Anabolic Steroids and Other Appearance and Performance Enhancing Drugs (APEDs)

Anabolic-androgenic steroids, often shortened to "anabolic steroids," "steroids," or "androgens,"^2,3 are the most widely misused APED. These are synthetic substances similar to the male sex hormone testosterone. They promote the growth of skeletal muscle (anabolic effects) and the development of male sexual characteristics (androgenic effects) in both males and females.²

These compounds are sometimes used medically to treat delayed puberty and muscle loss due to disease⁴ and to treat low levels of testosterone in men with an associated medical condition.⁵ Anabolic androgenic steroids can also improve feelings of well-being and increase bone strength, but are not approved for these purposes. However, testosterone-supplementation therapy is an increasingly common treatment for mood and sexual performance problems associated with male aging, and it is controversially being prescribed even for younger men.⁶

Note that in the context of this report, anabolic steroids refer only to the non-prescribed use (misuse) of testosterone and testosterone-like substances by athletes and non-athlete bodybuilders. This research report will not cover image enhancers, such as dermal fillers, Botox, or the skin tanner, melanotan.⁷

Non-steroidal anabolics, include insulin, insulin-like growth hormone (IGF), and human growth hormone (HGH)—substances that are produced by the human body and are prescribed for legitimate medical uses but also sometimes misused for performance enhancement.

Ergo/thermogenics are compounds used to decrease body fat or to promote leanness versus muscle mass in endurance athletes.⁸ The three main categories of ergo/thermogenics are:

• Xanthines: compounds that increase attention and wakefulness and suppress appetite. Examples are caffeine, the asthma drug theophylline, and theobromine—a substance found in chocolate, coffee, and tea.⁹
• Sympathomimetics: drugs that are similar in structure and action to epinephrine and norepinephrine—natural chemicals in the body that increase heart rate, constrict blood vessels, and raise blood pressure. An example is ephedrine, which is derived from the ephedra plant. Ephedrine/ephedra used to be included in dietary supplements that promoted weight loss, increased energy, and enhanced athletic performance.¹⁰ In 2004, the FDA banned the U.S. sale of dietary supplements containing ephedrine/ephedra due to various possible health risks including cardiovascular and nervous system effects.¹¹
• Thyroid hormones: substances that regulate metabolism by altering the function of the thyroid.¹² Cytomel is an example.

Nutritional/dietary supplements are substances purchased legally from nutritional stores or via the internet that are often taken in combination with other APEDs. Creatine, which boosts exercise capacity, is one common example.

In the United States, dietary supplements containing steroid precursors such as tetrahydrogestrinone (THG) and androstenedione previously could be purchased legally without a prescription. Athletes took steroid precursors in an effort to boost testosterone levels. Less is known about the side effects of steroid precursors, but if large quantities of these compounds substantially increase testosterone levels in the body, then they also are likely to produce the same side effects as anabolic steroids themselves.¹³ The purchase of these supplements, with the notable exception of dehydroepiandrosterone (DHEA), became illegal after the passage of the Anabolic Steroid Control Act of 2004, which amended the Controlled Substances Act.¹⁴

All data refer to the United States population.

It is difficult to estimate the prevalence of steroid misuse in the United States because many national surveys that ask about drug use do not include questions about steroids. However, data on steroid misuse among young students are available from the NIDA-supported Monitoring the Future Survey.

How many young students use steroids?

In 2022, an estimated 0.8% of 8th graders, 0.5% of 10th graders, and 1.3% of 12th graders reported misusing steroids in the past 12 months. Source: 2022 Monitoring the Future Survey.

Anabolic steroids increase lean muscle mass when used in conjunction with weight training. The aim, for non-athlete weightlifters, is typically improvement of appearance. Steroid use is often associated with a form of male body dysmorphic disorder called muscle dysmorphia, a preoccupation with the perceived inadequate size of their muscles.¹⁹

As a result, some users report taking anabolic steroids to increase confidence and because they feel that they are at a point where they can no longer get bigger through weight training alone. Most users report that anabolic steroids help them achieve their ideal body.²⁸

Increasing muscle mass may also promote strength, which can improve performance in certain types of sports. More benefit is seen for strength-dependent sports (weightlifting, shot-put throwing, football) than for sports that require speed, agility, flexibility, and/or endurance.²⁹

