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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. Access free multiple choice questions on this topic.

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]

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]

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]

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]

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]

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.

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]