Anabolic Steroids Nursing CE Course

2.0 ANCC Contact Hours AACN Category A

Syllabus

Learning Objectives

Upon completion of this activity, participants should be able to:

  1. Explore the various labeled usages for anabolic steroids.
  2. Reference the current statistics for anabolic steroid abuse.
  3. Recognize the signs and symptoms of anabolic steroid abuse.
  4. Review the harmful effects of anabolic steroid abuse on the various body systems.
  5. Investigate the nursing implications of caring for the patient who has abused anabolic steroids.

Purpose Statement

This module is intended to inform the healthcare professional of the intended usages and potential detrimental effects of the abuse of anabolic steroids. 

Case Study:

J.S., A 31-year-old male presents to the ED (Emergency Department) complaining of substernal chest pain radiating to the left arm that began after two hours of weightlifting in preparation for a bodybuilding competition. Assessment reveals an alert and oriented, well-nourished patient who is pale, diaphoretic, and verbalizes anxiety. His vital signs are as follows: B/P 185/99, HR 144, RR 28, Temp 98.3°F oral, SP02 94% on 2 liters of oxygen via nasal cannula. An EKG indicates tachycardia with widened QRS complexes. Troponin levels are elevated, along with increased creatinine from a basic metabolic panel. History contains the diagnoses of anxiety and depression.  Current medications include sertraline and a “supplement” that the patient purchases off of an internet site. (To be continued…)

Introduction

’Roids. Juice. Pump. Regardless of the nickname, most are familiar with the use of anabolic steroids in the general population. But what effects do anabolic steroids have on the human body? In this module, we will explore the intended uses and potential side effects of the misuse of anabolic steroids.

Anabolic steroids, more correctly known as anabolic-androgenic steroids or AAS, are prolific in current society. According to Ip et al. (2017), “the global lifetime prevalence rate of AAS use is 3.3%, and it is estimated that 2.9-4 million Americans aged 13-50 years old have used AAS (p 1532). Patients may use AASs for increased muscle mass, improved appearance, and increased confidence. 

Pharmacokinetics

Stemming from the Greek words for “upward” and “growth,” AASs are synthetic derivatives of testosterone (Thiblin et al., 2015). Steroids, along with drugs such as oxygen-transport enhancing drugs, diuretics, insulin, and other hormones, make up a large percentage of what is known as “performance-enhancing substances.”  There are two different types of the anabolic steroids, 17 alpha alkyl derivatives, and 17 beta ester derivatives, which include testosterone and nandrolone. Nandrolone was one of the first steroids abused in the Olympics in 1965. These derivatives may come in injectable, oral, or dermal applications. AASs act by changing the androgenic receptors in the nucleus of skeletal muscle cells, which increase in number with repeated exposure to the drug, thereby increasing the mass of the muscle itself.  Reportedly, AAS provides the muscle with increased recovery potential, thus improving exercise tolerance (Frati, Busardo, Cipolloni, De Dominicis, & Fineschi, 2015). 

History

The first report of steroid use was testosterone in the 1930s in Germany when scientists discovered the synthetic form of testosterone helped males who did not produce enough of the hormone endogenously for normal development. Later it was used as a performance enhancer by soldiers during World War II.  During the 1956 Olympics, it was noted that Russian athletes were performing extraordinarily well. This was attributed to synthetic testosterone usage. With this discovery, AAS usage blossomed in sports, both at major and minor league levels. 1975 brought about the banning of steroids in Olympic competition; however, it was not until the Anabolic Steroid Enforcement Act of 1990 that AASs were designated as a Schedule III controlled substance (Center for Substance Abuse Research, 2013).

