Diagnosis and Management of Anabolic Androgenic Steroid Use

Abstract

Context: The lifetime prevalence of anabolic androgenic steroid (AAS) use is estimated at 1% to 5% worldwide. AAS use occurs primarily male elite athletes and men who want a muscular appearance. The evidence for effective, safe management of AAS cessation and withdrawal is weak.

Design: Key studies were extracted from PubMed (1990-2018) and Google Scholar with reference searches from relevant retrieved articles.

Results: The proven adverse effects of AASs include suppression of the gonadal axis and infertility, hirsutism and defeminization in women, and erythrocytosis. Alkylated AASs that are taken orally may cause hepatopathy. There is an association between high-dosage AAS use and increased risk of cardiovascular disease. Clues for AAS use include very low serum high-density cholesterol and sex hormone-binding globulin concentrations and unexplained erythrocytosis. For elite athletes, the biological passport (monitoring of blood or urinary androgen and androgen precursor concentrations after determining the athlete's baseline) is useful for detecting AAS use. For nonelite athletes, the best method to confirm AAS use is to inquire in a nonjudgmental manner. Cessation of chronic AAS use is associated with a withdrawal syndrome of anxiety and depression.

Conclusions: Men who use AASs <1 year typically recover normal hypothalamic-pituitary-testicular axis function within 1 year after cessation. Men who have infertility due to high-dosage AAS use ≥1 year might benefit from short-term treatment with clomiphene or human chorionic gonadotropin.

Figure 1.

Simplified description of randomized response surveys. (A) Scenario of randomized response survey in which no one in a group of 20 uses AASs. In this simplified diagram, each subject responds to a question with a predetermined answer or truthfully based on the results of a coin flip that the researcher cannot see. While protecting anonymity of individual respondents, the reviewer can determine that a very small percentage of the truth responders use AASs. This method provides a range of likely percentages based on statistical analysis of the probability of the results for a given number of coin flips. (B) Scenario of randomized response survey in which everyone in a group of 20 uses AASs. In this simplified diagram, each subject responds to a question with a predetermined answer or truthfully based on the results of a coin flip that the researcher cannot see. While protecting anonymity of individual respondents, the reviewer can determine that a very large percentage of the truth responders use AAS.

Figure 2.

The biological passport. The circles at top show the steps for creating baseline measurements for an individual athlete’s biological passport. The circles at bottom show the monitoring cycle after establishment of the baseline. [Reproduced with permission from Anawalt BD. Detection of anabolic androgenic steroid use by elite athletes and by members of the general public. Mol Cell Endocrinol. 2018;464:21–27.]