Ep 209 – Anabolic steroid misuse

In this episode, Dr Roger Henderson explores the growing clinical challenge of anabolic–androgenic steroid (AAS) misuse, a condition increasingly seen in everyday practice. Here, we examine how AAS use has shifted toward appearance-driven motivations, the role of muscle dysmorphia and the influence of gym culture and online communities. This episode highlights key pathophysiological effects, including hypogonadism, cardiovascular risk and neuropsychiatric complications. It also reviews how AAS misuse presents in real-world clinical settings, often through indirect signs rather than disclosure. Finally, it covers practical approaches to recognition, withdrawal management and long-term care, equipping GPs to better identify and support patients affected by this evolving, multi-system disorder.

Key take-home points

• AASs are synthetic or natural derivatives of testosterone that are used medically but frequently misused at supra-physiologic doses.
• Non-medical use differs fundamentally from therapeutic prescribing in intent, dosing and risk profile.
• The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, guidelines do not classify AAS misuse as a standalone disorder. Instead, it is coded under “Other (or Unknown) Substance Use Disorder”.
• AAS misuse has shifted from elite athletes to the general population, particularly recreational gym users. Appearance-driven motivations now outweigh performance-based reasons in most users.
• Lifetime prevalence is estimated at roughly 1–5% globally, with higher rates in males. These figures likely underestimate true use due to underreporting and informal access routes.
• Muscle dysmorphia is a major psychological driver of AAS misuse. It often predates steroid use and contributes to escalation and dependence-like patterns.
• Social and cultural influences, including gym environments and online fitness communities, normalise AAS use. This normalisation reduces perceived risk and delays clinical recognition.
• AAS misuse suppresses the hypothalamic–pituitary–gonadal axis, leading to hypogonadism. Recovery of endogenous testosterone can be prolonged or incomplete after cessation.
• Cardiovascular complications include left ventricular hypertrophy, dyslipidaemia and accelerated atherosclerosis. These changes may persist even after discontinuation of AAS.
• Neuropsychiatric effects include aggression, mood instability and depression. These symptoms are linked to alterations in central neurotransmitter systems.
• Dependence-like features can develop, including tolerance and withdrawal. Withdrawal commonly presents with fatigue, low mood, insomnia and reduced libido.
• Clinical presentation is often indirect, with patients presenting with complications rather than disclosing use. Suspicion should be raised by signs such as gynaecomastia, testicular atrophy or unexplained hormonal abnormalities.
• In women, AAS misuse can cause virilisation, including hirsutism and voice deepening. Some of these changes may be irreversible.
• Management centres on cessation of AAS and monitoring for withdrawal symptoms. Hormonal recovery may require pharmacologic support in some cases.
• Psychological support, including cognitive behavioural therapy, is often necessary. Coexisting mental health and substance use disorders should be addressed concurrently.
• AAS misuse represents a multi-system disorder with endocrine, cardiovascular and psychiatric consequences. Early recognition is critical to prevent long-term morbidity and mortality.

Key references

1. Anawalt BD. J Clin Endocrinol Metab. 2019;104(7):2490-2500. doi: 10.1210/jc.2018-01882.
2. Pope Jr HG, Kanayama G. Endocrinol Metab Clin North Am. 2022;51(1):205-216. doi: 10.1016/j.ecl.2021.11.007.
3. Handelsman DJ. Endocr Rev. 2021;42(4):457-501. doi: 10.1210/endrev/bnab001.
4. NIH. 2023. https://nida.nih.gov/research-topics/anabolic-steroids.