Anabolic Steroid Use and Misuse Nursing CE Course

overns the Olympic, Paralympic, Pan American, and Parapan American sports anti-doping program. Professional sports leagues also use the WADA code as a guideline. Sports leagues regularly test their athletes with WADA-accredited labs for the presence of AAS in their system. The IOC, NCAA, and NFL have even banned the use of AAS precursors by their athletes. AAS misuse is typically discovered based on a urine or blood sample. Commonly used urine drug immunoassays can detect over 50 different compounds, including anabolic compounds. Professional sports organizations perform rigorous tests via blood and urine to identify athletes abusing AAS and other performance-enhancing drugs. The Partnership for Clean Competition (PCC) was created in 2008 by the USADA, MLB, and NFL to research the area of AAS and other doping agents (refer to the section on performance enhancers below). Since its inception, over 35 million dollars have been granted toward over 250 projects and over 130 researchers for anti-doping research. Despite this research in detecting AAS and other performance-enhancing substances, new compounds that are undetectable by current tests are continually being developed (Bhasin et al., 2021; Federal Register, 2023; NIDA, 2023; PCC, 2025; Robinson, 2024; USADA, n.d.-b; WADA, 2021; Wenbo & Yan, 2023).

Anabolic Androgenic Steroids

The two main types of misused AAS are oral 17 alpha alkyl derivatives (e.g., oxandrolone [Oxandrin], stanozolol [Winstrol], methandrostenolone [Dianabol]) and parenteral 17-β-ester derivatives, including nandrolone decanoate (Deca-Durabolin), testosterone cypionate (Azmiro), and nandrolone phenpropionate (Durabolin) (US Drug Enforcement Administration [DEA], 2024; Federal Register, 2023; Leslie et al., 2025; Kishner, 2024; NIDA, 2018, 2023). Steroids that are commercially available in the United States include:

• Oral steroids: oxymetholone (Anadrol), oxandrolone (Oxandrin), stanozolol (Winstrol), methyltestosterone (Methitest), fluoxymesterone (Androxy, Halotestin) (Drugs.com, 2023; UpToDate, n.d.-a, n.d.-b, n.d.-c)
• Injectable steroids: nandrolone decanoate (Deca-Durabolin), nandrolone phenpropionate (Durabolin), testosterone cypionate (Azmiro), testosterone enanthate (Delatestryl, Xyosted), testosterone propionate (Testoviron) (Snyder, 2024; UpToDate, n.d.-d)
• Veterinary steroids: boldenone (Equipoise), mibolerone (Matenon), and trenbolone (Revalor) (Federal Register, 2023; NIDA, 2018, 2023; Tauchen et al., 2021)

WADA has banned over 100 drugs, including illicitly marketed steroids that are not approved for use in the United States, such as methandriol (Anabol), oxymetholone (Anadrol), nandrolone (Deca Durabolin), and methandrostenolone (Dianabol). Some of these are also among the most misused steroids, which include testosterone (Testim), trenbolone (Parabolan), oxymetholone (Anadrol-50), methandrostenolone (Dianabol), nandrolone (Deca Durabolin), stanozolol (Winstrol), boldenone (Equipoise), and oxandrolone (Oxandrin) (DEA, n.d., 2024; Federal Register, 2023; NIDA, 2023).

 

Types of Performance Enhancers

Although this module focuses on AAS, other drugs are used for performance enhancement but are not addressed in detail in this module. These are referred to as image-, appearance-, or performance-enhancing drugs (IPEDs, APEDs, PEDs), and they are frequently used concurrently with AAS. Examples of IPEDs, APEDs, and PEDs include non-steroidal anabolics, ergo/thermogenics, and steroid precursors (NIDA, 2023).

Non-Steroidal Anabolics 

The class of non-steroidal anabolics includes insulin-like growth factor 1 (IGF-1), insulin, and recombinant human growth hormone (rhGH). These drugs have legitimate medical uses; however, they are used to promote increased lean muscle mass while remaining difficult to detect on routine drug screenings. IGF-1 has been associated with an increased risk of hypoglycemia and cancer. Using insulin as a PED could be potentially deadly due to the risks of insulin overdose, including severe hypoglycemia, coma, and death (NIDA, 2023; Snyder, 2024).