Therapeutic Use

AASs can be used for several medical diagnoses, including female breast cancer, hypogonadism, eunuchoidism, male climacteric, oligospermia, impotence, vulvar dystrophies, low testosterone levels, and delayed puberty. There are also off label uses such as weight loss in AIDs patients, andropause (decreased testosterone in males), anemia, and cryptorchidism (Skidmore, 2018). Essentially, when used therapeutically, AASs replenish hormone levels in disease processes that leave the body deficient of the hormone. Of note, Skidmore (2018) lists a black box warning regarding children and accidental exposure, pulmonary oil micro embolism (some of the injectable compounds are mixed in oil), and anaphylaxis. 

More recently, the Food and Drug Administration (FDA, 2015) released a safety announcement that “testosterone products are approved only for men who have low testosterone levels caused by certain medical conditions. The benefit and safety of these medications have not been established for the treatment of low testosterone levels due to aging, even if a man’s symptoms seem related to low testosterone.” The FDA (2015) noted that they are requiring drug manufacturers to change their labeling to reflect such changes, and that healthcare professionals should prescribe testosterone therapy “only for men with low testosterone levels caused by certain medical conditions and confirmed by laboratory tests (para. 1).”

Illegal Use

Classically speaking, AASs are widely abused among athletes, particularly bodybuilders, due to their effect on increased lean muscle mass. Steroid usage is less common among females, as the masculinizing results are less desirable. AAS abuse is also noted among adolescents. One study conducted by the Centers for Disease Control and Prevention (CDC) found that “among U.S. high school students, 4% of males and 2.2% of females have used anabolic steroids at least once in their lives (about 375,000 boys and 175,000 girls)” (National Institute on Drug Abuse [NIDA], 2018). NIDA (2018) postulates the difficulty in estimating the true prevalence of steroid abuse in the United States is “because many surveys that ask about illicit drug use do not include questions about steroids.” Abusers may divert the steroids; however, more commonly, drugs are smuggled from other countries. There is also an alarming trend of purchasing such medications off of the internet. According to the Center for Substance Abuse Research (2013), “there are more than 100 varieties of anabolic steroids that have been developed, but only a limited number have been approved for human or veterinary use.” This fact most certainly contributes to the adverse effects of steroid abuse discussed in the below sections. 

Abusers of AASs may utilize different routes for the administration of the drugs, including orally, intramuscularly, or dermally. The oral route generally clears from the body quicker than other routes, which the person may consider if drug testing is expected. Steroids may be used in specific patterns to produce an even greater effect on muscle mass- including mixing different types. Patterns for the misuse of steroids are referred to as stacking, pyramiding, cycling, or plateauing (NIDA, 2018).

Signs of Abuse

The patient who abuses AASs will have increased muscle mass and tone. They may have decreased self-esteem, depression, and/or anxiety. The healthcare professional may find that the individual has greater participation in sports emphasizing weight and shape, and may suffer from muscle dysmorphia (perception of looking small and weak, regardless of the actual size or body habitus) (NIDA, 2018). Upon assessment, the female patient may exhibit androgenic, or masculinizing effects, such as a deeper voice, increased facial hair, decreased scalp hair, menstrual irregularities, infertility, clitoromegaly, and reduced breast size (Ip et al., 2017). In addition to the above stated increased muscle mass, males may have small testes, reduced sperm count, gynecomastia, prostate enlargement, and alopecia. Both males and females may experience severe acne, both facial and on the body. Due to the nature of testosterone, emotional symptoms such as mood swings, the inability to sleep, and feelings of hostility and violence, commonly known as “roid rage”, are common (Wells & Davidson, 2016). 

Diagnosis of Abuse

A diagnosis of steroid abuse is typically based on a urine or blood sample. One commonly used laboratory advertises a urine test for 40 different anabolic compounds. Professional sports (for instance, mixed martial arts) perform rigorous tests via blood and urine to identify athletes that are abusing AASs and other performance-enhancing drugs. During eight years, the U.S. Anti-Doping Agency (USADA, 2019) budgeted $2 million per year to research the areas of AAS and other doping agents (hormones, oxygen transport-enhancing substances, and genetic doping, among others). Despite this research in the detection of steroids and other performance-enhancing substances, new compounds are continually being developed that are undetectable. 