Anabolic steroid users also report that their muscles recover faster from intense strain and muscle injury.³⁰ Research in animals has not conclusively supported this belief, with some showing that anabolic steroids can enhance recovery from certain types of muscle damage,^31,32 but others finding no benefit in taking anabolic steroids to enhance muscle recovery.³³

Anabolic steroid users report using an average of about 11 APEDs per year. They are also more likely than non-steroid users to take supplements such as protein powders and creatine; estrogen blockers; ergo/thermogenics, such as caffeine or ephedrine; medications for erectile dysfunction; and other hormones such as insulin, thyroid hormones, and human growth hormone.²⁶

Some anabolic steroids are taken orally, others are injected intramuscularly,²⁹ and still others are provided in gels or creams that are applied to the skin.³⁵ Many users start with the oral form and then progress to injectable forms,³⁶ since the latter causes less liver damage. However, oral steroids clear more rapidly from the body, often making this the preferred route for users concerned with drug testing.²⁹ Doses taken by people misusing these substances can be 10 to 100 times higher than the doses used to treat medical conditions.³⁶

Cycling, stacking, pyramiding, and plateauing

Steroids are often used in patterns called "cycling." This involves taking multiple doses of steroids over a specific period of time, stopping for a period, and starting again. People who misuse steroids also typically "stack" the drugs, meaning that they take two or more different anabolic steroids, mix oral and/or injectable types, and sometimes even take compounds that are designed for veterinary use.^37,38 The belief is that different steroids interact to produce an effect on muscle size that is greater than the effects of each drug individually,³⁶ a theory that has not been tested scientifically.

Another common mode of steroid misuse is referred to as "pyramiding," which typically involves taking them in a cycle of six to 12 weeks, tapering gradually rather than starting and finishing a cycle abruptly. At the beginning of a cycle, the person starts with low doses of the drugs being stacked and then slowly increases the doses. In the second half of the cycle, the doses are slowly decreased to zero. This is sometimes followed by a second cycle in which the person continues to train but without drugs. Steroid users believe that pyramiding allows the body time to adjust to the high doses, and the drug-free cycle allows the body's hormonal system time to recuperate.²

A technique called "plateauing" may also be used, whereby steroids are staggered, overlapped, or substituted with another type of steroid to avoid developing tolerance.³⁶ As with stacking, the effects of pyramiding, cycling, and plateauing have not been substantiated scientifically.

A variety of side effects can occur when anabolic steroids are misused, ranging from mild effects to ones that are harmful or even life-threatening. Most are reversible if the user stops taking the drugs. However, others may be permanent or semi-permanent.

Most data on the long-term effects of anabolic steroids in humans come from case reports rather than formal epidemiological studies. Serious and life-threatening adverse effects may be underreported, especially since they may occur many years later. One review found 19 deaths in published case reports related to anabolic steroid use between 1990 and 2012; however, many steroid users also used other drugs, making it difficult to show that the anabolic steroid use caused these deaths.³⁹ One animal study found that exposing male mice for one fifth of their lifespan to steroid doses comparable to those taken by human athletes caused a high frequency of early deaths.⁴⁰

Cardiovascular System

Steroid use has been associated with high blood pressure;⁴¹ decreased function of the heart’s ventricles;^23,41,42 and cardiovascular diseases such as heart attacks,⁴³ artery damage,⁴⁴ and strokes,^45,46 even in athletes younger than 30. Steroids contribute to the development of cardiovascular disease partly by increasing the level of low-density lipoprotein (LDL)⁴⁷ and decreasing the level of high-density lipoprotein (HDL).^47,48 High LDL and low HDL levels increase the risk of atherosclerosis, a condition in which fatty substances are deposited inside arteries and disrupt blood flow. If blood is prevented from reaching the heart or brain, the result can be a heart attack or stroke, respectively. Steroids also increase the risk that blood clots will form in blood vessels, potentially disrupting blood flow and damaging the heart muscle, so that it does not pump blood effectively.⁴⁹

