Review Article

Abuse of Supraphysiologic Doses of Anabolic Steroids

Authors: Ryan C. W. Hall, MD, Richard C. W. Hall, MD


The following article is a literature review of supraphysiologic doses of anabolic-androgenic steroids (AAS). This article contains a brief review of the history of AAS, the chemistry of the varying forms of AAS, and proposed mechanisms of action. The article then focuses on how AAS are used in an illicit manner by the general population. Terms such as “stacking” and “pyramiding” are discussed. The article concludes by looking at the major detrimental side effects, such as liver damage and cardiovascular changes, which physicians may encounter when treating AAS abusers.

Key Points

* Anabolic steroid abuse has become a major problem in the United States, with more than 1 million individuals abusing these drugs.

* Specific pharmacology that permits the production of “designer” molecules has produced a vast underground market for these illicit substances.

* The metabolism of these classes specifically affects their side effect profiles and physiologic effects.

* Stacking occurs when abusers choose medications of different classes to neutralize or enhance certain desired effects.

* The majority of abusers begin use by age 16 years and obtain their drugs on the black market, with physicians supplying a significant number of these abusers.

* The abuse of these compounds is often associated with the abuse of other substances.

* All, when taken in supraphysiologic doses, can produce significant mental changes including irritability, aggressivity, euphoria, grandiose beliefs, hyperactivity, and reckless and dangerous behavior.