Along with androgenic anabolic steroids, the United States Anti-Doping Agency (USADA) also prohibits other performance enhancing drugs and substances. USADA prohibits the use of blood and blood products, peptide hormones, growth factors, and hormone/metabolic modulators. They also note that they do not approve of any supplements due to the unregulated nature of the materials, and the potential for contamination with the abovementioned prohibited substances. USADA also has very specific guidelines for the use of other drugs as well, noting that they may only be used in out of competition times, for example, beta-blockers, stimulants, and narcotics (USADA, 2019).

Complications of Abuse

Muscle hypertrophy is generally the most well-known and desired side effect of AASs; however, they also come with their own set of detrimental and potentially lethal complications. Thiblin et al. (2015) found that the mortality rate of AAS users was 13.5% per 1000 person-years versus 6.7% per 1000 person-years in healthy controls, indicating twice the risk of death for AAS abusers. Complications are discussed by most pertinent body systems below. 

Psychological Complications

As discussed above, abusers of AASs are more prone to mood swings, hostility, and violence. Aggression during use and depression when the steroids are discontinued is common. Many abusers report that they partake in steroids purely for cosmetic purposes, rather than increased muscle strength, supporting the fact that many likely suffer from muscle dysmorphia.  In addition to these effects, steroid users are more prone to high-risk behaviors. AAS use in adolescents is associated with high-risk behaviors, including violence, binge-drinking, and sexual risk-taking (Ip et al., 2017). One postmortem study incidentally found that approximately 40% of the patients who tested positive for steroids had deaths that were due to homicide or suicide, versus just 14% of the subjects that tested negative for performance-enhancing substances (Thiblin et al., 2015).

Case Study Update

J.S. is sent for an echocardiogram, which reveals left ventricular hypertrophy. Upon hearing this diagnosis, J.S. begins crying and cursing, stating that he was “only trying to look better”. After calming down, J.S. endorses the use of an injectable steroid he calls “Arnolds” that he purchased at his local gym. Injection sites can be seen in various areas on his arms, along with multiple areas of inflamed cystic acne on his back. Testicular atrophy is noted on assessment, and J.S. endorses occasional impotence. J.S. then begins to share that he has suicidal ideations. He is transferred to a medical-surgical unit under suicide precautions for observation and treatment. (To be continued…)

Cardiovascular Complications

Cardiovascular complications are the “most frequently reported among the suggested severe, potentially life-threatening, undesired consequences of AAS use” (Thiblin et al., 2015, pp. 87). Although steroids have more of a propensity for skeletal muscle, cardiac muscle is affected by hormone usage as well. Cardiovascular effects could include ischemic cerebrovascular events, superior sagittal sinus thrombosis, pulmonary embolism, coronary disease, reduced systolic and diastolic function, arrhythmias, myocardial infarction, blood pressure elevation, and deep vein thrombus, among others (Frati et al., 2015).  Electrolyte imbalances from AAS abuse may result in lethal cardiac arrhythmias. The Endocrinology Society recommends against the use of testosterone (even on-label usage) in men who have a history of myocardial infarction or stroke in the past six months. This indicates the cardiac complications that could occur with a standard dose of the hormone, much less the stacked and pyramidal doses that abusers partake of (Bhasin et al., 2018). 

One Swedish population-based cohort study investigated the incidence of cardiovascular events in those who tested positive for AASs. The study noted that “when adjusting only for age, AAS exposure predicts and approximately doubled the risk of a cardiovascular event (Thiblin et al., 2015, pp. 89). The study defined cardiovascular events as those that fell under ICD-10 chapter IX codes, which include hypertension, myocardial infarction, and other circulatory issues. This finding, along with warnings from the FDA calling for the decreased prescription of AASs, leads healthcare providers to the conclusion that these medications should only be used when necessary (Thiblin et al., 2015). 