Hormonal System

Steroid use disrupts the normal production of hormones in the body. Changes that can be reversed include decreased sperm production,^56–59 decreased function of the testes (hypogonadism) that leads to low testosterone levels,⁶⁰ and shrinking of the testicles (testicular atrophy).^56,61 Irreversible changes include male-pattern baldness and breast development (gynecomastia) in men.^59,62 Anabolic steroids may also act upon the hormone system to increase the risk of testicular cancer, especially when steroids are used in combination with insulin-like growth factor.⁶³

In females, anabolic steroids cause masculinization. Specifically, breast size and body fat decrease, the skin becomes coarse, and the voice deepens.⁶⁴ Women may experience excessive growth of body hair but lose scalp hair.⁶⁵ With continued administration of steroids, some of these effects become irreversible. It is commonly believed that anabolic steroids will produce irreversible enlargement of the clitoris in females, although there are no studies on this.⁶⁶

Infections

Many people who inject anabolic steroids may use nonsterile injection techniques or share contaminated needles with other users. This puts these steroid users at risk for acquiring life threatening viral infections, such as HIV and hepatitis B and C.⁷⁶ In addition, animal models indicate that anabolic steroids suppress the immune system,⁷⁷ which could worsen infections.

Liver

Steroid misuse has been associated with liver damage,^50,51 tumors,^46,52,53 and a rare condition called peliosis hepatis, in which blood-filled cysts form in the liver.⁵⁴ The cysts can rupture, causing internal bleeding and even death in rare cases.⁵⁵

Musculoskeletal System

Rising levels of testosterone and other sex hormones normally trigger the growth spurt that occurs during puberty and adolescence. These rising levels of testosterone also provide the signals to stop growth.⁶⁷ When a child or adolescent takes anabolic steroids, the resulting artificially high sex hormone levels can prematurely signal the bones to stop growing.⁶⁸

Evidence suggests that weightlifters who misuse anabolic steroids have stiffer tendons, which could lead to an increased risk for tendon injury.⁶⁹

Skin

Steroid misuse can cause acne,^70–72 hair loss on the head, cysts, and oily hair and skin.⁶⁵ Users who inject steroids may also develop pain and abscess formation at injection sites.⁷³

Anabolic steroids can also produce jaundice, or yellowing of the skin or eyes, as a result of damage to the liver.^74,75

Aggression

Case reports and small studies indicate that anabolic steroids increase irritability and aggression,⁷⁵ although findings may be confounded by personality traits that are overrepresented in steroid users (i.e., antisocial, borderline, and histrionic personality disorder)⁷⁸ and use of other drugs.⁷⁹ People who misuse anabolic steroids report more anger than nonusers,⁸⁰ as well as more fights, verbal aggression, and violence toward their significant others,⁸¹ sometimes called "roid rage." One study suggests that the mood and behavioral effects seen during anabolic-androgenic steroid misuse may result from secondary hormonal changes.⁸²

Scientists have attempted to test the association between anabolic steroids and aggression by administering high steroid doses or placebo for days or weeks to human volunteers and then assessing behavioral symptoms. In one such study, researchers found that testosterone over a six week period was associated with increased aggression, as assessed by a questionnaire and computer-based model of aggressive behavior.⁸³ In addition, high steroid doses produced greater feelings of irritability and aggression than placebo,⁸⁴ although the effects appear to be highly variable across individuals,¹⁹ and other studies have not shown that effect.⁸⁵ One possible explanation, according to the researchers, is that some but not all anabolic steroids increase irritability and aggression.

Psychiatric Disorders

Anabolic steroid users are more likely than nonusers to report anxiety.^34,86 Moderate to high doses of anabolic steroids are also associated with major mood disorders such as mania, hypomania,⁸⁷ and major depression.^86,87 In one study, manic symptoms were not uniform across individuals, with most showing little psychological change, whereas a few demonstrated prominent effects.¹⁹

Other Drug Use

Anabolic steroid users are more likely to use drugs such as marijuana, prescription opioids, cocaine,⁸⁸ or heroin.⁸⁶ In a study of men admitted to treatment for opioid use disorders, 25 percent reported prior use of anabolic steroids. Some described first learning about opioids from friends at the gym, and that they first purchased opioids from the same person who had sold them the anabolic steroids.⁸⁹ In a study of anabolic steroid users dependent upon the injectable opioid analgesic nalbuphine, most reported that they began using nalbuphine to treat pain from weightlifting injuries. They also described widespread use of nalbuphine in their gyms.⁹⁰

