg at 10-week intervals.
  • Testosterone gel dosage varies according to the hormone concentration. One gel preparation is given as 11 mg 3 times daily for a total daily dose of 33 mg. Another testosterone gel is given at the dose of 40 mg once a day every morning with a maximum dose of 70 milligrams per day. Some compounding pharmacies may produce a similar gel at a lower cost than commercially manufactured preparations.
  • Transdermal testosterone is applied as a 50 mg patch once daily in the morning to the upper limb, shoulder, or abdomen, with a maximum daily dose of 100 mg.
  • Oral testosterone preparations are generally not recommended due to hepatic toxicity except for testosterone undecanoate, which is now FDA-approved.[42][43][44][45][46][47] The primary problem with testosterone undecanoate is the cost (without insurance or other discounts, the cost is over $1,200 per month).

For more information on the administration and therapeutic medical use of anabolic steroids, see the companion StatPearls' references on "Androgen Replacement" and Male Hypogonadism," respectively, at www.statpearls.com/point-of-care/23268 and www.statpearls.com/point-of-care/17525.[7][40]

Off-Label Medical Use

  • Nandrolone decanoate dosing is 100 mg per week for comfort and relief of joint pain. To increase growth and athletic performance, the dose range is 200 mg to 400 mg per week. This drug is often used for about 10 to 12 weeks to get the desired "optimal" results in athletes, powerlifters, and bodybuilders.
  • Dromostanolone is used at 200 to 400 mg weekly, which bodybuilders use to enhance their athletic performance. Because of its short half-life, dromostanolone injections must be administered every 3 to 4 days.

Among anabolic steroid abusers, the amounts of anabolic steroids used are often markedly above usual dosage levels when utilized appropriately for medical indications, often by 10-fold or more. They may take different forms of anabolic steroid preparations or mix oral and parenteral drugs, a process called "stacking." Frequently, they will administer the steroids in cycles of 6, 12, or 18 weeks, which is known as "pyramiding."[11] Users believe these techniques will improve the results while minimizing adverse effects, but no scientific evidence supports such conclusions.[11] 

The use of post-cycle withdrawal therapy, with human chorionic gonadotropin and clomiphene, is a common practice intended to minimize withdrawal symptoms, but it has not undergone stringent scientific review or study.[48][49]

Adverse Effects

Early abnormal measurable adverse effects of anabolic steroid use include abnormal liver enzymes, hypercholesterolemia, hypertension, and polycythemia.[50] Long-term adverse events are not well studied, randomized trials would not be ethical, and large prospective studies are not available.[11] This leaves only case-control studies and small series that are often methodologically flawed.[11] Some adverse effects associated with anabolic steroid use are listed below by organ system.[24][35][51][52][53][54][55]

  • Cardiovascular: Early or accelerated coronary heart disease, cardiomyopathy, hypertension (3% or less), left ventricular hypertrophy, decreased cardiac function, increased cardiac fibrosis, intraventricular dyssynchrony, arrhythmias, and even sudden cardiac death.[56][57][58][59][60][61]
  • Dermatologic: Skin blister (12%), acne vulgaris (8% or less), crusted skin, nasal excoriation (6% or less), contact dermatitis, bulla, skin rash, and pruritus.[62][63]
  • Endocrine and metabolic: Decreased HDL cholesterol (6% or less), hyperlipidemia (6% or less), hypokalemia, increased serum triglycerides thyroid-stimulating hormone level and plasma estradiol concentration, decreased libido (3% or less), gynecomastia (3% or less), hot flashes and weight gain.[64] Gynecomastia and/or breast tenderness may develop.[11]
  • Gastrointestinal: Gingivitis (9% or less), mouth irritation (9% or less), increased serum bilirubin, abnormal hepatic function tests, decreased appetite, dysgeusia, gastroesophageal reflux disease, and gastrointestinal hemorrhage.[65][66]
  • Genitourinary: Increase in prostate-specific antigen (topical 18% or less), benign prostatic hypertrophy (12%), testicular atrophy (6% or less), suppression of spermatogenesis, mastalgia, hypogonadism (following withdrawal), prostatitis, dysuria, hematuria, impotence, pelvic pain, urinary incontinence, urinary tract infection, testicular tenderness, male infertility (severe oligospermia with permanent subfertility), ejaculatory disorders and erectile dysfunction (nandrolone).[67]
  • Hematologic and oncologic: Polycythemia (6%) and prostate carcinoma (less than 3%). There is conflicting evidence for any hypercoagulability effects.[35][68][69] Impaired fibrin clot lysis has been found in androgenic anabolic steroid abusers.[70]
  • Hepatic: Abnormal liver function or peliosis hepatitis may be found. Continuous use can cause the malignant transformation of benign hepatic neoplasms to hepatocellular carcinoma.[71][72][73][74][75]
  • Nandrolone causes hirsutism and deepening of voice in a woman with extended periods of use due to its androgenic properties.[76]
  • Neuromuscular and skeletal: Myalgia (6% or less), premature epiphyseal closure (when taken before completion of puberty), limb pain, tendon rupture, abnormal bone growth, and hemarthrosis.[77] They also have an increased rate of Achilles tendon rupture compared to other weight-trained athletes who are not taking anabolic steroids.[78]
  • Neuropsychiatric: Emotional lability, major mood disorders, anosmia, anxiety, headache, depression, nervousness, dementia, body pain, violence, insomnia, and aggressive behavior.[79][80][81][82] About two-thirds of androgen-abusing weight lifters have reported significant sleep disturbances, which may worsen during immediate periods of withdrawal.[83]
  • Renal: Increase in serum creatinine and frequency of urination.[84][85]

Contraindications

Testosterone supplements are contraindicated in the presence of severe renal, cardiac, and hepatic disease, men with breast or prostate cancer, venous thromboembolism, pregnant women, women who may become pregnant, breastfeeding mothers, and hypersensitivity to any component of the formulation. 

The Endocrinology Society suggests that it may be judicious to avoid treatment with testosterone in men who have a history of myocardial infarction or stroke in the last 6 months.[86][87]

Monitoring

Before initiating treatment with testosterone, a diagnosis of male hypogonadism requires confirmation by measuring low early morning testosterone levels on 2 separate days.[7][88] Lipid profile, liver function tests, hemoglobin, hematocrit, FSH, LH, estradiol, prostate-specific antigen, and a prostate exam in patients older than 40 are necessary before initiating treatment.[7][89] Thyroid function testing has also been recommended. Patients should be warned that they will become infertile while on testosterone therapy even if properly monitored and dosed, although this can be mitigated with simultaneous clomiphene treatment.[7][41]

During treatment with anabolic steroids, clinicians should periodically obtain the patient's lipid profile, hepatic function tests, hemoglobin, hematocrit (at 3 to 6 months, then every year), PSA, and testosterone levels. Patients on testosterone should be monitored for their response to treatment and adverse effects 3 to 6 months after initiation of therapy and then every year, especially for cardiac adverse events. Women treated with testosterone for breast cancer require monitoring for signs of virilization.

Men over 40 years of age with baseline prostate-specific antigen (PSA) of more than 0.6 ng/mL should have their PSA levels measured and a prostate examination at 3 to 6 months. Treatment should be withheld in men with a palpable prostate nodule or prostate-specific antigen of more than 4 ng/mL and in patients at high risk of prostate malignancy with prostate-specific antigen of more than 3 ng/mL.

According to Endocrine Society 2010 guidelines, testosterone levels should be measured midway between injections of testosterone enanthate or cypionate. Any dose and frequency adjustments should keep the testosterone concentration between 400 and 700 ng/dL. However, some experts recommend checking the peak testosterone levels, which are best obtained 2 days after an IM injection once maintenance levels are reached. The goal is to keep the peak level in the middle third of the normal range, avoid the potential toxicity of supernormal testosterone levels, and relieve the specific symptom of hypogonadism that justified its use initially. There is no need to check trough levels if the patient is not symptomatic.