Genitourinary Complications

As testosterone is the male reproductive hormone, it is responsible for many areas of growth and development in males and females. When used in large quantities, patients might present with one of many genitourinary complications. Ganesan and Zito (2015) list potential complications as “an increase in prostate-specific antigen, benign prostatic hypertrophy, testicular atrophy, suppression of spermatogenesis, mastalgia, hypogonadism, prostatitis, dysuria, hematuria, impotence, pelvic pain…ejaculatory tenderness, and erectile dysfunction (Adverse effects section, Genitourinary para.).”  Patients could also present with renal impairment from increased serum creatinine due to increased protein synthesis from the synthetic hormone mechanism of action (Thiblin et al., 2015).

Musculoskeletal Complications

When taken in adolescence, AASs are associated with premature epiphyseal (growth plate) closure, resulting in short stature. Patients may present with muscle pain and tendon rupture due to the rapid muscle hypertrophy associated with AAS abuse. Hemarthrosis, or bleeding into joint capsules, may also be present (Thiblin et al., 2015).

Other Complications

As testosterone is a systemic hormone, it is associated with side effects that span the entire body. From gingivitis to increased urination, AAS abuse can cause a litany of unwanted symptoms. Hepatic impairment may be present. Patients may present with severe acne and other dermatologic complaints. Pertinent to the route of injection, abusers of steroids may subscribe to risky injection practices, making them more prone to blood borne pathogens such as hepatitis B, hepatitis C, and HIV/AIDS.  (Ip et al., 2017). Signs and symptoms of hepatitis C vary from asymptomatic to chronic issue. Initially the person may complain of generalized malaise, pain, weakness, nausea, vomiting, and liver enlargement/tenderness. This usually occurs in the first 21 days of infection, otherwise known as the preicteric phase. The patient then may enter a phase with the presentation of classic jaundice, clay colored stools, and dark urine, which is the icteric phase. Finally, in the posticteric phase, fatigue and liver enlargement may continue for several months (Linton, 2020).

Treatment Considerations

Noting these complications, healthcare providers should educate those at increased risk for AAS abuse (young, athletic males) about the detrimental effects of these potent drugs. The increased number of supplements sold via the internet, which have no purity standards and unknown ingredients, could potentially be toxic if taken by well-meaning patients to improve health and promote wellness. Referral to a psychiatrist or other mental health practitioner may help with any existing self-esteem and muscle dysmorphia issues, along with any other possible addictions. Patients may be prescribed antidepressants as well (McBride, Carson & Coward, 2016).

Along with the psychosocial issues, the physiological complications must be addressed. In most cases, sperm production can spontaneously recover, but in other cases, pharmacologic intervention may be necessary. Drugs that can potentially re-induce spermatogenesis include gonadotropin therapy, such as human chorionic gonadotropins (McBride & Coward, 2016).

Patients with cardiac issues related to AAS abuse should be followed by a specialist in that area. Left sided hypertrophy and subsequent potential heart failure would need to be addressed immediately, particularly in those who are prone to aggressive, strenuous exercise. When patients are prescribed steroids for medical reasons, many different areas are monitored. Blood work should be done regularly, including lipid profiles, hepatic function tests, hemoglobin, hematocrit, and prostate-specific antigen. A prostate exam in patients over 40 is also recommended (Thiblin et al., 2015). It would stand to reason that providers should monitor these same potential concerns in known AAS users as well. 

Noting that AAS abusers may engage in risky injection behaviors, the healthcare provider should screen regularly for blood borne pathogens like HIV and hepatitis and treat accordingly. While acute hepatitis C is noted typically treated, it is of note that there is a cure rate of over 90% of chronic hepatitis C patients with 8-12 weeks of oral therapy regardless of HCV genotype (Centers for Disease Control [CDC], 2019).

 It is also of note that this module only addresses AASs. This is only one drug in the class of drugs that are considered to be appearance and performance-enhancing drugs, or APEDS. Other drugs that a person abusing AASs may also be taking are listed as below from the NIDA website (2018).