Research also indicates that some users might turn to other drugs to alleviate some of the negative effects of anabolic steroids. For example, a study of 227 men admitted in 1999 to a private treatment center for addiction to heroin or other opioids found that 9.3 percent had previously misused anabolic steroids. Of these, most reported using opioids to counteract insomnia, irritability, depression, and withdrawal from anabolic steroids.⁹¹

Unlike most illicit drug use, misuse of anabolic steroids most commonly begins in young adulthood rather than adolescence. But steroid use in teens is of concern, especially since the hormonal systems they interact with play a critical role in brain development during these years.^92–96 In adolescent rodents, exposure to anabolic steroids increased neuronal spine densities in the hippocampus and amygdala—brain regions involved in learning and emotions (e.g., aggression), respectively. Four weeks after withdrawal, these increases in neuronal spine densities returned to normal in the amygdala, but not in the hippocampus. This suggests that pubertal steroid exposure could produce long-lasting structural changes in certain brain regions.⁹⁷

Teens who use anabolic steroids may also be at increased risk for some cognitive side effects compared with adults. For example, males who begin using anabolic steroids during the teen years show increased impulsivity and decreased attention, compared to men who began using steroids in their adult years.⁹⁸ In adolescent rats, anabolic steroid exposure is associated with electrolytic imbalances, hyperactivity, anxiety, and increased sympathetic autonomic modulation (e.g., fight or flight response) during adulthood, even when steroid use was discontinued during adolescence.⁹⁹ In addition, adolescent male hamsters given anabolic steroids show increased aggression, even after steroid use is discontinued. These aggressive effects are paralleled by changes in levels of serotonin ^100,101 and androgen receptors in the rodent brain.¹⁰²

Anabolic steroids act at androgen receptors to influence cellular functioning and gene expression. In addition to regulating pathways involved in the development of male characteristics,¹⁰³ activation of androgen receptors also produces rapid increases in calcium levels within skeletal muscle, heart, and brain cells.¹⁰⁴ Calcium plays important roles in neuronal signaling.

Research with human cells demonstrates that anabolic steroids also interact with certain types of GABA_A receptors, which could mediate the increased anxiety reported by steroid users.^105,106 In addition, animal studies show that anabolic steroids increase serotonin levels in brain regions involved in mood ¹⁰⁷ and dopamine levels in reward-related brain regions.^107,108 Chronic use of anabolic steroids has also been shown to cause dysfunction of these reward pathways in animals. Specifically, rats given twice daily nandrolone injections for four weeks showed loss of sweet preference (a sign of reward dysfunction) that was accompanied by reductions of dopamine, serotonin, and noradrenaline in the nucleus accumbens, a reward-related brain region.¹⁰⁹

An undetermined percentage of steroid users may develop a steroid use disorder. Substance use disorders are defined by continued use despite adverse consequences; for steroid users, these may include physical or psychological problems such as breast growth (in men), sexual dysfunction, high blood pressure, excessive fats in the blood, heart disease, mood swings, severe irritability, or aggressiveness. Anabolic steroid users also may give up other important activities for fear that they will miss workouts, violate their dietary restrictions, or be prevented from using steroids. Steroid users also typically spend large amounts of time and money obtaining the drugs, and they may try to reduce or stop anabolic steroid use without success—possibly due to depression, anxiety about losing muscle mass, or and other unpleasant effects of withdrawal.¹¹⁰

Withdrawal from steroids occurs when an individual develops dependence. A review of the research suggests that about 32 percent of people who misuse anabolic steroids become dependent.²³ Symptoms of dependence can include tolerance, which is needing to take more steroids to achieve the same effects. Another indicator of dependence is withdrawal once anabolic steroid use stops.¹¹⁰ Withdrawal symptoms can include fatigue, restlessness, loss of appetite, insomnia, reduced sex drive, and steroid cravings.¹¹¹ The most dangerous of the withdrawal symptoms is depression, because it sometimes leads to suicide attempts.¹¹²

Although non-athlete weightlifters account for the bulk of anabolic steroid misuse, occasional steroid use by professional and Olympic athletes to improve performance or cheat in competition ("doping") has done the most to raise awareness of steroid misuse. The World Anti-Doping Agency (WADA) was founded in 1999 to consistently apply anti-doping policies across sports organizations and governments around the world. Non-compliant organizations can face sanctions such as event cancellation, loss of WADA funding, or ineligibility to host events.¹¹⁴

Image

Source: WADA. 2015 Anti-Doping Rule Violations (ADRVs) Report. 2017.