For most patients, 100 mg of injectable testosterone (cypionate or enanthate) is sufficient to maintain optimal testosterone levels.[7][90] A 2- or 3-week interval dosage schedule will either be inadequate or produce above-normal peak levels.[7] Serum testosterone levels should be measured 2 to 8 hours after transdermal or gel application and after 14 days of starting the therapy or with dose titration in patients using a topical testosterone solution.  

Total serum testosterone should be measured periodically, starting from the first month after initiating therapy in patients using nasal testosterone gel, and treatment should terminate if total testosterone exceeds 1050 ng/dL or the upper limit of normal for the reference laboratory. Serum testosterone level should be measured approximately 14 days after initiation of therapy, in the morning, before application of transdermal testosterone, at the end of the dosing interval in testosterone pellets, 4 to 12 weeks after initiation of treatment, and before the morning dose in patients using a buccal form of testosterone.[91][92]

Toxicity

Even when therapeutic levels of testosterone are maintained and the patient is properly monitored, minimal toxicity may be present. Even correctly administered testosterone for medically appropriate indications can reduce male fertility due to its lowering of FSH and LH.[7][40] This effect can be mitigated by simultaneously administering clomiphene.[7][40][41]

The risks of short-term androgenic anabolic steroid abuse include polycythemia, increased PSA levels, benign prostatic hyperplasia, an increased risk of prostate cancer, oligospermia, and emotional effects such as dramatic mood swings, aggressive behavior, impaired judgment, and episodes of intense anger (known as "roid rage").[93][94]

Chronic anabolic steroid abuse carries significant potential morbidities. The effects on liver metabolism, kidney function, and spermatogenesis are generally limited and reversible, but other effects, such as cardiac disorders and sudden cardiac death, require further study.[11][93]

Male infertility (due to steroid-induced azoospermia, oligospermia, increased abnormal sperm morphology, and decreased motility) tends to resolve slowly over time after cessation of testosterone.[67][93][95][96][97][98][99] While this may normalize in 3 to 4 months, the recovery of normal spermatogenesis and testosterone levels may take an additional 1 to 3 years.[93][95][96][97][100]

Potentially dangerous changes in cardiac structure and function include left ventricular hypertrophy (which can lead to arrhythmias and congestive heart failure), premature atherosclerosis, cardiomyopathy, and an increased risk of sudden cardiac death.[56][93][101][102][103] Autopsy studies have shown otherwise unexplained cardiac muscle damage with focal injury and hypertrophy of cardiac muscle cells, small vessel disease, and subepicardial interstitial fibrosis.[104] Recent evidence indicates men who were chronic anabolic steroid abusers demonstrated decreased myocardial flow reserve from impaired coronary microcirculation even when the hormonal drugs were stopped years earlier.[23][56][103]

Sudden cardiac death in anabolic steroid abusers has been linked primarily to several underlying pathophysiological processes. These include arrhythmias induced by anabolic steroid-related cardiac hypertrophy, fibrosis, and tissue necrosis, direct myocardial injury, increased thrombosis, nitric oxide-induced vasospasm, and accelerated arteriosclerosis.[60][101][105][106][107][108][109]

Female anabolic steroid abuse is increasing in both professional and amateur athletics but is still far less common than in males at an estimated prevalence of 1.6%.[110] The adverse effects are similar to those experienced by males, but there is limited data regarding this topic. Abnormal menstrual effects are common in female athletes. Illegal use of anabolic steroids in women is an underestimated problem in public health and presents a significant diagnostic challenge for healthcare professionals.[110]

Withdrawal from anabolic steroid abuse is associated with various adverse effects, including anorexia, body image dissatisfaction, decreased appetite, depression and depressed mood, fatigue, headache, insomnia, low libido, myalgia, restlessness, suicidal ideations, urges to resume steroids, and weight loss.[77] 

Agents that may help minimize withdrawal symptoms and more quickly restore normal spermatogenesis include aromatase inhibitors (eg, anastrozole, exemestane, letrozole), selective estrogen receptor modulators (eg, clomiphene, tamoxifen), and injectable gonadotropins.[111] However, their true clinical benefit is still unclear due to a lack of high-quality studies.[111][112][113] There is evidence that such treatment reduces the reported urge to resume anabolic steroid use by 60% and suicidal ideations by 50%, although there is limited objective data to support this conclusion.[49][95][112]

The incidence of prolonged androgen-induced hypogonadism with reduced quality-of-life scores after withdrawal from anabolic steroid abuse is expected to increase in the coming years. Treatment methods to reactivate the hypothalamic-pituitary-testicular axis (ie, aromatase inhibitors, clomiphene, and human chorionic gonadotropin, along with phosphodiesterase inhibitors for men with ED) have been used with some success, but these therapies have not been standardized and controlled trials have not yet been performed.[49][114][115][116][117][118]

Human chorionic gonadotropin (HCG) can effectively promote testosterone production and spermatogenesis but does not stimulate gonadotropin production.[11] HCG administration may prolong the recovery of natural gonadotropin production indirectly by suppressing hypothalamic activity due to increased serum testosterone levels.[11]

Psychiatric evaluation and treatment may be necessary in patients who develop major depression, paranoia, suicidal ideations, and similar disorders during anabolic steroid withdrawal.[119] If not appropriately addressed, this can lead to a resumption of illicit anabolic androgen use and possibly increase the patient's risk of suicide.[114] Many anabolic steroid abusers have underlying mental health problems.[11]

Better management guidelines from appropriate professional organizations are needed to better evaluate and standardize the treatment of this growing disorder.[11] An extensive review of the adverse effects of unauthorized or excessive anabolic steroid use can be found in the companion StatPearls' reference review on Anabolic Steroid Toxicity at www.statpearls.com/point-of-care/291.[24]

Enhancing Healthcare Team Outcomes

There is no question that anabolic steroids carry therapeutic benefits for patients with HIV, liver disease, renal failure, some malignancies, symptomatic hypogonadism, and burns. But today, the biggest problem with these agents is misuse.[34] Despite legislation to limit the empirical prescription and dispensing of these agents, these medications continue to be misused by many individuals, especially athletes.

Several measures designed to decrease the incidence of anabolic steroid abuse have been suggested, which include:

  • Increased education regarding anabolic steroids to susceptible patient groups, healthcare professionals, educators, school administrators and nurses, personal trainers, non-governmental organizations, social workers, behavioral health workers, and law enforcement.
  • Increased and more stringent preventive measures in gyms and athletic training facilities.
  • Legislative changes should be made to allow for simplified steroid abuse testing, and federal regulations should be made to allow for the inspection of suspicious mailed items.[120]

Other barriers to the treatment of anabolic steroid abuse involve healthcare professionals more directly.[11][121] These measures include:

  • Some clinicians may be reluctant to treat patients with such self-destructive behaviors involving the use of illicit drugs. Advising such patients to suddenly stop their use without extensive discussion and without being prepared to deal with withdrawal symptoms is not likely to be successful.
  • Many physicians may have limited experience treating anabolic androgen abusers or dealing with symptoms of their withdrawal. This is partly due to the general lack of clinical studies to guide the treatment of anabolic steroid abuse adverse effects and withdrawal symptoms.
  • Many anabolic steroid abusers do not expect their physicians to be sympathetic or knowledgeable about this problem.
  • They also develop strong but often erroneous opinions regarding anabolic steroid use based on incomplete and biased information from unreliable sources.[11]

To prevent anabolic drug abuse, the role of nurses and pharmacists is critical. Athletes must be educated about the serious potential harm from these drugs, which may be irreversible and even lethal, and that there are now very sophisticated methods of detecting them in the blood and urine. Athletes also need to know that many anabolic steroids bought illegally and online are counterfeit and contain potentially toxic additives.

Users must also understand that the psychoactive effects of anabolic steroids can be deadly, resulting in sudden bouts of anger, suicidal thoughts, rage, loss of judgment, and extreme violence.[122] The abuse of anabolic steroids is a problem at all levels of schooling and includes both genders. The clinician, primary care provider, physician assistant, nurse, and pharmacist should encourage the cessation of these agents when used illicitly and refer the patient to the appropriate specialist for treatment.[123][124] All healthcare team members should also be aware of the effects of androgen withdrawal and be prepared to identify possible symptoms requiring further treatment by the physician. Behavioral health professionals should become involved when psychological side effects are observed.