The use of rhGHs has been linked to many professional athletes in various sports. In addition, approximately 5% of high-school students report using rhGH. The risks and side effects of using rhGH include insulin resistance, hyperglycemia, sodium retention, hypertension, and myopathy. It is also reported that weightlifters who use rhGH have a higher rate of illicit drug use, including cocaine and opioids (NIDA, 2023; Snyder, 2024).

Ergo/Thermogenics

Ergo/thermogenics are used to decrease body fat or promote leanness. This category of PEDs includes xanthines, sympathomimetics, and thyroid hormones. Xanthines are compounds that increase wakefulness and suppress appetite and include caffeine, theobromine (found in chocolate, tea, and coffee), and the respiratory medication theophylline (Theo-24, Uniphyl). Theophylline (Theo-24, Uniphyl) can cause many adverse effects when used as prescribed, including insomnia, anxiety, nausea, vomiting, tachycardia, seizures, flushing, headaches, and diarrhea. Those who misuse this medication will not self-report use and are at high risk of toxicity and associated detrimental effects (NIDA, 2023).

Sympathomimetics are drugs similar in chemical structure and action to the natural epinephrine and norepinephrine produced in the body. These chemicals increase heart rate, constrict blood vessels, and increase blood pressure. Examples of sympathomimetics are ephedrine (Corphedra, Akovaz) and the herbal supplement ephedra. Due to significant evidence regarding the safety of ephedra-containing products, in April of 2004, the FDA issued a final rule banning the sale of dietary supplements containing ephedrine alkaloids (ephedra) because they pose an unacceptable risk of injury or illness. This announcement resulted from many studies indicating an increased risk of seizures, psychiatric events, palpitations, and cerebrovascular events, among others. With the expanding use of the internet to obtain supplements with questionable ingredients, providers should be aware of the potential effects of sympathomimetic drugs, particularly such as ephedra found in herbal supplements. Another sympathomimetic drug, clenbuterol (Dilaterol), commonly known as Clen, is a highly potent and long-lasting bronchodilator approved for human use in other countries but only approved for use in horses in the United States. Bodybuilders and athletes misuse this drug due to its ability to increase lean muscle mass and reduce body fat. Clenbuterol (Dilaterol) is popular among athletes assigned female at birth due to its ability to repartition body fat with fewer masculinizing side effects (DEA, 2019; Drugs.com, 2024; NIDA, 2023).

Erythropoietin (EPO)

The hormone erythropoietin (EPO) regulates RBC production and is commonly used to treat anemia. EPO stimulates erythropoiesis, increasing RBCs and hemoglobin mass. This increase allows hemoglobin to carry more oxygen. EPO's positive impact on aerobic exercise capacity within athletics is widely known, and it is often misused by athletes who compete in endurance sports (Haider et al., 2020; Snyder, 2024).

Androgen Precursors 

Some dietary supplements contain steroid precursors and are taken in conjunction with AAS. Steroid precursors previously sold in the United States include androstenedione (ASD), dehydroepiandrosterone (DHEA), and tetrahydrogestrinone (THG). Athletes frequently consume steroid precursors to boost testosterone and the effects of AAS. There is limited research on these substances; however, because they increase testosterone levels in the body, they produce similar side effects to AAS. After the Anabolic Steroid Control Act of 2004 was passed, the OTC sale of THG and ASD was made illegal. DHEA is still available as a nutritional supplement and is widely promoted by bodybuilding and fitness magazines as a substance that can increase muscle strength (NIDA, 2023; Snyder, 2024).

Use in Adolescents

AAS use is not just a problem among adults. Adolescents have also reported using AAS, which can be even more detrimental to their still-developing bodies. It is difficult to determine the prevalence of AAS misuse among adolescents because their use is not typically included in questionnaires. In the United States, the use of AAS is more prevalent among children and adolescents assigned male at birth compared to those assigned female at birth. The NIDA-funded study Monitoring the Future reported steroid use prevalence in 2024 in 8th graders (0.6%), 10th graders (0.7%), and 12th graders (1.0%) compared to data from 2021 in 8th graders (0.5%), 10th graders (0.3%), and 12th graders (0.5%). It is thought that the lower level of AAS use in adolescents during 2021 was due to the decrease in sporting events and the closure of gyms during the COVID-19 pandemic. This is likely, considering the increase between 2021 and 2024. Drug testing for AAS in high school athletes is controversial. Because attending public high schools is a right, students cannot be required to undergo drug testing to attend. However, participating in extracurricular activities is considered a privilege, and drug-testing requirements can be enforced for those who wish to take part. This highlights the importance of understanding the factors that lead to AAS use. A cohort study spanning 14 years between 2007 and 2021 with 4,073 adolescents and young adults showed that using muscle-building dietary supplements during adolescence and young adulthood significantly increased the likelihood that an individual would use AAS within the next 1 to 5 years. An ongoing longitudinal study started in 1994 of 12,695 young adults also showed that the use of legal PEDs during adolescence and young adulthood significantly increased the likelihood that an individual would use AAS as an adult (ages 24 to 32) (Johnson, 2024; Bulens et al., 2024; Miech et al., 2024; Nagata et al., 2020; NIDA, 2023).