Non-steroidal anabolics- This class of drugs includes insulin, insulin-like growth hormone (IGF), and human growth hormone (HGH). Each of these drugs have legitimate medical uses; however, they are attractive to potential abusers due to the mechanism of action of increased lean muscle mass and decreased ability of detection on routine drug screenings. This may be a hallmark of a potentially deadly trend, due to the known risks of insulin overdose- namely severe hypoglycemia and death (Nicholls & Holt, 2016).

Ergo/thermogenics- includes drugs such as xanthines, sympathomimetics, and thyroid hormones (NIDA, 2018). Xanthines increase wakefulness and suppress appetite and include caffeine 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, headache and diarrhea. Theophylline (Theo-24, Uniphyl) blood levels must be monitored closely to prevent toxicity (Skidmore, 2018). Skidmore implies that   those who abuse this medication will not self-report use and are at high risk of toxicity and associated detrimental effects (2018).  

An example of a sympathomimetic is ephedrine (Corphedra, Akovaz) and the herbal supplement ephedra. Sympathomimetic drugs mimic the action of endogenous epinephrine and norepinephrine, which increases heart rate and causes vasoconstriction (NIDA, 2018). On February 9, 2014 the FDA “issued a final rule prohibiting the sale of dietary supplements containing ephedrine alkaloids (ephedra) because such supplements present an unreasonable risk of illness or injury” (National Institutes of Health, 2004, para.1). This announcement was a result of many studies indicating that these supplements cause an increased risk of a multitude of adverse symptoms, including seizures, serious psychiatric events, palpitations, and cerebrovascular events among others With the expanding use of the internet as a means to obtain supplements with questionable ingredients, providers should be aware of the potential effects of sympathomimetic drugs, particularly with ingredients such as ephedra found in herbal supplements (National Institutes of Health, 2004).

Thyroid hormones include levothyroxine (Synthroid) and liothyronine (Cytomel). These drugs both carry a black box warning for the treatment of obesity due to multiple drug interactions and potentially lethal side effects. These medications, when they are used for the treatment of hypothyroidism, require much education and careful monitoring. Healthcare providers should be aware that the person abusing these medications would likely not be aware of such serious side effects, and would be less inclined to communicate that they were utilizing these medications (Skidmore, 2018). 

Ideally, the patient may recover from the negative effects of AASs. However, with potential complications such as left ventricular hypertrophy, hepatitis and other blood borne pathogens, along with co-addictions, the patient will need to procure care from multiple healthcare providers. This could create serious issues depending on the patient’s socioeconomic status. Medication compliance is another concern the interdisciplinary team may need to address if chronic medications are needed to manage the abovementioned problems at hand. (McBride, Carson & Coward, 2016).

Considerations for Future Research

Ip et al. identified a concerning trend in their 2017 study regarding AAS use in the homosexual community. 10% of the respondents in this particular study reported using steroids, and homosexual individuals were more likely to engage in risky injection practices, such as sharing needles and vials of medication. In the study, 25.9% of homosexual men self-reported being seropositive for HIV. They also reported increased binge drinking episodes and anxiety disorders (Ip et al., 2017). This evidence is indicative of a need for more in-depth research of AAS abuse among the homosexual population, and potential need for additional educational and psychosocial outreach in that particular population.  

One study addresses the “neuroendocrine whiplash” noted in lab rats that were abruptly removed from AASs in addition to receiving repeated mild traumatic brain injuries. This study was conducted to simulate the common issue of adolescent males that play contact sports (thereby receiving the mild traumatic brain injuries from frequent concussions), and are also at increased risk for AAS abuse. Of interest in the study, the lab rats that were left on the AAS were less likely to exhibit neurological and psychological symptoms as badly as the rats who were abruptly removed.  Based on the data from this study, hypothetically the healthcare provider could leave the adolescent suffering from repeated mild traumatic brain injury on the AAS until the injury is healed and then taper the steroids in order to prevent a sort of “double stress” on the patient’s neuroendocrine system (Tabor, Collins, Debert, Shultz, and Mychasiuk, 2019).