Even when correctly utilized for approved medical indications, additional barriers to treatment include inadequate knowledge of appropriate dosing and monitoring, failing to obtain a full hormonal panel with 2 abnormal testosterone readings before initiating treatment, not knowing that only total testosterone is used, and not having an identifiable potentially treatable symptom of hypogonadism.

For those anabolic steroid abusers who truly wish to stop exogenous hormone use, it is helpful for them to avoid training partners who still use anabolic steroids and gyms where such use is common. They must also accept that there will be an obligatory loss of strength and muscle mass. Testosterone supplements should be avoided as much as possible as they will delay the recovery of normal pituitary-hypothalamic-gonadal function. The administration of tamoxifen 20 mg daily may help with gynecomastia, but this may recur if the anabolic steroid abuse continues.[11][125]

Proper therapeutic use and dealing with illegal misuse of anabolic steroids require an interprofessional team effort. In addressing illicit use, all members need to be aware of the signs of steroid misuse and be prepared to counsel as necessary to attempt to resolve the issue. In legitimate therapeutic use, the clinician will prescribe an agent based on clinical necessity for a specific symptom or indication, and the pharmacist can verify appropriate dosing and check for drug interactions. Nurses can provide counseling on administration along with the pharmacist and monitor for adverse effects on follow-up visits. Pharmacists and nurses need an open communication channel with the prescriber. These actions show the potential effectiveness of an interprofessional team approach to anabolic steroid use or misuse.

Outcomes

When used appropriately, anabolic steroids can aid weight gain, improve appetite, and alleviate a multitude of symptoms associated with hypogonadism, but members of the interprofessional team must monitor the patient closely for adverse effects and potentially toxic testosterone levels. In general, when used and monitored properly for appropriate medical indications, anabolic steroids can reverse many unpleasant symptoms of hypogonadism, but they are also very prone to misuse. Healthcare workers should be fully aware that these drugs are often misused and that close monitoring is necessary.[126][127]


Details

Editor:

Kavitha Ganesan

Updated:

2/6/2025 1:10:41 AM

References


[1]

Yesalis CE, Kennedy NJ, Kopstein AN, Bahrke MS. Anabolic-androgenic steroid use in the United States. JAMA. 1993 Sep 8:270(10):1217-21     [PubMed PMID: 8355384]


[2]

Hildebrandt T, Harty S, Langenbucher JW. Fitness supplements as a gateway substance for anabolic-androgenic steroid use. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2012 Dec:26(4):955-62. doi: 10.1037/a0027877. Epub 2012 Apr 9     [PubMed PMID: 22486333]


[3]

Piacentino D, Kotzalidis GD, Del Casale A, Aromatario MR, Pomara C, Girardi P, Sani G. Anabolic-androgenic steroid use and psychopathology in athletes. A systematic review. Current neuropharmacology. 2015 Jan:13(1):101-21. doi: 10.2174/1570159X13666141210222725. Epub     [PubMed PMID: 26074746]

Level 1 (high-level) evidence

[4]

Lusetti M, Licata M, Silingardi E, Bonsignore A, Palmiere C. Appearance/Image- and Performance-Enhancing Drug Users: A Forensic Approach. The American journal of forensic medicine and pathology. 2018 Dec:39(4):325-329. doi: 10.1097/PAF.0000000000000424. Epub     [PubMed PMID: 30153114]


[5]

Jones IA, Togashi R, Hatch GFR 3rd, Weber AE, Vangsness CT Jr. Anabolic steroids and tendons: A review of their mechanical, structural, and biologic effects. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 2018 Nov:36(11):2830-2841. doi: 10.1002/jor.24116. Epub 2018 Sep 5     [PubMed PMID: 30047601]


[6]

Armstrong JM, Avant RA, Charchenko CM, Westerman ME, Ziegelmann MJ, Miest TS, Trost LW. Impact of anabolic androgenic steroids on sexual function. Translational andrology and urology. 2018 Jun:7(3):483-489. doi: 10.21037/tau.2018.04.23. Epub     [PubMed PMID: 30050806]


[7]

Sizar O, Leslie SW, Pico J. Androgen Replacement. StatPearls. 2025 Jan:():     [PubMed PMID: 30521274]


[8]

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. Annals of epidemiology. 2014 May:24(5):383-98. doi: 10.1016/j.annepidem.2014.01.009. Epub 2014 Jan 30     [PubMed PMID: 24582699]

Level 1 (high-level) evidence

[9]

Cohen J, Collins R, Darkes J, Gwartney D. A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States. Journal of the International Society of Sports Nutrition. 2007 Oct 11:4():12. doi: 10.1186/1550-2783-4-12. Epub 2007 Oct 11     [PubMed PMID: 17931410]


[10]

Sjöqvist F, Garle M, Rane A. Use of doping agents, particularly anabolic steroids, in sports and society. Lancet (London, England). 2008 May 31:371(9627):1872-82. doi: 10.1016/S0140-6736(08)60801-6. Epub     [PubMed PMID: 18514731]


[11]

de Ronde W, Smit DL. Anabolic androgenic steroid abuse in young males. Endocrine connections. 2020 Apr:9(4):R102-R111. doi: 10.1530/EC-19-0557. Epub     [PubMed PMID: 32229704]


[12]

Pope HG Jr, Kanayama G, Hudson JI. Risk factors for illicit anabolic-androgenic steroid use in male weightlifters: a cross-sectional cohort study. Biological psychiatry. 2012 Feb 1:71(3):254-61. doi: 10.1016/j.biopsych.2011.06.024. Epub 2011 Aug 12     [PubMed PMID: 21839424]

Level 2 (mid-level) evidence

[13]

Friedl KE, Dettori JR, Hannan CJ Jr, Patience TH, Plymate SR. Comparison of the effects of high dose testosterone and 19-nortestosterone to a replacement dose of testosterone on strength and body composition in normal men. The Journal of steroid biochemistry and molecular biology. 1991:40(4-6):607-12     [PubMed PMID: 1958561]


[14]

McBride JA, Carson CC 3rd, Coward RM. The Availability and Acquisition of Illicit Anabolic Androgenic Steroids and Testosterone Preparations on the Internet. American journal of men's health. 2018 Sep:12(5):1352-1357. doi: 10.1177/1557988316648704. Epub 2016 May 11     [PubMed PMID: 27170675]


[15]

Fyksen TS, Vanberg P, Gjesdal K, von Lueder TG, Bjørnerheim R, Steine K, Atar D, Halvorsen S. Cardiovascular phenotype of long-term anabolic-androgenic steroid abusers compared with strength-trained athletes. Scandinavian journal of medicine & science in sports. 2022 Aug:32(8):1170-1181. doi: 10.1111/sms.14172. Epub 2022 May 4     [PubMed PMID: 35460300]


[16]

Hudson JI, Hudson Y, Kanyama G, Schnabel J, Javaras KN, Kaufman MJ, Pope HG Jr. Causal factors in childhood and adolescence leading to anabolic-androgenic steroid use: A machine learning approach. Drug and alcohol dependence reports. 2024 Mar:10():100215. doi: 10.1016/j.dadr.2023.100215. Epub 2023 Dec 29     [PubMed PMID: 38304122]


[17]

Smit DL, de Hon O, Venhuis BJ, den Heijer M, de Ronde W. Baseline characteristics of the HAARLEM study: 100 male amateur athletes using anabolic androgenic steroids. Scandinavian journal of medicine & science in sports. 2020 Mar:30(3):531-539. doi: 10.1111/sms.13592. Epub 2019 Nov 21     [PubMed PMID: 31663164]


[18]

Bulens A, Calzo JP, Eik-Nes TT, Beccia A, Raffoul A, Sarda V, Austin SB. Anabolic Steroid Initiation Among Boys and Young Men After Use of Muscle-Building Supplements. JAMA network open. 2024 Dec 2:7(12):e2450566. doi: 10.1001/jamanetworkopen.2024.50566. Epub 2024 Dec 2     [PubMed PMID: 39666340]