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1. Basaria S, Wahlstrom JT, Dobs A. Anabolic-androgenic steroid therapy in the treatment of chronic diseases. J Clin Endocrinol Metab 2001;86:5108–5117.
2. Wilson JD. Androgens, in Hardman JG, Limbird LE (eds): Goodman and Gilman's The Pharmacological Basis of Therapeutics. New York, McGraw-Hill, 1996, pp 1441–1457.
3. Sturmi JE, Diorio DJ. Anabolic agents. Clin Sports Med 1998;17:261–282.
4. Dezelsky TL, Toohey JV, Shaw RS. Non-medical drug use behavior at five United States universities: a 15-year study. Bull Narc 1989;37:49–53.
5. US Department of Health and Human Services, Office of Inspector General-Richard P. Kusserow: Adolescent steroid use. Publication OEI-06–90–01080, February 1991.
6. DuRant RH, Rickert VI, Ashworth CS, et al. Use of multiple drugs among adolescents who use anabolic steroids. N Engl J Med 1993;328:922–926.
7. Stedman's Electronic Medical Dictionary v 4.0. Baltimore, Williams & Wilkins, 1998.
8. Rogol AD, Yesalis CE. Anabolic-androgenic steroids and athletes: what are the issues? J Clin Endocrinol Metab 1992;74:465–469.
9. Stone MH. Literature review: anabolic-androgenic steroid use by athletes. Natl Strength Conditioning Assoc J 1993;15:10–28.
10. Karila T, Hovatta O, Seppala T. Concomitant abuse of anabolic androgenic steroids and human chorionic gonadotrophin impairs spermatogenesis in power athletes. Int J Sports Med 2004;25:257–263.
11. Hartgens F, Kuipers H. Effects of androgenic-anabolic steroids in athletes. Sports Med2004;34:513–554.
12. No authors listed. Medical aspects of drug use in the gym. Drug Ther Bull 2004;42:1–5.
13. Tilley WD, Marcelli M, Wilson JD, et al. Characterization and expression of a cDNA encoding the human androgen receptor. Proc Natl Acad Sci U S A 1989;86:327–331.
14. Lombardo JA, Sickles RY. Medical and performance-enhancing effects of anabolic steroids.Psychiatr Ann 1992;22:19–23.
15. Haupt HA, Rovere GD. Anabolic steroids: a review of the literature. Am J Sports Med 1984;12:69–84.
16. Wilson JD. Androgen abuse by athletes. Endocr Rev 1988;9:181–199.
17. McPherron AC, Lee SJ. Double muscling in cattle due to mutations in the myostatin gene. Proc Natl Acad Sci U S A 1997;94:12457–12461.
18. Gonzalez-Cadavid NF, Taylor WE, Yarasheski K, et al. Organization of the human myostatin gene and expression in healthy men and HIV-infected men with muscle wasting. Proc Natl Acad Sci U S A1998;95:14938–14943.
19. Yarasheski KE, Bhasin S, Sinha-Hikim I, et al. Serum myostatin-immunoreactive protein is increased with muscle wasting and advanced age. Proceedings of the 81st Annual Meeting of The Endocrine Society, San Diego, CA, 1999, OR-9–2.
20. Shivji R, Bhasin S, Byhower F, et al. Myostatin and IGF-I and -2 expression in muscle wasting resulting from exposure to the microgravity environment of a space shuttle flight. Proceedings of the 81st Annual Meeting of The Endocrine Society, San Diego, CA, 1999, OR-32–3.
21. Congeni J, Millier S. Supplements and drugs used to enhance athletic performance. Pediatr Clin North Am 2002;49:435–461.
22. Clark AS, Henderson LP. Behavioral and physiological responses to anabolic-androgenic steroids.Neurosci Biobehav Rev 2003;27:413–436.
23. Lukas SE. Current perspectives on anabolic-androgenic steroid abuse. Trends Pharmacol Sci1993;14:61–67.
24. Bagatell CJ, Bremner WJ. Androgens in men: uses and abuses. N Engl J Med 1996;334:707–714.
25. Behre HM, Nieschlag E. Testosterone buciclate (20 Aet-1) in hypogonadal men: pharmacokinetics and pharmacodynamics of the new long-acting androgen ester. J Clin Endocrinol Metab 1992;75:1204–1210.
26. Griffin JE, Wilson JD. Disorders of the testes and the male reproductive tract, in Wilson JD, Foster DW, Kronenberg HM, Larsen PR (eds): Williams Textbook of Endocrinology. Philadelphia, Saunders, 1998, ed 9, pp 819–876.
27. Foster ZJ, Housner JA. Anabolic-androgenic steroids and testosterone precursors: ergogenic AIDS and sport. Curr Sports Med Rep 2004;3:234–241.
28. Porcerelli JH, Sandler BA. Anabolic-androgenic steroid abuse and psychopathology. Psychiatr Clin North Am 1998;21:829–833.
29. Yesalis CE. Epidemiology and patterns of anabolic-androgenic steroid use. Psychiatr Ann1992;22:7–18.
30. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Adolescents and anabolic steroids: a subject review. Pediatrics 1997;99:904–908.
31. Bahrke MS, Yesalis CE, Kopstein AN, et al. Risk factors associated with anabolic-androgenic steroid use among adolescents. Sports Med 2000;29:397–405.
32. Buckley WE, Yesalis CE, Friedl KE, et al. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA 1988;260:3441–3445.
33. DuRant RH, Escobedo LG, Heath GW. Anabolic-steroid use, strength training, and multiple drug use among adolescents in the United States. Pediatrics 1995;96:23–28.
