The Health Threat Posed by the Hidden Epidemic of Anabolic Steroid Use and Body Image Disorders Among Young Men

Anna L. Goldman; Harrison G. Pope, Jr.; Shalender Bhasin


J Clin Endocrinol Metab. 2019;104(4):1069-1074. 

In This Article

Adverse Health Effects of AAS use

There are few systematically collected data from prospective observational studies on the adverse health outcomes associated with AAS use. Data from randomized controlled trials of testosterone have sometimes been extrapolated to infer that AAS use produces few adverse effects. However, these conclusions are misleading, because clinical trials have typically used physiologic doses in the range of 100 mg of testosterone per week, with only a handful of studies using as much as 600 mg per week. By contrast, AAS users may often use the equivalent of 1000 to 5000 mg of testosterone per week. Moreover, users often combine AASs with multiple other appearance- and performance-enhancing drugs, adjunctive drugs to counteract the side effects of AASs, and other classical drugs of abuse (e.g., opioids, cocaine, and amphetamines). Potential adverse effects among these individuals may be compounded further by AAS-associated high-risk behaviors such as sharing of needles, unprotected sex, or involvement in violent behaviors. Thus, the full magnitude of AAS-associated morbidity and mortality is likely much greater than was generally believed two or three decades ago (Table 1).

Evolving data have implicated four categories of adverse AAS effects that appear particularly concerning: cardiovascular disorders, psychiatric disorders, AAS-withdrawal hypogonadism, and neurotoxic effects.[4] Long-term AAS use is clearly associated with cardiomyopathy and acceleration of coronary atherosclerosis,[17–19] very likely causing an increased risk of myocardial infarction, cerebrovascular accidents, and death. Psychiatric effects of AAS use may include mania and hypomania, aggression, and violent behavior during AAS use; and depression, sometimes associated with suicidality, during AAS withdrawal.[4,20–22] Another psychiatric consequence of AAS use is possible progression to use of other classical drugs of abuse. For example, a recent analysis of 233 AAS users and nonusers, assessing potential causal pathways using directed acyclic graphs, found that AAS use substantially increased the risk for subsequent development of opioid use disorders.[23] Exogenous AASs suppress the hypothalamic-pituitary-testicular (HPT) axis, and the HPT axis may take months or even years to recover when AASs are discontinued.[24,25] Recent evidence suggests that HPT recovery may remain incomplete or fail entirely in some men.[24,25] In some men's health clinics, prior AAS abuse has emerged as a frequent cause of hypogonadism and infertility.[26] Some men whose testosterone levels remain low even after prolonged withdrawal from AASs may have had underlying hypogonadism that had not been detected prior to the initiation of AAS use. The distressing symptoms of AAS-withdrawal hypogonadism, including loss of libido, erectile dysfunction, fatigue, and sometimes serious depression, may lead some men to resume AAS use, perpetuating a vicious cycle of AAS dependence.[4] Finally, supraphysiologic doses of AASs have been observed to exert toxic effects on neuronal cells in vitro, raising the concern that long-term use of high doses of these compounds could lead to early-onset dementia.[27,28] In a preliminary neuroimaging study, AAS users displayed substantial deficits of scyllo-inositol in the anterior cingulate region of the brain as compared with otherwise similar nonusing weightlifters.[29] Scyllo-inositol protects against the toxicity of β-amyloid, a protein implicated in Alzheimer's disease, suggesting that depletion of scyllo-inositol could be one potential mechanism whereby AASs might contribute to early dementia.

Additional potential adverse effects of AAS abuse include gynecomastia, acne, hair loss, nephrotoxicity, hepatotoxicity, and musculoskeletal injuries such as tendon ruptures (Table 1).[4] Marked muscle hypertrophy may render AAS-using weightlifters susceptible to injuries of articular and juxta-articular soft tissues, such as tendons and ligaments.[30] Upper extremity tendon ruptures are almost always associated with AAS abuse. Needle-sharing practices can increase the risk of needle-borne infections such as the human immunodeficiency virus, hepatitis C, and skin and muscle abscesses.[31]