[19]

Eik-Nes TT, Austin SB, Blashill AJ, Murray SB, Calzo JP. Prospective health associations of drive for muscularity in young adult males. The International journal of eating disorders. 2018 Oct:51(10):1185-1193. doi: 10.1002/eat.22943. Epub 2018 Sep 10     [PubMed PMID: 30260492]


[20]

Tucker J, Fischer T, Upjohn L, Mazzera D, Kumar M. Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US Food and Drug Administration Warnings. JAMA network open. 2018 Oct 5:1(6):e183337. doi: 10.1001/jamanetworkopen.2018.3337. Epub 2018 Oct 5     [PubMed PMID: 30646238]


[21]

Cohen PA, Avula B, Katragunta K, Travis JC, Khan I. Presence and Quantity of Botanical Ingredients With Purported Performance-Enhancing Properties in Sports Supplements. JAMA network open. 2023 Jul 3:6(7):e2323879. doi: 10.1001/jamanetworkopen.2023.23879. Epub 2023 Jul 3     [PubMed PMID: 37459101]


[22]

Wenbo Z, Yan Z. The Uses of Anabolic Androgenic Steroids Among Athletes; Its Positive and Negative Aspects- A Literature Review. Journal of multidisciplinary healthcare. 2023:16():4293-4305. doi: 10.2147/JMDH.S439384. Epub 2023 Dec 29     [PubMed PMID: 38170017]


[23]

Bulut Y, Rasmussen JJ, Brandt-Jacobsen N, Frystyk J, Thevis M, Schou M, Gustafsson F, Hasbak P, Kistorp C. Coronary Microvascular Dysfunction Years After Cessation of Anabolic Androgenic Steroid Use. JAMA network open. 2024 Dec 2:7(12):e2451013. doi: 10.1001/jamanetworkopen.2024.51013. Epub 2024 Dec 2     [PubMed PMID: 39680410]


[24]

Middlebrook I, Schoener B. Anabolic Steroid Toxicity. StatPearls. 2025 Jan:():     [PubMed PMID: 31334979]


[25]

Windfeld-Mathiasen J, Horwitz H, Biering-Sørensen T, Olsen FJ. Anabolic steroids and cardiovascular morbidity. Ugeskrift for laeger. 2024 Oct 14:186(42):. pii: V04240260. doi: 10.61409/V04240260. Epub     [PubMed PMID: 39531029]


[26]

Kaufman MJ, Kanayama G, Hudson JI, Pope HG Jr. Supraphysiologic-dose anabolic-androgenic steroid use: A risk factor for dementia? Neuroscience and biobehavioral reviews. 2019 May:100():180-207. doi: 10.1016/j.neubiorev.2019.02.014. Epub 2019 Feb 25     [PubMed PMID: 30817935]


[27]

Iacovino JR. Non-Physiologic Doses of Androgenic Anabolic Steroids: Mortality and Underwriting Assessment. Journal of insurance medicine (New York, N.Y.). 2024 Nov 1:51(3):171-174. doi: 10.1029/AAIMEDICINE-D-24-00028.1. Epub     [PubMed PMID: 39586065]


[28]

Nolan T. Mortality of anabolic steroids users and other research. BMJ (Clinical research ed.). 2024 Mar 21:384():q680. doi: 10.1136/bmj.q680. Epub 2024 Mar 21     [PubMed PMID: 38514077]


[29]

Pärssinen M, Kujala U, Vartiainen E, Sarna S, Seppälä T. Increased premature mortality of competitive powerlifters suspected to have used anabolic agents. International journal of sports medicine. 2000 Apr:21(3):225-7     [PubMed PMID: 10834358]


[30]

Fabresse N, Grassin-Delyle S, Etting I, Alvarez JC. Detection and quantification of 12 anabolic steroids and analogs in human whole blood and 20 in hair using LC-HRMS/MS: application to real cases. International journal of legal medicine. 2017 Jul:131(4):989-999. doi: 10.1007/s00414-017-1552-3. Epub 2017 Feb 24     [PubMed PMID: 28236045]

Level 3 (low-level) evidence

[31]

So YM, Kwok WH, Ching CCW, Wong COL, Wan TSM, Ho ENM. Detection of Over 110 Anabolic-Androgenic Steroids, Corticosteroids and/or Their Esters in Horse Hair Using Ultra-High-Performance Liquid Chromatography-High-Resolution Mass Spectrometry and Gas Chromatography-Tandem Mass Spectrometry After Solid-Supported Liquid Extraction. Drug testing and analysis. 2024 Dec 10:():. doi: 10.1002/dta.3837. Epub 2024 Dec 10     [PubMed PMID: 39655796]


[32]

Ji Z, Liao L, Ge Y, Liu M, Fang X, Sun H, Zheng S, Deng X. Screening anabolic androgenic steroids in human urine: an application of the state-of-the-art gas chromatography-Orbitrap high-resolution mass spectrometry. Analytical and bioanalytical chemistry. 2024 May:416(13):3223-3237. doi: 10.1007/s00216-024-05272-2. Epub 2024 Apr 4     [PubMed PMID: 38573345]


[33]

Bohlin KP, Pohanka A, Andersson A, Villén T, Ekström L. Detection of anabolic agents including selective androgen receptor modulators in samples outside of sport. Drug testing and analysis. 2024 Aug:16(8):827-834. doi: 10.1002/dta.3600. Epub 2023 Nov 20     [PubMed PMID: 37986708]


[34]

AlShareef S, Gokarakonda SB, Marwaha R. Anabolic Steroid Use Disorder. StatPearls. 2025 Jan:():     [PubMed PMID: 30844201]


[35]

Bond P, Smit DL, de Ronde W. Anabolic-androgenic steroids: How do they work and what are the risks? Frontiers in endocrinology. 2022:13():1059473. doi: 10.3389/fendo.2022.1059473. Epub 2022 Dec 19     [PubMed PMID: 36644692]


[36]

Melo Junior AF, Dalpiaz PLM, Sousa GJ, Oliveira PWC, Birocale AM, Andrade TU, Abreu GR, Bissoli NS. Nandrolone alter left ventricular contractility and promotes remodelling involving calcium-handling proteins and renin-angiotensin system in male SHR. Life sciences. 2018 Sep 1:208():239-245. doi: 10.1016/j.lfs.2018.07.041. Epub 2018 Jul 21     [PubMed PMID: 30040952]


[37]

Zhou S, Glowacki J. Dehydroepiandrosterone and Bone. Vitamins and hormones. 2018:108():251-271. doi: 10.1016/bs.vh.2018.01.005. Epub 2018 Feb 24     [PubMed PMID: 30029729]


[38]

Kadi F. Cellular and molecular mechanisms responsible for the action of testosterone on human skeletal muscle. A basis for illegal performance enhancement. British journal of pharmacology. 2008 Jun:154(3):522-8. doi: 10.1038/bjp.2008.118. Epub 2008 Apr 14     [PubMed PMID: 18414389]


[39]

Singh R, Artaza JN, Taylor WE, Gonzalez-Cadavid NF, Bhasin S. Androgens stimulate myogenic differentiation and inhibit adipogenesis in C3H 10T1/2 pluripotent cells through an androgen receptor-mediated pathway. Endocrinology. 2003 Nov:144(11):5081-8     [PubMed PMID: 12960001]


[40]

Sizar O, Leslie SW, Schwartz J. Male Hypogonadism. StatPearls. 2025 Jan:():     [PubMed PMID: 30422528]


[41]

Mbi Feh MK, Patel P, Wadhwa R. Clomiphene. StatPearls. 2025 Jan:():     [PubMed PMID: 32644718]


[42]

Goldstein I, Chidambaram N, Dobs A, King S, Miner M, Ramasamy R, Yafi FA, Khera M. Newer formulations of oral testosterone undecanoate: development and liver side effects. Sexual medicine reviews. 2025 Jan 31:13(1):33-40. doi: 10.1093/sxmrev/qeae062. Epub     [PubMed PMID: 39291780]


[43]

