Description

• Anabolic-androgenic steroids (AAS) are medically indicated for the treatment of endocrine disorders such as primary or secondary hypogonadism. These agents increase muscle strength and lean muscle mass, which can alter physical appearance. This has led to the abuse of AAS. AAS include exogenous testosterone, synthetic androgens, synthetic androgen receptor modulators, androgen precursors, and other androgen stimulators.
• AAS are administered orally, transdermally, topically, or intramuscularly.
• When used in supraphysiologic doses, AAS contribute to muscle building and masculinization.
• Individuals typically “stack” steroids, using a cocktail of multiple agents at high doses and then discontinuing use for a period of weeks to reduce side effects and avoid detection.
• Side effects of AAS are typically dose dependent. Some reverse when use is discontinued. There is growing concern over long-term side effects.
• Many AASs are purchased on the Internet from unregulated sources. There are multiple street names (“roids” or “juice”) for AAS.
• AAS use is not associated with an immediate “high” (seen with other drugs of abuse). Dependence is possible.
• AAS use is prohibited by the World Anti-Doping Agency (WADA) list. In 2010, AAS accounted for 60% of positive results in WADA laboratories. Testosterone, stanozolol, and nandrolone were the most frequent AAS identified.
• There is no evidence that AAS abuse or dependence develops from the therapeutic use of AAS.

Epidemiology

Incidence
Rates are difficult to estimate because AAS use is typically concealed.

Prevalence

• Epidemiologic studies suggest that the lifetime prevalence of AAS use in men is at least 6.4% and 1.6% in females.
• In power sports or weight lifting, the prevalence has been estimated to be as high as 10–50%.
• Past estimates suggest there are up to 3 million AAS users in the United States at any one time.
• Usage rates in men exceed those in women.

Etiology and Pathophysiology

• Natural testosterone is produced in small amounts by the adrenal gland and ovaries and in large amounts by the testes.
• AAS exert their anabolic effects through increased protein production, particularly in muscle cells.
• AAS decrease catabolism by blocking cortisol effects.
• Administration of exogenous testosterone suppresses the hypothalamic-pituitary-gonadal (HPG) axis, causing testicular atrophy and suppressed spermatogenesis. Human chorionic gonadotropin (hCG) is often used concurrently to mitigate this side effect.
• Aromatase inhibitors are concurrently used to counteract gynecomastia, which occurs with exogenous AAS use due to peripheral conversion of testosterone to estradiol.
• AAS use in adolescents accelerates cartilage formation, leading to premature epiphyseal closure.
• Muscle mass decreases after cessation of AAS use.

Genetics
Genetic variations in enzymatic and androgen receptor activity impacts AAS pharmacodynamics including anabolic and toxic effects.

Risk Factors

• Male gender
• Age 20 to 30 years
• Participation in power sports
• Use is more common in developed countries.
• Concurrent use of legal performance-enhancing substances
• Use of alcohol and/or illicit drugs
• Lower education level

General Prevention

• There is insufficient evidence to recommend routine screening for anabolic steroid abuse.
• At-risk individuals should be counseled about negative side effects associated with AAS abuse.

Commonly Associated Conditions

• Major depressive disorder
• Body dysmorphic disorder
• Substance abuse