Therapeutic Use 

There are FDA-approved indications for prescribing AAS, as well as off-label use. FDA-approved indications include primary hypogonadism, delayed puberty in adolescents assigned male at birth, hypogonadotropic hypogonadism, gonadotropin and luteinizing hormone-releasing hormone deficiency, pituitary-hypothalamic axis dysfunction, and primary testicular failure in patients diagnosed with cryptorchidism, orchitis, testicular torsion, vanishing testis syndrome, Klinefelter syndrome, or damage from heavy metals. Off-label or non-FDA-approved uses of AAS include bone marrow stimulation in patients diagnosed with leukemia, aplastic anemia, growth failure, and stimulation of muscle mass in patients with cachexia from malignancy or AIDS. Research on the use of AAS for these indications is promising but ongoing. These medications are available as pills, topical creams or gels, and transdermal patches (Giovanelli & Quinton, 2022; Leslie et al., 2025; Pagliuca et al., 2024; Wenbo & Yan, 2023).

Recently, testosterone supplementation has become more popular among those assigned male at birth to combat the natural decrease of testosterone associated with aging, to improve sexual performance, and to boost muscle mass. AAS have even been prescribed, controversially, to younger adults assigned male at birth for this purpose. Consequently, the FDA released a safety announcement that testosterone is only approved for those assigned male at birth with low testosterone due to a medical condition such as disorders of the testicles, pituitary gland, or brain-causing hypogonadism. This safety announcement was released due to the increasing number of people being prescribed AAS for no other reason than decreased testosterone due to aging. The FDA also cited an increased risk of heart attack, stroke, and death in aging persons assigned male at birth using testosterone. In February 2025, they retracted the boxed warning for stroke and heart attack risk and added a warning regarding elevated blood pressure based on recent research. The FDA requires all manufacturers of testosterone to change their labels to reflect this increased risk (FDA, 2025a, 2025b; Leslie et al., 2025; NIDA, 2023; Zaami et al., 2021).

Before treatment with AAS is initiated, the patient must have a documented diagnosis of hypogonadism. This diagnosis must be supported by low early morning testosterone levels on three separate days, as measured via serum blood draw. A baseline serum luteinizing hormone, follicle-stimulating hormone, hemoglobin (Hgb), hematocrit (Hct), and dual-energy x-ray absorptiometry (DEXA) scan is recommended, plus other tests depending on comorbidities. For patients who have male reproductive organs and are over 40, a prostate-specific antigen (PSA) test and digital rectal exam must be completed before treatment. Testosterone levels should be checked 1 month after initiation of treatment, with any dose adjustments, and every 6 to 12 months while on therapy. It is also recommended to monitor a lipid profile, hepatic function, Hgb, and Hct at 3 to 6 months and then annually. Because the prostate is a testosterone-dependent gland with an androgen receptor (AR), AAS binds to this receptor and promotes cell growth. This cell growth can increase PSA, benign prostatic hypertrophy (BPH), and prostatitis. Therefore, if the patient has an initial PSA above 0.6 ng/mL, they should have their PSA monitored and undergo a prostate exam 3 to 6 months after initiating treatment. The use of AAS can also lead to the proliferation of androgen-based malignant cells. Due to this, AAS use is contraindicated in patients with a PSA greater than 4 ng/mL or a palpable prostate nodule and those with a high risk of developing prostate cancer with a PSA greater than 3 ng/mL (FDA, 2025a; Leslie et al., 2025; Mulhall et al., 2024; Sizar et al., 2024; Snyder, 2022).