Miner M, Wang C, Kaminetsky J, Khera M, Goldstein I, Carson C 3rd, Chidambaram N, King S, Dobs A. Safety, efficacy, and pharmacokinetics of oral testosterone undecanoate in males with hypogonadism. Andrology. 2024 Sep 10:():. doi: 10.1111/andr.13747. Epub 2024 Sep 10     [PubMed PMID: 39252657]


[44]

Bernstein JS, Dhingra OP. A phase III, single-arm, 6-month trial of a wide-dose range oral testosterone undecanoate product. Therapeutic advances in urology. 2024 Jan-Dec:16():17562872241241864. doi: 10.1177/17562872241241864. Epub 2024 Apr 10     [PubMed PMID: 38606384]

Level 3 (low-level) evidence

[45]

Mann A, Strange RC, König CS, Hackett G, Haider A, Haider KS, Desnerck P, Ramachandran S. Testosterone replacement therapy: association with mortality in high-risk patient subgroups. Andrology. 2024 Sep:12(6):1389-1397. doi: 10.1111/andr.13582. Epub 2023 Dec 26     [PubMed PMID: 38148671]


[46]

Campbell K, Muthigi A, Ghomeshi A, Schuppe K, Sandler MD, Ramasamy R. Safety Aspects and Rational Use of Testosterone Undecanoate in the Treatment of Testosterone Deficiency: Clinical Insights. Drug, healthcare and patient safety. 2023:15():73-84. doi: 10.2147/DHPS.S383130. Epub 2023 Mar 31     [PubMed PMID: 37025099]


[47]

Solimini R, Rotolo MC, Mastrobattista L, Mortali C, Minutillo A, Pichini S, Pacifici R, Palmi I. Hepatotoxicity associated with illicit use of anabolic androgenic steroids in doping. European review for medical and pharmacological sciences. 2017 Mar:21(1 Suppl):7-16     [PubMed PMID: 28379599]


[48]

Pope HG Jr, Kanayama G. Body Image Disorders and Anabolic Steroid Withdrawal Hypogonadism in Men. Endocrinology and metabolism clinics of North America. 2022 Mar:51(1):205-216. doi: 10.1016/j.ecl.2021.11.007. Epub 2022 Feb 8     [PubMed PMID: 35216717]


[49]

Grant B, Kean J, Vali N, Campbell J, Maden L, Bijral P, Dhillo WS, McVeigh J, Quinton R, Jayasena CN. The use of post-cycle therapy is associated with reduced withdrawal symptoms from anabolic-androgenic steroid use: a survey of 470 men. Substance abuse treatment, prevention, and policy. 2023 Nov 11:18(1):66. doi: 10.1186/s13011-023-00573-8. Epub 2023 Nov 11     [PubMed PMID: 37951896]

Level 3 (low-level) evidence

[50]

Dunn M, Dawe J, Eu B, Lee K, Piatkowski T, Stoové M. The health effects of non-prescribed anabolic-androgenic steroid use: Findings from The Performance and image-enhancing drugs UseRS' Health (PUSH) audit. Drug and alcohol review. 2024 Nov:43(7):1967-1975. doi: 10.1111/dar.13899. Epub 2024 Jul 7     [PubMed PMID: 38973204]


[51]

Albano GD, Amico F, Cocimano G, Liberto A, Maglietta F, Esposito M, Rosi GL, Di Nunno N, Salerno M, Montana A. Adverse Effects of Anabolic-Androgenic Steroids: A Literature Review. Healthcare (Basel, Switzerland). 2021 Jan 19:9(1):. doi: 10.3390/healthcare9010097. Epub 2021 Jan 19     [PubMed PMID: 33477800]


[52]

Azevedo RA, Gualano B, Teixeira TA, Nascimento BCG, Hallak J. Abusive use of anabolic androgenic steroids, male sexual dysfunction and infertility: an updated review. Frontiers in toxicology. 2024:6():1379272. doi: 10.3389/ftox.2024.1379272. Epub 2024 Apr 22     [PubMed PMID: 38711907]


[53]

Vorona E, Nieschlag E. Adverse effects of doping with anabolic androgenic steroids in competitive athletics, recreational sports and bodybuilding. Minerva endocrinologica. 2018 Dec:43(4):476-488. doi: 10.23736/S0391-1977.18.02810-9. Epub 2018 Feb 19     [PubMed PMID: 29463075]


[54]

Skrzypiec-Spring M, Rozmus J, Abu Faraj G, Brawańska-Maśluch K, Kujawa K, Szeląg A. Abuse of Anabolic-Androgenic Steroids as a Social Phenomenon and Medical Problem-Its Potential Negative Impact on Reproductive Health Based on 50 Years of Case Report Analysis. Journal of clinical medicine. 2024 Oct 2:13(19):. doi: 10.3390/jcm13195892. Epub 2024 Oct 2     [PubMed PMID: 39407952]

Level 3 (low-level) evidence

[55]

Grant B, Hyams E, Davies R, Minhas S, Jayasena CN. Androgen abuse: Risks and adverse effects in men. Annals of the New York Academy of Sciences. 2024 Aug:1538(1):56-70. doi: 10.1111/nyas.15187. Epub 2024 Jul 23     [PubMed PMID: 39041466]


[56]

Momoh R. Anabolic-Androgenic Steroid Abuse Causes Cardiac Dysfunction. American journal of men's health. 2024 Mar-Apr:18(2):15579883241249647. doi: 10.1177/15579883241249647. Epub     [PubMed PMID: 38686840]


[57]

Tungesvik HM, Bjørnebekk A, Hisdal J. Impaired vascular function among young users of anabolic-androgenic steroids. Scientific reports. 2024 Aug 19:14(1):19201. doi: 10.1038/s41598-024-70110-5. Epub 2024 Aug 19     [PubMed PMID: 39160232]


[58]

Grandperrin A, Schuster I, Rupp T, Izem O, Obert P, Nottin S. Left ventricular dyssynchrony and post-systolic shortening in young bodybuilders using anabolic-androgenic steroids. American journal of physiology. Heart and circulatory physiology. 2021 Sep 1:321(3):H509-H517. doi: 10.1152/ajpheart.00136.2021. Epub 2021 Jul 9     [PubMed PMID: 34242095]


[59]

Darke S, Torok M, Duflou J. Sudden or unnatural deaths involving anabolic-androgenic steroids. Journal of forensic sciences. 2014 Jul:59(4):1025-8. doi: 10.1111/1556-4029.12424. Epub 2014 Feb 19     [PubMed PMID: 24611438]


[60]

Abdullah R, Bjørnebekk A, Hauger LE, Hullstein IR, Edvardsen T, Haugaa KH, Almaas VM. Severe biventricular cardiomyopathy in both current and former long-term users of anabolic-androgenic steroids. European journal of preventive cardiology. 2024 Mar 27:31(5):599-608. doi: 10.1093/eurjpc/zwad362. Epub     [PubMed PMID: 37992194]


[61]

Thiblin I, Garmo H, Garle M, Holmberg L, Byberg L, Michaëlsson K, Gedeborg R. Anabolic steroids and cardiovascular risk: A national population-based cohort study. Drug and alcohol dependence. 2015 Jul 1:152():87-92. doi: 10.1016/j.drugalcdep.2015.04.013. Epub 2015 May 11     [PubMed PMID: 26005042]


[62]

Momin SB, Peterson A, Del Rosso JQ. A status report on drug-associated acne and acneiform eruptions. Journal of drugs in dermatology : JDD. 2010 Jun:9(6):627-36     [PubMed PMID: 20645524]


[63]

Heerfordt IM, Windfeld-Mathiasen J, Dalhoff KP, Mogensen M, Andersen JT, Horwitz H. Cutaneous manifestations of misuse of androgenic anabolic steroids: A retrospective cohort study. Journal of the American Academy of Dermatology. 2024 May:90(5):1047-1048. doi: 10.1016/j.jaad.2024.01.007. Epub 2024 Jan 10     [PubMed PMID: 38215797]

