Approach

Anabolic-androgenic steroid (AAS) use may not be disclosed by patients. Diagnosis requires a high index of suspicion and observing various signs and symptoms in addition to laboratory tests.

History

Clinicians should suspect AAS use in a muscular man who presents with concerns of infertility, gynaecomastia, or evaluation for testosterone supplementation; or a hirsute, muscular woman who reports amenorrhea.[1]

AAS use is most common in male athletes.[1]​ The practice is more prevalent among participants in competitive sport, particularly power sports such as bodybuilding, powerlifting, and weightlifting.[28]​ The practice is also widespread among participants in many other competitive sports.[6][7][28]​ A history of muscle dysmorphia or other body image disorder is a key risk factor.[31]

Many people who use AASs do not seek medical advice or treatment for health conditions potentially associated with the use of AASs.[37]​ Users will often live with numerous cosmetic, endocrine, and hepatic toxicities, seeking help only if these seem worse than coaches or peers told them to expect, or if symptoms do not abate after decreasing or stopping their AAS use.

The most useful tool for diagnosis is to ask about the use of AASs in a non-judgemental way.[1][38]​ A suggested approach is to ask about the frequency and intensity of training sessions, the goals of such training, their perceptions of their body image, and if they have been offered or used steroids.[19]​ In those who state that they use AASs, attempt to establish the substances involved and duration and pattern of use, including mode of administration.[38]

Psychiatric and neurological symptoms

Psychiatric symptoms (mania, hypomania, depression, aggression, cognitive deficits) are common. However, the potential confounding effects of other illicit substance use and prior psychiatric history need to be considered.[6][19]​ People with a narcissistic personality disorder may be more prone to use AASs.[39]

AASs in supraphysiological concentrations influence several central nervous system functions, such as memory, aggressiveness, anxiety, and depression, particularly in predisposed individuals.[40]​ There seems to be a dose-related effect of AAS use on mood disorders, with very high dosages of AASs causing manic symptoms in normal men.[1][41]​ ‘Roid rage' is the classic lay term to describe aggressive behaviour that is seemingly due to AAS use.[2]

Take a detailed drug history

Many people with AAS use disorder also use other drugs to alleviate the negative effects associated with AAS use, so a full drug history should be taken:[2][42]

  • Aromatase inhibitors (e.g., anastrozole) are used to prevent the conversion of testosterone to estradiol

  • Anti-oestrogens (tamoxifen) are used to block oestrogen receptors

  • Clomiphene/human chorionic gonadotrophin (hCG) are taken to prevent testicular atrophy and infertility

  • PDE-5 inhibitors (sildenafil, tadalafil) for sexual dysfunction (low libido, erectile dysfunction)

  • Furosemide is used to treat oedema

  • Anxiolytics are used to prevent anxiety

  • Acne medications are used to treat acne and oily skin

  • Nutritional supplements (e.g., protein, creatine), used by many bodybuilders and athletes

  • Probenecid and epitestosterone may be used to mask AAS detection.

AAS dependence

On cessation of AAS use, users may feel depressed, fatigued, unable to concentrate, and suicidal.[6]​ The euphoric effects of AAS use and the dysphoric effects of withdrawal may contribute to dependence in some people.[1]

Physical examination

Body composition and muscularity (including height, weight, and body mass index) should be noted and compared with previous measurements, if available. Adolescents who use AASs may have short stature due to closure of the epiphyseal plates.[21]​ 

In most people, regular doses of AAS will produce well-recognised physical changes:[19]

  • In men: acne, oily skin, muscular development, changes in libido, testicular atrophy, erectile dysfunction, infertility, temporal hairline recession, and gynaecomastia.

  • In women: acne, oily skin, muscular development, menstrual irregularities, and changes in libido. The potential irreversible masculinising effects include hirsutism, male pattern baldness, deepening of the voice, and clitoral hypertrophy.[20]

Clinical features related to chronic use are varied and depend on the body system affected.[1][2][42]

Dermatological

  • Temporal hairline recession

  • Striae or keloids

  • Needle marks

  • Signs of cellulitis or skin abscess (e.g., local swelling, fluctuance, hardening of the tissue, red open [or closed] sore that may be draining fluid, fever).

Endocrine

  • Testicular atrophy, prostatic enlargement, and gynaecomastia in males

  • Clitoral hypertrophy in females

  • Premature masculinisation/feminisation in adolescents who use AASs.

Psychiatric

  • Aggressive behaviour is common

  • Anxiety, mania, depression, psychosis, or tics may indicate psychiatric complications.

Cardiovascular/hepatic

  • Hypertension may indicate the presence of cardiovascular complications

  • Jaundice may indicate the presence of hepatic complications.

Laboratory investigations

In professional athletes, World Anti-Doping Agency compliant testing of urinary and serum testosterone, dihydrotestosterone, epitestosterone, and their precursors is undertaken at baseline (before the athlete's first competition that has anti-doping regulations) and is followed longitudinally.[1]​ The specimen should be obtained under direct observation. The test may be of limited value, as an experienced athlete is likely to be aware of methods of hiding or masking drug use. 

The ratio of testosterone to epitestosterone (T/E ratio) should be ordered, as gas chromatography with mass spectrometry cannot distinguish between endogenous and exogenous testosterone. Patients taking exogenous testosterone will have a higher T/E ratio.

There is no practical diagnostic test to detect AAS use in the general population.[1]​ Because AASs suppress circulating gonadotrophin concentrations, the most useful of the commonly available tests are measurements of serum testosterone, follicle-stimulating hormone, and luteinising hormone concentrations.[1]​

Indirect markers of anabolic-androgenic steroid use

If AAS use is suspected, consider the following investigations:[6][38]​​[43]​​​

  • Full blood count

  • Serum glucose

  • Lipid panel

  • Urea and electrolytes

  • Liver function tests

  • Gamma-GT levels (elevated in liver damage)

  • Creatine kinase (elevated in muscle damage)

  • Prolactin.

Needle sharing places patients at risk for contracting infectious diseases. Therefore, patients should be routinely tested for viral hepatitis and HIV.[38]​[42]​​

An ECG and echocardiogram may be warranted if cardiovascular complications are suspected (i.e., if dyspnoea, palpitations, syncope, murmur, or chest pain is present).[38]​ Nuclear medicine imaging modalities may facilitate improved diagnosis of cardiovascular pathology.[44][45][46][47]

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