 

Illegal Use

In general, AAS tends to be misused by athletes, particularly bodybuilders, due to their ability to increase lean muscle mass. Steroid usage is less common among those assigned female at birth. Historically, most people who misused AAS were competitive athletes or professional weightlifters who were assigned male at birth in their 20s or 30s; however, a recent survey revealed that 75% of AAS users are noncompetitive bodybuilders and athletes who use AAS for cosmetic effects instead of performance enhancement. Common names for anabolic steroids include Arnolds, pumpers, gym candy, gear, roids, stackers, weight gainers, and juice. People who misuse AAS may administer the drugs using different routes, including orally, IM, or, less commonly, topically. When AAS are misused, the dosage is often 10 to 100 times higher than the therapeutic dose. The oral route generally clears from the body quicker than other routes, which users may prefer if drug testing is expected. AAS may be used in specific patterns to produce an even more significant effect on muscle mass, including mixing different types (DEA, n.d., 2024; Federal Register, 2023; Leslie et al., 2025; Miech et al., 2024; NIDA, 2018, 2023).

Various patterns of misusing steroids have been documented (Bhasin et al., 2021; DEA, 2024; Federal Register, 2023; Leslie et al., 2025; NIDA, 2018, 2023).

• Cycling involves taking AAS for a period, discontinuing use for a time, and then resuming AAS use. Cycling periods usually last 6 to 16 weeks. The perceived benefits of cycling include reducing tolerance and adverse effects, preventing detection, and ensuring peak performance.
• Stacking occurs when an individual combines different AAS or uses multiple administration routes (e.g., IM and oral).
• Pyramiding involves a slow increase in AAS dosage or frequency of use until a peak amount is reached and then tapering off the dosage or frequency until discontinuation. This regimen is thought to give optimal effects while decreasing the likelihood of detection.
• Plateauing describes the process of alternating, overlapping, or changing the AAS used to prevent developing a tolerance.

Individuals can obtain illegal AAS through various avenues. AAS are commonly smuggled into the United States through Mexico or European countries. The drugs are easier to obtain in these countries because a prescription is not required for purchase. Sometimes, AAS are stolen from legitimate sources (e.g., pharmacies or veterinary offices) or obtained through inappropriate prescribing by healthcare professionals (HCPs) (DEA, 2019, 2024; Federal Register, 2023; NIDA, 2023).

As technology improves and individuals buy more goods online, AAS is not exempt from this practice. The drugs are often produced in laboratories and sold on the internet. Researchers of one study evaluated information accessibility and the availability of oxandrolone (Oxandrin), DHEA, and ASD. Research on oxandrolone (Oxandrin) revealed that there were 977 websites with availability, only eight of which required a prescription. DHEA is widely available on the internet (555 websites), and only seven of the sites reviewed require a prescription. ASD had less availability, but none of the websites required a prescription. The forms offered were oral, powder, topical, and parenteral. Most websites were dedicated to sports, nutrition, and dietary products, with only a minority being actual pharmacies. Products could be shipped to other countries. The websites offered resources on benefits with very little information on the adverse effects (DEA, 2024; Federal Register, 2023; Garcia et al., 2023; Miech et al., 2024).

Complications of Misuse

AAS use affects many body systems. Some side effects are long-lasting, and some are more serious than others. Due to the lack of honest AAS use reporting, signs and symptoms may be the only indication an HCP has that an individual is using AAS (refer to Table 1). The possible adverse effects of AAS are discussed in Table 2.

 

Table 1

Signs and Symptoms That Increase Suspicion of AAS Use

Child or adolescent who is experiencing early development of secondary sexual characteristics, decrease in height, and premature closure of epiphyses

People assigned female at birth experiencing temporal hair recession, hirsutism, acne, irregular menses, breast atrophy, deepening of the voice (irreversible), clitoromegaly, decrease in total body fat, and increase in muscle mass

People assigned male at birth exhibiting rapid increases in muscle mass and strength and experiencing changes such as gynecomastia, small testes, low sperm count, impotence, and acne

(AlShareef et al., 2023)