Level 2 (mid-level) evidence

[64]

van Breda E, Keizer HA, Kuipers H, Wolffenbuttel BH. Androgenic anabolic steroid use and severe hypothalamic-pituitary dysfunction: a case study. International journal of sports medicine. 2003 Apr:24(3):195-6     [PubMed PMID: 12740738]

Level 3 (low-level) evidence

[65]

McGettigan MJ, Menias CO, Gao ZJ, Mellnick VM, Hara AK. Imaging of Drug-induced Complications in the Gastrointestinal System. Radiographics : a review publication of the Radiological Society of North America, Inc. 2016 Jan-Feb:36(1):71-87. doi: 10.1148/rg.2016150132. Epub     [PubMed PMID: 26761532]


[66]

Modlinski R, Fields KB. The effect of anabolic steroids on the gastrointestinal system, kidneys, and adrenal glands. Current sports medicine reports. 2006 Apr:5(2):104-9     [PubMed PMID: 16529682]


[67]

Ledesma BR, Weber A, Venigalla G, Muthigi A, Thomas J, Narasimman M, White J, Ramasamy R. Fertility outcomes in men with prior history of anabolic steroid use. Fertility and sterility. 2023 Dec:120(6):1203-1209. doi: 10.1016/j.fertnstert.2023.09.016. Epub 2023 Sep 26     [PubMed PMID: 37769866]


[68]

Chang S, Rasmussen JJ, Frandsen MN, Schou M, Johansen ML, Faber J, Münster AB, Sidelmann JJ, Kistorp C. Procoagulant State in Current and Former Anabolic Androgenic Steroid Abusers. Thrombosis and haemostasis. 2018 Apr:118(4):647-653. doi: 10.1055/s-0038-1636540. Epub 2018 Apr 4     [PubMed PMID: 29618151]


[69]

Ansell JE, Tiarks C, Fairchild VK. Coagulation abnormalities associated with the use of anabolic steroids. American heart journal. 1993 Feb:125(2 Pt 1):367-71     [PubMed PMID: 8427129]


[70]

Sidelmann JJ, Gram JB, Rasmussen JJ, Kistorp C. Anabolic-Androgenic Steroid Abuse Impairs Fibrin Clot Lysis. Seminars in thrombosis and hemostasis. 2021 Feb:47(1):11-17. doi: 10.1055/s-0040-1714398. Epub 2020 Oct 5     [PubMed PMID: 33017849]


[71]

Stoot JH, Coelen RJ, De Jong MC, Dejong CH. Malignant transformation of hepatocellular adenomas into hepatocellular carcinomas: a systematic review including more than 1600 adenoma cases. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2010 Oct:12(8):509-22. doi: 10.1111/j.1477-2574.2010.00222.x. Epub     [PubMed PMID: 20887318]

Level 1 (high-level) evidence

[72]

Gorayski P, Thompson CH, Subhash HS, Thomas AC. Hepatocellular carcinoma associated with recreational anabolic steroid use. British journal of sports medicine. 2008 Jan:42(1):74-5; discussion 75. doi: 10.1136/bjsm.2007.03932. Epub     [PubMed PMID: 18178686]


[73]

Woodward C, Smith J, Acreman D, Kumar N. Hepatocellular carcinoma in body builders; an emerging rare but serious complication of androgenic anabolic steroid use. Annals of hepato-biliary-pancreatic surgery. 2019 May:23(2):174-177. doi: 10.14701/ahbps.2019.23.2.174. Epub 2019 May 31     [PubMed PMID: 31225420]


[74]

Khalid S, Laput G, Khorfan K, Roytman M. Development of Liver Cancers as an Unexpected Consequence of Anabolic Androgenic Steroid Use. Cureus. 2023 Jan:15(1):e34357. doi: 10.7759/cureus.34357. Epub 2023 Jan 29     [PubMed PMID: 36874750]


[75]

Chegeni R, Pallesen S, McVeigh J, Sagoe D. Anabolic-androgenic steroid administration increases self-reported aggression in healthy males: a systematic review and meta-analysis of experimental studies. Psychopharmacology. 2021 Jul:238(7):1911-1922. doi: 10.1007/s00213-021-05818-7. Epub 2021 Mar 20     [PubMed PMID: 33745011]

Level 1 (high-level) evidence

[76]

Mustafa R, Hashmi HA. Drug-induced hirsutism. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2006 Jul:16(7):485-6     [PubMed PMID: 16827963]


[77]

Sharma A, Grant B, Islam H, Kapoor A, Pradeep A, Jayasena CN. Common symptoms associated with usage and cessation of anabolic androgenic steroids in men. Best practice & research. Clinical endocrinology & metabolism. 2022 Sep:36(5):101691. doi: 10.1016/j.beem.2022.101691. Epub 2022 Aug 12     [PubMed PMID: 35999138]


[78]

Albright JA, Lou M, Rebello E, Ge J, Testa EJ, Daniels AH, Arcand M. Testosterone replacement therapy is associated with increased odds of Achilles tendon injury and subsequent surgery: a matched retrospective analysis. Journal of foot and ankle research. 2023 Nov 11:16(1):76. doi: 10.1186/s13047-023-00678-0. Epub 2023 Nov 11     [PubMed PMID: 37950322]

Level 2 (mid-level) evidence

[79]

Sinha A, Deb VK, Datta A, Yadav S, Phulkar A, Adhikari S. Evaluation of structural features of anabolic-androgenic steroids: entanglement for organ-specific toxicity. Steroids. 2024 Dec:212():109518. doi: 10.1016/j.steroids.2024.109518. Epub 2024 Sep 24     [PubMed PMID: 39322097]


[80]

Tricker R, Casaburi R, Storer TW, Clevenger B, Berman N, Shirazi A, Bhasin S. The effects of supraphysiological doses of testosterone on angry behavior in healthy eugonadal men--a clinical research center study. The Journal of clinical endocrinology and metabolism. 1996 Oct:81(10):3754-8     [PubMed PMID: 8855834]


[81]

Börjesson A, Möller C, Hagelin A, Vicente V, Rane A, Lehtihet M, Dahl ML, Gårevik N, Ekström L. Male Anabolic Androgenic Steroid Users with Personality Disorders Report More Aggressive Feelings, Suicidal Thoughts, and Criminality. Medicina (Kaunas, Lithuania). 2020 May 28:56(6):. doi: 10.3390/medicina56060265. Epub 2020 May 28     [PubMed PMID: 32481676]


[82]

Karagun B, Altug S. Anabolic-androgenic steroids are linked to depression and anxiety in male bodybuilders: the hidden psychogenic side of anabolic androgenic steroids. Annals of medicine. 2024 Dec:56(1):2337717. doi: 10.1080/07853890.2024.2337717. Epub 2024 Apr 8     [PubMed PMID: 38590148]


[83]

Klonteig S, Scarth M, Bjørnebekk A. Sleep pathology and use of anabolic androgen steroids among male weightlifters in Norway. BMC psychiatry. 2024 Jan 22:24(1):62. doi: 10.1186/s12888-024-05516-6. Epub 2024 Jan 22     [PubMed PMID: 38254047]


[84]

Al-Hwiesh A, Al-Amoudi K, Alshehabi K, Abdelgalil M, Al-Hwiesh B, Alhwiesh A, Al-Audah N, Al Solami SM, Hamza WM, Abdul-Rahman IS. Coexistence of Interstitial Nephritis and the Cellular Variant of Focal Segmental Glomerulosclerosis Secondary to Anabolic Steroid Abuse. Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia. 2022 Nov 1:33(6):839-843. doi: 10.4103/1319-2442.390263. Epub 2023 Nov 29     [PubMed PMID: 38018725]


[85]

Shirpoor A, Naderi R. Nandrolone decanoate induced kidney injury through miRNA-146a targeting IRAK1 and TRAF6 via activation of the NF-κB pathway: The effect of moderate exercise. Steroids. 2024 Nov:211():109503. doi: 10.1016/j.steroids.2024.109503. Epub 2024 Aug 27     [PubMed PMID: 39208922]


[86]

Garner O, Iardino A, Ramirez A, Yakoby M. Cardiomyopathy induced by anabolic-androgenic steroid abuse. BMJ case reports. 2018 Jul 23:2018():. pii: bcr-2017-223891. doi: 10.1136/bcr-2017-223891. Epub 2018 Jul 23     [PubMed PMID: 30037963]