McBride, Carson and Coward (2018) investigated the purchase of AASs over the Internet. Their study simply searched Google for “buy steroids”. Eight of the ten sites recovered met inclusion criteria for the research. They found that 87% of sites offered several different types of steroids. None of the sites they investigated required a prescription for such medications, but instead included a disclaimer that consumers were subject to local laws. 75% of these websites accepted common forms of payment (i.e., credit cards), and products could be shipped to the buyer’s home address.  The websites even offered resources on how to take these medications, including stacking and pyramiding information. Additionally, none of the medications offered on the reviewed websites were oral meds; they were all injectable options (McBride, Carson and Coward, 2018). These findings should be of paramount interest to the healthcare provider, particularly to those caring for at-risk populations. The information discovered in this study suggests a potential trend shift from clandestine meetings to simply ordering drugs off of the internet to partake in AAS abuse.  The fact that the drugs on the websites reviewed in this study were only offered in injectable forms raises the concern even higher for the risk of blood borne pathogens, such as Hepatitis B, Hepatitis C, and HIV. The ease with which consumers can obtain such high-risk medications should spur more research into the measures that could be taken to prevent such risky behaviors. 

A small study on weightlifters with a history of chronic AAS use found abnormalities in the amygdala and the functional connectivity of the brain.  By using diffusion tensor imaging (DTI), researchers observed the functional tendencies of the brain’s white matter.  By observing the differences in water diffusion among the axis of white matter axonal fiber bundles, researchers observed the function of those particular nerve cells in this patient population.  It was noted as well that the research participants had increased white matter, which may “indicate an abnormality of reward circuits, possible associated with vulnerability for drug dependence” (Seitz et al., 2017, pp.4). While this study has several limitations, including group size and reporting bias, it has potential to support the call for further research to examine the potential for AAS users to have an increased inclination for substance abuse. 

The vast majority of literature vocalizes an overall need for increased research on AAS abuse and its complications. However, the research comes with many roadblocks, namely the reporting biases by the research participants. Few people will admit to illegally using a controlled substance. With so many illicit compounds being sold with ease over the Internet, research on the effect of particular compounds will present its own set of challenges (McBride, Carson & Coward, 2016). 

Case Study Update

Cardiology is consulted and medications are administered to control J.S.’s hypertension and minimize the effects of the left ventricular hypertrophy. J.S.’s interdisciplinary team includes his hospitalist, psychiatry team, pharmacist, nurse, and ancillary staff, who all work together to address his needs. J.S. endorses feeling “emotional” since receiving his diagnosis, but agrees that partaking in steroids is no longer something he desires to do. He attends group cognitive behavioral therapy and his antidepressant medications are adjusted. His creatinine trends down with gentle intravenous hydration.  Three days later, J.S. is discharged to his home with his support system and follow up with his various providers, including a reproductive health specialist. 

Conclusion

When used appropriately, AAS usage can help a number of disease processes. However, due to the frequent misuse and abuse among the general population, particularly young athletes, healthcare professionals must be vigilant in the recognition, treatment, and education of individuals who are abusing these substances. Due to the lethal nature of the cardiac complications of AASs, healthcare providers should be actively engaged in the detection of AAS abuse, leading to early education and (hopefully!) cessation of the abuse of these high-risk medications. 