Table 2

Adverse Effects of AAS 

Body System	Negative Effects
Brain and behavior	Addiction Extreme irritability and aggression Depressed or anxious mood Mood swings Psychosis Headache Anosmia (partial or total loss of smell) Sleep disturbances
Endocrine and metabolic	Decreased high-density lipoprotein (HDL) cholesterol Dyslipidemia Hypokalemia
Hepatic	Cholestasis (reduced bile flow) Hepatitis Peliosis hepatis (blood-filled cysts formed in the liver that can rupture and lead to internal bleeding) Hepatic adenoma (benign liver tumor) Hepatocellular carcinoma (primary liver cancer) Increased total bilirubin (normal 0.3 to 1.0 mg/dL)
Musculoskeletal	Tendon injury and rupture Premature epiphyseal closure in adolescents
Cardiovascular	Hypertension Left ventricular hypertrophy Thrombosis Coronary heart disease Cardiomyopathy Stroke
Renal	Acute renal failure (ARF) Increased blood urea nitrogen (BUN) (normal 8 to 25 mg/dL) Increased creatinine (normal 0.5 to 1.3 mg/dL) Focal segmental glomerulosclerosis Wilms tumor (renal cancer)
Gastrointestinal	Gingivitis Oral irritation Decreased appetite Gastroesophageal reflux disease (GERD) Gastrointestinal hemorrhage
Hematologic	Polycythemia vera (overproduction of RBCs)
Dermatologic	Skin blisters Acne Contact dermatitis Pruritis Thinning hair or baldness Hirsutism in females
Reproductive	Assigned male at birth	Assigned female at birth
	Decreased reproductive hormones Gynecomastia Impotence Prostatic hypertrophy Testicular atrophy Loss of sexual drive Sterility Decreased sperm production and motility	Breast atrophy Clitoral hypertrophy Menstrual irregularities Uterine atrophy Infertility

(ABIM, 2024; Albano et al., 2021; Bond et al., 2022; DEA, 2024; Federal Register, 2023; Leslie et al., 2025; NIDA, 2023; Snyder, 2024)

Because AAS misuse may be associated with risky injection behaviors, HCPs should screen patients regularly for blood-borne pathogens such as HIV, hepatitis B, and hepatitis C and treat them accordingly (NIDA, 2018; Vauhkonen et al., 2023).

AAS Addiction and Treatment

AAS does not produce a high, but these substances can be addictive, leading to dependency in up to one-third of users. Substance use disorder, potentially progressing to addiction, is demonstrated by an individual continuing to use AAS despite experiencing physical and psychological adverse effects, the high cost of obtaining the drugs, and the detrimental impact on personal relationships. If a person abruptly stops using AAS, they can experience withdrawal effects, including fatigue, restlessness, loss of appetite, sleep problems, decreased sex drive, cravings, mood swings, and depressed mood, which can last for up to a year and lead to suicide in some cases. To help manage withdrawal symptoms, individuals can be prescribed medications to restore hormonal balance, antidepressants to manage depression, and pain medication to relieve headaches and muscle and joint pain (AlShareef et al., 2023; DEA, 2024; Federal Register, 2023; NIDA, 2023; Vauhkonen et al., 2023).

Anti-Doping Campaign

The most effective way to decrease AAS misuse is through education, which is considered the first line of defense to protect clean athletes in sports. The USADA provides thousands of athletes each year with education and conducts research and testing to promote fair, drug-free athletic competitions. Topics of discussion include which substances are prohibited, sample collection procedures, and awareness of dietary supplement ingredients. Instruction is provided through in-person training, webinars, interactive tutorials, and distribution materials such as brochures, pamphlets, and packets. The USADA is often referred to as the gold standard of the anti-doping movement (USADA, n.d.-a).

Research has shown that prevention has positive effects on anti-doping efforts. Education should be provided to young children in a setting such as a physical education class that involves all students, not just elite athletes. Programs such as iPlayClean, Clean Sports, Athletes Training and Learning to Avoid Steroids (ATLAS), and Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA) are anti-doping programs created to address adolescent steroid use specifically. ATLAS and ATHENA were designed to reduce or eliminate the use of AAS, alcohol, illicit drugs, and supplements while promoting healthy dietary and exercise practices. A peer instructor delivers the education in person to schools or athletic teams. This approach promotes positive peer pressure and role modeling. Programs consist of educational games, skill-building, role-playing exercises, creating public service announcements, and competition among the groups. The program aims to teach students that they can achieve their performance goals using high-quality nutrition, safe supplements, and equipment (Pöppel, 2021).

Future Research 

The literature highlights the need for increased research on AAS misuse and its complications. However, this research faces several challenges, such as reporting biases by the research participants, as few people will admit to illegally using a controlled substance. Additionally, the ever-changing landscape of PEDs, with new illicit compounds readily available online, makes researching the effects of both existing and new anabolic compounds more challenging (AlShareef et al., 2021; Garcia et al., 2023; Mazzoni & Rabin, 2024).

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