Level 3 (low-level) evidence

[87]

Costanzo PR, Pacenza NA, Aszpis SM, Suárez SM, Pragier UM, Usher JGS, Vásquez Cayoja M, Iturrieta S, Gottlieb SE, Rey RA, Knoblovits P. Clinical and Etiological Aspects of Gynecomastia in Adult Males: A Multicenter Study. BioMed research international. 2018:2018():8364824. doi: 10.1155/2018/8364824. Epub 2018 May 29     [PubMed PMID: 30003107]

Level 2 (mid-level) evidence

[88]

Mulhall JP, Trost LW, Brannigan RE, Kurtz EG, Redmon JB, Chiles KA, Lightner DJ, Miner MM, Murad MH, Nelson CJ, Platz EA, Ramanathan LV, Lewis RW. Evaluation and Management of Testosterone Deficiency: AUA Guideline. The Journal of urology. 2018 Aug:200(2):423-432. doi: 10.1016/j.juro.2018.03.115. Epub 2018 Mar 28     [PubMed PMID: 29601923]


[89]

Gibbons SM, Moulding M, Bailey K, Stuart K, Wiffen S, Lewington AJ, Parker R, Lippiatt C, Guha N, O'Shea J, Owen M, Abbas A, Barth JH. Essential blood testing in the patient using androgenic anabolic steroids: a clinical practice guideline for primary care. The British journal of general practice : the journal of the Royal College of General Practitioners. 2024 Apr:74(741):187-190. doi: 10.3399/bjgp24X737013. Epub 2024 Mar 27     [PubMed PMID: 38538136]

Level 1 (high-level) evidence

[90]

Basaria S. Male hypogonadism. Lancet (London, England). 2014 Apr 5:383(9924):1250-63. doi: 10.1016/S0140-6736(13)61126-5. Epub 2013 Oct 10     [PubMed PMID: 24119423]


[91]

Moretti S, Lega F, Rigoni L, Saluti G, Giusepponi D, Gioiello A, Manuali E, Rossi R, Galarini R. Multiclass screening method to detect more than fifty banned substances in bovine bile and urine. Analytica chimica acta. 2018 Nov 22:1032():56-67. doi: 10.1016/j.aca.2018.06.037. Epub 2018 Jun 14     [PubMed PMID: 30143222]


[92]

Dahmani H, Louati K, Hajri A, Bahri S, Safta F. Development of an extraction method for anabolic androgenic steroids in dietary supplements and analysis by gas chromatography-mass spectrometry: Application for doping-control. Steroids. 2018 Oct:138():134-160. doi: 10.1016/j.steroids.2018.08.001. Epub 2018 Aug 15     [PubMed PMID: 30118779]


[93]

Smit DL, Bond P, de Ronde W. Health effects of androgen abuse: a review of the HAARLEM study. Current opinion in endocrinology, diabetes, and obesity. 2022 Dec 1:29(6):560-565. doi: 10.1097/MED.0000000000000759. Epub 2022 Aug 4     [PubMed PMID: 35938779]

Level 3 (low-level) evidence

[94]

Batrinos ML. Testosterone and aggressive behavior in man. International journal of endocrinology and metabolism. 2012 Summer:10(3):563-8. doi: 10.5812/ijem.3661. Epub 2012 Jun 30     [PubMed PMID: 23843821]


[95]

Rajmil O, Moreno-Sepulveda J. Recovery of spermatogenesis after androgenic anabolic steroids abuse in men. A systematic review of the literature. Actas urologicas espanolas. 2024 Mar:48(2):116-124. doi: 10.1016/j.acuroe.2023.07.007. Epub 2023 Aug 9     [PubMed PMID: 37567343]

Level 1 (high-level) evidence

[96]

McBride JA, Coward RM. Recovery of spermatogenesis following testosterone replacement therapy or anabolic-androgenic steroid use. Asian journal of andrology. 2016 May-Jun:18(3):373-80. doi: 10.4103/1008-682X.173938. Epub     [PubMed PMID: 26908067]


[97]

Esposito M, Salerno M, Calvano G, Agliozzo R, Ficarra V, Sessa F, Favilla V, Cimino S, Pomara C. Impact of anabolic androgenic steroids on male sexual and reproductive function: a systematic review. Panminerva medica. 2023 Mar:65(1):43-50. doi: 10.23736/S0031-0808.22.04677-8. Epub 2022 Feb 11     [PubMed PMID: 35146992]

Level 1 (high-level) evidence

[98]

de Souza GL, Hallak J. Anabolic steroids and male infertility: a comprehensive review. BJU international. 2011 Dec:108(11):1860-5. doi: 10.1111/j.1464-410X.2011.10131.x. Epub 2011 Jun 17     [PubMed PMID: 21682835]


[99]

Campbell KJ. Anabolic steroid use and the uphill road to fertility recovery. Fertility and sterility. 2023 Dec:120(6):1173. doi: 10.1016/j.fertnstert.2023.10.012. Epub 2023 Oct 12     [PubMed PMID: 37838139]


[100]

Rasmussen JJ, Selmer C, Østergren PB, Pedersen KB, Schou M, Gustafsson F, Faber J, Juul A, Kistorp C. Former Abusers of Anabolic Androgenic Steroids Exhibit Decreased Testosterone Levels and Hypogonadal Symptoms Years after Cessation: A Case-Control Study. PloS one. 2016:11(8):e0161208. doi: 10.1371/journal.pone.0161208. Epub 2016 Aug 17     [PubMed PMID: 27532478]

Level 2 (mid-level) evidence

[101]

Frati P, Busardò FP, Cipolloni L, Dominicis ED, Fineschi V. Anabolic Androgenic Steroid (AAS) related deaths: autoptic, histopathological and toxicological findings. Current neuropharmacology. 2015 Jan:13(1):146-59. doi: 10.2174/1570159X13666141210225414. Epub     [PubMed PMID: 26074749]


[102]

Barbosa Neto O, da Mota GR, De Sordi CC, Resende EAMR, Resende LAPR, Vieira da Silva MA, Marocolo M, Côrtes RS, de Oliveira LF, Dias da Silva VJ. Long-term anabolic steroids in male bodybuilders induce cardiovascular structural and autonomic abnormalities. Clinical autonomic research : official journal of the Clinical Autonomic Research Society. 2018 Apr:28(2):231-244. doi: 10.1007/s10286-017-0470-2. Epub 2017 Oct 10     [PubMed PMID: 29019018]


[103]

Zhao H, Li JM, Li ZR, Zhang Q, Zhong MK, Yan MM, Qiu XY. Major adverse cardiovascular events associated with testosterone treatment: a pharmacovigilance study of the FAERS database. Frontiers in pharmacology. 2023:14():1182113. doi: 10.3389/fphar.2023.1182113. Epub 2023 Jul 12     [PubMed PMID: 37502210]

Level 2 (mid-level) evidence

[104]

Esposito M, Licciardello G, Privitera F, Iannuzzi S, Liberto A, Sessa F, Salerno M. Forensic Post-Mortem Investigation in AAS Abusers: Investigative Diagnostic Protocol. A Systematic Review. Diagnostics (Basel, Switzerland). 2021 Jul 21:11(8):. doi: 10.3390/diagnostics11081307. Epub 2021 Jul 21     [PubMed PMID: 34441242]

Level 1 (high-level) evidence

[105]

Farzam K, Rajasurya V, Ahmad T. Sudden Death in Athletes. StatPearls. 2025 Jan:():     [PubMed PMID: 30969530]


[106]

Dotka M, Małek ŁA. Myocardial Infarction in Young Athletes. Diagnostics (Basel, Switzerland). 2023 Jul 25:13(15):. doi: 10.3390/diagnostics13152473. Epub 2023 Jul 25     [PubMed PMID: 37568836]


[107]