34. Scott DM, Wagner JC, Barlow TW. Anabolic steroid use among adolescents in Nebraska schools.Am J Health Syst Pharm 1996;53:2068–2072.
35. Terney R, McLain LG. The use of anabolic steroids in high school students. Am J Dis Child1990;144:99–103.
36. Yesalis CE, Barsukiewicz CK, Kopstein AN, et al. Trends in anabolic-androgenic steroid use among adolescents. Arch Pediatr Adolesc Med 1997;151:1197–1206.
37. Faigenbaum AD, Zaichkowsky LD, Gardner DE, et al. Anabolic steroid use by male and female middle school students. Pediatrics 1998;101:E6.
38. Brower KJ. Anabolic steroid abuse and dependence. Curr Psychiatry Rep 2002;4:377–387.
39. Congeni J, Millier S. Supplements and drugs used to enhance athletic performance. Pediatr Clin North Am 2002;49:435–461.
40. Pope HG, Katz DL. Psychiatric and medical effects of anabolic-androgenic steroid use: a controlled study of 160 athletes. Arch Gen Psychiatry 1994;51:375–382.
41. Dias JP. Adolescent substance abuse: Assessment in the office. Pediatr Clin North Am2002;49:269–300.
42. Kanayama G, Pope HG, Cohane G, et al. Risk factors for anabolic-androgenic steroid use among weightlifters: a case-control study. Drug Alcohol Depend 2003;71:77–86.
43. Kanayama G, Cohane GH, Weiss RD, et al. Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: an underrecognized problem? J Clin Psychiatry 2003;64:156–160.
44. Karila TA, Karjalainen JE, Mantysaari MJ, et al. Anabolic androgenic steroids produce dose-dependent increase in left ventricular mass in power athletes, and this effect is potentiated by concomitant use of growth hormone. Int J Sports Med 2003;24:337–343.
45. Suttmann U, Ockenga J, Selberg O, et al. Incidence and prognostic value of malnutrition and wasting in human immunodeficiency virus-infected outpatients. J Acquired Immune Defic Syndr Hum Retrovirol 1995;8:239–246.
46. Gurakar A, Caraceni P, Fagiuoli S, et al. Androgenic/anabolic steroid-induced intrahepatic cholestasis: a review with four additional case reports. J Okla State Med Assoc 1994;87:399–404.
47. Soe KL, Soe M, Gluud C. Liver pathology associated with the use of anabolic-androgenic steroids.Liver 1992;12:73–79.
48. Stimac D, Milic S, Dintinjana RD, et al. Androgenic/anabolic steroid-induced toxic hepatitis. J Clin Gastroenterol 2002;35:350–352.
49. Hartgens F, Reitjens G, Keizer HA, et al. Effects of androgenic-anabolic steroids on apolipoproteins and lipoprotein (a). Br J Sports Med 2004;38:253–259.
50. Urhausen A, Albers T, Kindermann W. Are the cardiac effects of anabolic steroid abuse in strength athletes reversible? Heart 2004;90:496–501.
51. Thompson PD, Cullinane EM, Sady SP, et al. Contrasting effects of testosterone and stanozolol on serum lipoprotein levels. JAMA 1989;261:1165–1168.
52. McNutt RA, Ferenchick GS, Kirlin PC, et al. Acute myocardial infarction in a 22-year-old world-class weight lifter using anabolic steroids. Am J Cardiol 1988;62:164.
53. Frankle MA, Eichberg R, Zachariah SB. Anabolic androgenic steroids and a stroke in an athlete: case report. Arch Phys Med Rehabil 1988;69:632–633.
54. Ferenchick G, Schwartz D, Ball M, et al. Androgenic-anabolic steroid abuse and platelet aggregation: a pilot study in weight lifters. Am J Med Sci 1992;303:78–82.
55. Togna GI, Togna AR, Graziani M, et al. Testosterone and cocaine: vascular toxicity of their concomitant abuse. Thromb Res 2003;109:195–201.
56. Urhausen A, Torsten A, Wilfried K. Reversibility of the effects on blood cells, lipids, liver function and hormones in former anabolic-androgenic steroid abusers. J Steroid Biochem Mol Biol 2003;84:369–375.
57. Laseter JT, Russell JA. Anabolic steroid-induced tendon pathology: a review of the literature. Med Sci Sports Exerc 1991;23:1–3.
58. Michna H. Tendon injuries induced by exercise and anabolic steroids in experimental mice. Int Orthop 1987;11:157–162.
59. Miles JW, Grana WA, Egle D, et al. The effect of anabolic steroids on the biochemical and histological properties of rat tendon. J Bone Joint Surg Am 1992;74:411–422.
60. Stannard JP, Bucknell AL. Rupture of the triceps tendon associated with steroid injections. Am J Sports Med 1993;21:482–485.
61. David HG, Green JT, Grant AJ, et al. Simultaneous bilateral quadriceps rupture: a complication of anabolic steroid abuse. J Bone Joint Surg Br 1995;77:159–160.
62. Visuri T, Lindholm H. Bilateral distal biceps tendon avulsions with use of anabolic steroids. Med Sci Sports Exerc 1994;26:941–944.
63. Shifren JL. The role of androgens in female sexual dysfunction. Mayo Clin Proc 2004;79(Suppl 4):S19–S24, 2004.
64. Pope HG, Katz DL. Psychiatric effects of anabolic steroids. Psychiatr Ann 1992;22:24–29.
65. Hall RCW. Psychiatric complications of anabolic steroid abuse. Psychosomatics In press.
66. Pope HG, Kanayama G, Ionescu-Pioggia M, Hudson JI. Anabolic steroid users' attitudes towards physicians. Addiction 2004;99:1189–1194.