References

Bhasin, S., Brito, J.P., Cunningham, G.R., Hayes, F.J., Nodis, H.N., Matsumoto, A.M., Snyder., P.J., Swerdloff, R.S., Wu, F.C., Yialamas, M.A. (2018). Testosterone therapy in men with hypogonadism: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 103(5), 1715-1744. doi:10.1210/jc.2018-00229

Centers for Disease Control and Prevention. (2019). Hepatitis C information. Retrieved from https://www.cdc.gov/hepatitis/hcv/index.htm

Center for Substance Abuse Research, University of Maryland (2013). Anabolic Steroids. Retrieved from: http://cesar.umd.edu/cesar/drugs/steroids.asp

Frati, P., Busardo, F.P., Cipolloni, L., De Dominicis, E.D., & Fineschi, V. (2015). Anabolic androgenic steroid (AAS) related deaths: autoptic, histopathological and toxicological finding. Current Neuropharmacology, 13(1), 146-159. doi: 10.2174/1570159X13666141210225414

Ip, E.J., Yadao, M.A., Shah, B.M., Doroudgar, S., Perry, P.J., Tenerowicz, M.J., Newson, L., Mann, A.A., Mkrtchyan, H., & Pope, H.G. Jr. (2017). Polypharmacy, infectious disease, sexual behavior, and psychophysical health among anabolic steroid-using homosexual and heterosexual gym patrons in San Francisco’s Castro district. Substance Use & Misuse, 1532-2491. doi: 10.1080/10826084.2016.1267224

McBride, J.A., & Coward, R.M. (2016). Recovery of spermatogenesis following testosterone replacement therapy or anabolic-androgenic steroid use. Asian Journal of Andrology, 18(3), 373-380. doi: 10.4103/1008-632X.173938 

McBride, J.A., Carson, C.C., & Coward, R.M. (2016). The availability of illicit anabolic androgenic steroids and testosterone preparations on the internet. American Journal of Men’s Health, 12(5), 1352-1357. doi: 10.1177/1557988316648704

National Institute on Drug Abuse. (2018). Steroids and other appearance and performance enchancing drugs (APEDS). Retrieved from https:www.drugabuse.gov

National Institutes of Health. (2004). Ephedra and ephedrine alkaloids for weight loss and athletic performance. Retrieved from: https://ods.od.nih.gov/factsheets/ephedraandephedrine-HealthProfessional/

Nicholls, A.R., & Holt, R.I.G. (2016).  Growth hormone and insulin-like growth factor-1. Sports Endocrinology, 47, 101-114. doi:10.1159/000445173 

Seitz, J., Lyall, A.E., Kanayama, G., Makris, N., Hudson, J.I., Kubicki, M., Pope, H.G., & Kaugman, M.J. (2017). White matter abnormalities in long-term anabolic-androgenic steroid users: a pilot study. Psychiatry Research: Neuroimaging, 1-5. doi: 10.1016/j.psychresns.2016.12.003

Skidmore, L.R. (2018). Mosby’s 2018 nursing drug reference, 31st ed., St. Louis, Missouri: Elsevier.

Tabor, J., Collins, R., Debert, C.T., Shultz, S.R., & Mychasiuk, R. (2019). Neuroendocrine whiplash: slamming the breaks on anabolic-androgenic steroids following repetitive mild traumatic brain injury in rats may worsen outcomes. Frontiers in Neurology, 10, 481. doi: 10.3389/fneur.2019.00481

Thiblin, R., Garmo, H., Garle, M., Holmberg, L., Byberg, L., Michaëlsson, K., & Dedebor, R. (2015). Anabolic steroids and cardiovascular risk: a national-population-based cohort study. Drug and Alcohol Dependence, 152,  87-92. doi: 10.1016/j.drugalcdep.2015.04.013

Wells, K.R. & Davidson, T. (2016). Anabolic steroid use. The Gale Encyclopedia of Children’s Health: Infancy through Adolescence, 1(3),  108. Gale, a Cengage company.

U.S. Food and Drug Administration. (2014). FDA drug safety communication: FDA cautions about using testosterone products for low testosterone due to aging; requires labeling change to inform of possible increased risk of heart attack and stroke with use. Retrieved from https://www.fda.gov/media/91048/download

United States Anti-Doping Agency (2019). Education. Retrieved from https://www.usada.org/about/programs/