Torrisi M, Pennisi G, Russo I, Amico F, Esposito M, Liberto A, Cocimano G, Salerno M, Li Rosi G, Di Nunno N, Montana A. Sudden Cardiac Death in Anabolic-Androgenic Steroid Users: A Literature Review. Medicina (Kaunas, Lithuania). 2020 Nov 4:56(11):. doi: 10.3390/medicina56110587. Epub 2020 Nov 4     [PubMed PMID: 33158202]


[108]

Hernández-Guerra AI, Tapia J, Menéndez-Quintanal LM, Lucena JS. Sudden cardiac death in anabolic androgenic steroids abuse: case report and literature review. Forensic sciences research. 2019:4(3):267-273. doi: 10.1080/20961790.2019.1595350. Epub 2019 Aug 19     [PubMed PMID: 31489392]

Level 3 (low-level) evidence

[109]

Lichtenfeld J, Deal BJ, Crawford S. Sudden cardiac arrest following ventricular fibrillation attributed to anabolic steroid use in an adolescent. Cardiology in the young. 2016 Jun:26(5):996-8. doi: 10.1017/S104795111600007X. Epub 2016 Mar 16     [PubMed PMID: 26980272]


[110]

Karila D, Kerlan V, Christin-Maitre S. Androgenic steroid excess in women. Annales d'endocrinologie. 2024 Apr:85(2):142-149. doi: 10.1016/j.ando.2023.11.001. Epub 2023 Nov 29     [PubMed PMID: 38040089]


[111]

Havnes IA, Henriksen HCB, Johansen PW, Bjørnebekk A, Neupane SP, Hisdal J, Seljeflot I, Wisløff C, Jørstad ML, McVeigh J, Jørgensen AP. Off-label use of clomiphene citrate to treat anabolic androgenic steroid induced hypogonadism upon cessation among men (CloTASH) - A pilot study protocol. MethodsX. 2024 Dec:13():102810. doi: 10.1016/j.mex.2024.102810. Epub 2024 Jun 19     [PubMed PMID: 39022178]

Level 3 (low-level) evidence

[112]

Grant B, Campbell J, Pradeep A, Burns AD, Bassett P, Abbara A, Saket P, Minhas S, Dhillo WS, McVeigh J, Bhasin S, Jayasena CN. Factors predicting normalization of reproductive hormones after cessation of anabolic-androgenic steroids in men: a single center retrospective study. European journal of endocrinology. 2023 Dec 6:189(6):601-610. doi: 10.1093/ejendo/lvad164. Epub     [PubMed PMID: 38102386]

Level 2 (mid-level) evidence

[113]

Solanki P, Eu B, Smith J, Allan C, Lee K. Physical, psychological and biochemical recovery from anabolic steroid-induced hypogonadism: a scoping review. Endocrine connections. 2023 Dec 1:12(12):. pii: e230358. doi: 10.1530/EC-23-0358. Epub 2023 Oct 19     [PubMed PMID: 37855241]

Level 2 (mid-level) evidence

[114]

Pope HG Jr, Kanayama G. Reduced Quality of Life in Former Androgen Users: An Evolving Public-Health Concern. The Journal of clinical endocrinology and metabolism. 2024 Apr 19:109(5):e1400-e1401. doi: 10.1210/clinem/dgad661. Epub     [PubMed PMID: 37955864]

Level 2 (mid-level) evidence

[115]

Bulut Y, Brandt-Jacobsen N, Buhl L, Schou M, Frystyk J, Kistorp C, Rasmussen JJ. Persistently Decreased Quality of Life and its Determinants in Previous Illicit Androgen Users. The Journal of clinical endocrinology and metabolism. 2024 Jan 18:109(2):e689-e697. doi: 10.1210/clinem/dgad551. Epub     [PubMed PMID: 37708363]

Level 2 (mid-level) evidence

[116]

Kanayama G, Hudson JI, DeLuca J, Isaacs S, Baggish A, Weiner R, Bhasin S, Pope HG Jr. Prolonged hypogonadism in males following withdrawal from anabolic-androgenic steroids: an under-recognized problem. Addiction (Abingdon, England). 2015 May:110(5):823-31. doi: 10.1111/add.12850. Epub 2015 Feb 25     [PubMed PMID: 25598171]


[117]

Al Hashimi M. The deleterious effects of anabolic androgenic steroid abuse on sexual and reproductive health and comparison of recovery between treated and untreated patients: Single-center prospective randomized study. Andrologia. 2022 Dec:54(11):e14576. doi: 10.1111/and.14576. Epub 2022 Sep 5     [PubMed PMID: 36065528]

Level 1 (high-level) evidence

[118]

Vilar Neto JO, da Silva CA, Bruno da Silva CA, Pinto DV, Caminha JSR, de Matos RS, Nunes Filho JCC, Alves FR, Magalhães SC, De Francesco Daher E. Anabolic androgenic steroid-induced hypogonadism, a reversible condition in male individuals? A systematic review. Andrologia. 2021 Aug:53(7):e14062. doi: 10.1111/and.14062. Epub 2021 Apr 22     [PubMed PMID: 33887077]

Level 1 (high-level) evidence

[119]

Talih F, Fattal O, Malone D Jr. Anabolic steroid abuse: psychiatric and physical costs. Cleveland Clinic journal of medicine. 2007 May:74(5):341-4, 346, 349-52     [PubMed PMID: 17506239]


[120]

Kvillemo P, Gripenberg J, Strandberg AK, Elgán TH. Police officers' perspective on doping and prevention among recreational athletes: a cross-sectional study. Frontiers in sports and active living. 2023:5():1251531. doi: 10.3389/fspor.2023.1251531. Epub 2023 Oct 23     [PubMed PMID: 37936878]

Level 2 (mid-level) evidence

[121]

Pope HG, Kanayama G, Ionescu-Pioggia M, Hudson JI. Anabolic steroid users' attitudes towards physicians. Addiction (Abingdon, England). 2004 Sep:99(9):1189-94     [PubMed PMID: 15317640]


[122]

Piatkowski T, De Andrade D, Neumann D, Tisdale C, Dunn M. Examining the association between trenbolone, psychological distress, and aggression among males who use anabolic-androgenic steroids. The International journal on drug policy. 2024 Dec:134():104636. doi: 10.1016/j.drugpo.2024.104636. Epub 2024 Oct 31     [PubMed PMID: 39486244]


[123]

Smit DL, de Ronde W. Outpatient clinic for users of anabolic androgenic steroids: an overview. The Netherlands journal of medicine. 2018 May:76(4):167     [PubMed PMID: 29845939]

Level 3 (low-level) evidence

[124]

Creagh S, Warden D, Latif MA, Paydar A. The New Classes of Synthetic Illicit Drugs Can Significantly Harm the Brain: A Neuro Imaging Perspective with Full Review of MRI Findings. Clinical radiology & imaging journal. 2018:2(1):. pii: 000116. Epub 2018 Apr 25     [PubMed PMID: 30027157]

Level 3 (low-level) evidence

[125]

Rahnema CD, Lipshultz LI, Crosnoe LE, Kovac JR, Kim ED. Anabolic steroid-induced hypogonadism: diagnosis and treatment. Fertility and sterility. 2014 May:101(5):1271-9. doi: 10.1016/j.fertnstert.2014.02.002. Epub 2014 Mar 14     [PubMed PMID: 24636400]


[126]

Andrews MA, Magee CD, Combest TM, Allard RJ, Douglas KM. Physical Effects of Anabolic-androgenic Steroids in Healthy Exercising Adults: A Systematic Review and Meta-analysis. Current sports medicine reports. 2018 Jul:17(7):232-241. doi: 10.1249/JSR.0000000000000500. Epub     [PubMed PMID: 29994823]

Level 1 (high-level) evidence

[127]

Elliott J, Kelly SE, Millar AC, Peterson J, Chen L, Johnston A, Kotb A, Skidmore B, Bai Z, Mamdani M, Wells GA. Testosterone therapy in hypogonadal men: a systematic review and network meta-analysis. BMJ open. 2017 Nov 16:7(11):e015284. doi: 10.1136/bmjopen-2016-015284. Epub 2017 Nov 16     [PubMed PMID: 29150464]

Level 1 (high-level) evidence