Refinements in drug testing have improved the ability to detect anti-doping violations, resulting in increased numbers of reported violations over recent years. For example, the discovery of long-term steroid metabolites has lengthened the drug detection window, making it more difficult for athletes to pass drug tests by simply discontinuing steroid use just prior to an event. In addition, more sensitive technologies have allowed detection of lower metabolite thresholds.¹¹⁵

Although testing procedures are now in place to deter steroid use among professional and Olympic athletes, new designer drugs constantly become available that can escape detection and put athletes willing to cheat one step ahead of testing efforts.^116–118 To detect early use of designer steroids and provide more accurate baseline standards for each athlete, testing laboratories store data from each drug testing sample. These samples are then used as reference points for future testing, thereby eliminating the possibility that a person tests positive simply because he or she has naturally elevated levels of testosterone when compared to the general population.¹¹⁹ Long-term use of designer steroids suppresses levels endogenous steroids in urine samples, which could be the first indication that an athlete is taking a designer steroid.¹¹⁷

According to WADA’s codes, athletes are responsible for any prohibited substance found in their samples, regardless of whether ingestion was intentional or unintentional. However, sanctions may be reduced or avoided if the athlete can demonstrate that the substance was ingested through no significant fault or negligence on his/her part, or in some circumstances where the athlete did not intend to enhance performance.¹²⁶

Research suggests that high school athletes are less likely to use steroids if their peers and parents disapprove, indicating that peers and parents can be strong partners in prevention efforts.¹²⁷

However, research shows that simply teaching students about steroids' adverse effects does not convince adolescents that they will be adversely affected, nor does such instruction discourage young people from taking steroids in the future. Presenting both the risks and benefits of anabolic steroid use is more effective in convincing adolescents about steroids' negative effects, apparently because the students find a balanced approach more credible.¹²⁸

Research also indicates that some adolescents misuse steroids as part of a pattern of high-risk behaviors such as drinking and driving, carrying a gun, driving a motorcycle without a helmet, and using other illicit drugs. This suggests that a prevention program should focus on comprehensive high-risk behavior screening and counseling among teens who use anabolic steroids.¹²⁹

The Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA) program was patterned after the ATLAS program, but designed for adolescent girls on sports teams. Early testing of girls enrolled in the ATHENA program showed significant decreases compared to controls in risky behaviors such as riding with an intoxicated driver or engaging in sexual activity with new partners. ATHENA participants were also less likely to use diet pills, amphetamines, anabolic steroids, and muscle-building supplements during the sports season. Although the program had no immediate effect on tobacco, alcohol, or marijuana use,¹³¹ ATHENA-trained athletes reported less lifetime use of these substances when surveyed one to three years following high school graduation. Diet pill and steroid use declined by this one to three year follow-up for both ATHENA-trained and control-group athletes, so that these groups no longer differed in their use of these substances.¹³²

People who use steroids often do not seek treatment for their use, with one study reporting that 56 percent of users had never told their physician about their use.¹³³ This could be because users feel their physician lacks knowledge about anabolic steroids.¹³³ In addition, many internet sites devoted to anabolic steroids and other APEDs challenge the professionalism of health care providers and offer their own medically questionable advice on the use of APEDs.¹³⁴ This makes it important for health care providers to be educated on the signs and symptoms of steroid use in their patients.¹¹¹

Current views recommend that treatment for steroid use address the underlying causes of the steroid use. This can include:

• psychological therapies (and possibly medications) for muscle dysmorphia
• endocrine therapies to restore function in those suffering from hypogonadism and to alleviate symptoms of depression
• antidepressants for those whose depression does not respond to endocrine therapies
• pharmacological and psychosocial treatments for patients who are also dependent on opioids, which appear to also be effective in alleviating signs of anabolic steroid dependence ¹³⁵