Anabolic steroid use by athletes and body-builders has captured public attention but remains poorly understood by most physicians. This is not surprising because users of anabolic-androgenic steroids (AAS):
- rarely seek treatment or disclose their drug use
- frequently distrust professionals.
If you are a clinician who regularly sees male adolescents and young men, you need to become familiar with—and watch for—this often-secret form of substance abuse. This article provides the groundwork for that understanding, starting with the story of “Aaron”—a composite patient whose case represents experiences and verbatim quotes from AAS users known to the authors.
CASE REPORT: ‘I FEEL INVINCIBLE’
At his first visit, Aaron, age 18, told the psychiatrist he had no complaints but was coming to please his parents. “I have a lot of arguments with my Dad,” he said, “and they keep thinking something’s wrong with me.”
The patient was very muscular and dressed in baggy sweats that masked his body proportions. He was appropriately groomed and darkly tanned but displayed some acne. The clinician guessed he weighed about 175 lbs and stood at about 65 inches, with very low body fat. Although superficially confident, he seemed restless, somewhat anxious, and guarded as the interview progressed.
Aaron admitted he experienced prominent mood swings. During rage outbursts, he had damaged objects and put his fist through the wall. “There’s holes all over the wall of my room,” he joked.
He also had assaulted a motorist in a traffic altercation, then left the scene. “Did you hurt him?” the clinician asked. Somewhat sheepishly, Aaron responded, “Well, I bought the newspaper and kept checking the obituaries for about 2 weeks afterwards.”
He spoke with pride about his weightlifting, which was the focus of his life. He revealed that he was preparing for a body-building contest in 2 months. The psychiatrist asked him about use of supplements—protein shakes, creatine, and “andro” (androstenedione)—all of which Aaron acknowledged. The psychiatrist then gently asked about anabolic steroid use (Box 1).
Initially, Aaron strongly denied using AAS. The psychiatrist persisted, pointing out that no information would be disclosed to his parents, and asked again using colloquial terms from the AAS subculture: “Anybody who is prepping for an untested contest in a couple of months is going to be on a cycle. Come on, what are you taking?”
What are anabolic-androgenic steroids?
Anabolic-androgenic steroids (AAS) are hormones that include testosterone—nature’s own AAS—and more than 100 synthetically developed testosterone relatives. All AAS possess anabolic (muscle-building) and androgenic (masculinizing) properties; no known compound can produce one of these effects without the other.
Because of their masculinizing effects, AAS are rarely used by women—and even then in much lower doses than those used by men. Thus, this article focuses on evaluating and treating male adolescents and men.
AAS are not:
- Corticosteroids (such as cortisol) are often called “steroids” but possess no muscle-building properties. Corticosteroids’ prominent but idiosyncratic psychiatric effects are usually seen in consultation-liaison settings where patients have been prescribed these drugs, rather than among substance abusers.
- Androstenedione (“andro”) and its relatives are adrenal steroids that are weakly metabolized into testosterone or other AAS. These substances were sold legally without prescription in the United States for many years but were banned by federal law in October 2004. Their anabolic and psychiatric effects are much weaker than those of AAS.
- Athletic “supplements” with names designed to sound like AAS (such as beginning with “Ana…”) or supplements claimed to be “testosterone-releasers” or the like. If sold legally in supplement stores, an athletic supplement is not an AAS. Psychiatric effects are extremely unlikely.
Eventually it emerged that Aaron had taken five 8- to 20-week AAS “cycles” (courses), during which he had “stacked” (combined) various “injectables” such as IM testosterone and “orals” such as methyltestosterone (Table 1). His current cycle included:
- a blend of testosterone esters (Sustanon), 500 mg IM once a week
- boldenone (Equipoise), a veterinary AAS normally used for horses, 200 mg IM per week
- oxymetholone (Anadrol), 50 mg orally per day.
Table 1
Commonly used anabolic-androgenic steroids
| ‘Injectables’ (usually administered only by injection) | |
| Boldenone (Equipoise)* | |
| Methenolone (Primobolan depot) | |
| Nandrolone (Deca-Durabolin, Durabolin, Laurabolin, others) | |
| Stanozolol (Winstrol-V)* | |
| Testosterone esters (Depo-testosterone, Sten, Sustanon, others) | |
| Trenbolone (Finajet, Parabolan) | |
| ‘Orals’ | |
| Methandienone (formerly called methandrostenolone) (Dianabol, others) | |
| Methenolone (Primobolan) | |
| Methyltestosterone (Android, others) | |
| Mibolerone (Checque Drops)* | |
| Oxandrolone (Anavar, Lipidex) | |
| Oxmetholone (Anadrol, Anapolon) | |
| Stanoxolol (Stromba, Winstrol) | |
| Other anabolic substances sold on the ‘black market’ | |
| Human growth hormone (HGH) | Possesses anabolic properties |
| Extremely expensive | |
| Almost impossible to detect by testing | |
| Lacks androgenic effects | |
| Psychiatric effects appear negligible | |
| Large doses can cause acromegaly | |
| Clenbuterol | Beta-adrenergic agonist with stimulant and anabolic properties |
| Used less commonly than AAS | |
| Lacks androgenic effects and assists fat loss | |
| Can produce psychiatric effects similar to those of amphetamine abuse (rare, in the authors’ experience) | |
| Human chorionic gonadotropin (HCG) | Stimulates testes to produce more testosterone, creating an AAS effect |
| Most commonly used near the end of an AAS “cycle” to “jump-start” the hypothalamic-pituitary-testicular axis and minimize AAS withdrawal | |
| * Veterinary preparation | |
| AAS: anabolic-androgenic steroid | |