Anabolic-Androgenic Steroids: Incidence of Use and

Health Implications

“The use of performance-enhancing drugs like steroids in baseball, football and other sports is dangerous, and it sends

the wrong message–that there are shortcuts to accomplishment, and that performance is more important than character.”

President George W. Bush, State of the Union address, January 20, 2004 

Note from the Editors

In recent months there have been more that a few stories in the national media related to the use of anabolic-androgenic steroids among

athletes. Because of this attention, and because steroid abuse is not limited to athletes, the editors felt that the time was right for an issue of

the Research Digest devoted to steroids. As the reference list for this article attests, Charles Yesalis and Michael Bahrke, the authors of this

issue of the Research Digest, are widely published experts on steroid use and abuse. Yesalis and Bahrke were charged with presenting the

evidence about steroid use, something that they did quite well. The authors were not asked to dwell on the legal and ethical issues

associated with the use of steroids. For this reason, the editors wish to make it clear to readers, especially youth who might read this paper,

that anabolic-androgenic steroids are illegal drugs when used for performance enhancement and attempting to increase muscle mass. In

addition most sports organizations, including the Olympics, the NCAA, high school athletic groups, and professional sports, ban the use of

these substances. These bans are based on the notion that the use of performance-enhancing drugs is not only illegal, but unethical. More

importantly, as the authors of this issue point out, there are many negative health consequences associated with the inappropriate use of

steroids.

Introduction

Testosterone is the primary natural male hormone (produced primarily by the testes).

Though testosterone is considered to be the “male” hormone, it is also present in females

in lesser amounts. Testosterone has androgenic or masculinizing effects such as growth of

facial and body hair and deepening of the voice. In addition, testosterone has anabolic or

tissue-building effects such as increases in muscle cell size. Because males produce more

testosterone as they mature, both masculinizing and tissue-building changes are observed

during adolescence and into adulthood. Tissue building is increased in females as well, but

not to the same extent as for males. 

By 1935, testosterone had been isolated and chemically characterized, and the nature of its

anabolic effects elucidated (Kochakian & Yesalis, 2000). Anabolic-androgenic steroids, as

discussed in this paper, are synthetic derivatives of testosterone. A pure anabolic steroid

has yet to be discovered, but many different forms of derivatives of this drug (with many

different names) are now in distribution (See Table 1), all properly referred to as anabolicandrogenic steroids. The more common term “anabolic steroid” is used here for

convenience. Related substances include prohormones, such as androstenedione (“Andro”)

and dehydroepiandrosterone (DHEA), which are steroids in the biosynthesis pathway.

Most commonly, anabolic steroids are taken orally or by intra-muscular injection (See

Table 2). More recently, gels and creams are being used by elite athletes as delivery

mechanisms in an attempt to circumvent drug testing.

As will be discussed in greater detail later in this paper, as many as one million young

people have used steroids even though they are illegal and banned by most sports

organizations. Health concerns are the principal reason for prohibiting the sales of

anabolic steroids while sporting organizations have banned their use for ethical reasons.

Why do people use anabolic steroids? 

There are many different reasons why people choose to use steroids. Use was initially

most prevalent among athletes with goals of enhancing performance. However, in recent

years use by non-athletes has become more prevalent. Now an increasing number of

anabolic steroid users simply want to “look good”—which to many people means being

big and muscular. 

Series 5, No. 5 March 2005

Published quarterly by the

President’s Council on

Physical Fitness and Sports

Washington, D.C.

★

Guest Authors:

Charles E. Yesalis, College of Health

and Human Development,

Pennsylvania State University,

University Park, Pennsylvania.

Michael S. Bahrke, Scientific,

Technical and Medical Division,

Human Kinetics, Champaign, Illinois.

★

Co-edited by:

Drs. Charles B. Corbin and

Robert P. Pangrazi,

Arizona State University, and

Dr. Deborah Young,

University of Maryland

President’s Council on Physical Fitness and Sports

ResearchDi est
The goals of individuals who use anabolic steroids in sport and

exercise are dependent on the activity in which they participate.

Bodybuilders desire more lean body mass and less body fat.

Weight lifters desire to lift the maximum amount of weight

possible. Field athletes want to put the shot, or throw the

hammer, discus, or javelin, farther than their competitors or

holders of previous records. Swimmers and runners hope to be

able to perform their frequent, high-intensity, long-duration

workouts without physical breakdown. Football players want to

increase their lean body mass and strength so they can be

successful at the high school, college, or professional level. 

Anabolic steroids have traditionally been taken in “cycles,”

which are episodes of use lasting 6 to 12 weeks or more

(Llewellyn, 2000). Athletes often take more than one steroid at a

time; this is referred to as “stacking.” In an attempt to avoid

developing a tolerance to a particular anabolic steroid

(“plateauing”), some users stagger their drugs, taking the

anabolic steroids in an overlapping pattern, or stop one drug and

start another (Duchaine, 1989; Gallaway, 1997). Often steroid

users will “pyramid” their administration patterns, moving from

a low daily dose at the beginning of the cycle to a higher dose

and then tapering down the dose toward the end of their cycle

(Grundig & Bachmann, 1995; Wright, 1982). In addition,

individuals may use other drugs concurrently with anabolic

steroids to counteract the common adverse effects of steroids.

These drugs include diuretics, antiestrogens, human chorionic

gonadotrophin, and anti-acne medications. This polypharmacy

is termed an “array” (Duchaine, 1989). The frequency of

concurrent drug use or the frequency or efficacy of each of these

administration patterns is poorly documented.

The dosage of anabolic steroids depends on the sport as well as

on the particular needs of the athlete. Endurance athletes use

steroids primarily for their alleged catabolism-blocking effects,

i.e., to forestall the occurrence of “overtraining” (decreased

natural testosterone levels, fatigue, muscle atrophy and soreness,

etc.) (Friedl, 2000a). These athletes, for the most part, are trying

to maintain their testosterone levels in the “normal” range. Thus,

they use dosages at or slightly below physiological replacement

levels, that is, about 7 mg/day of testosterone (Yen & Jaffe,

1978). Participants in the traditional strength sports, seeking to

“bulk up,” have generally used dosages that exceed

physiological replacement levels by 10 to 100 times or more

(Kerr, 1982; Wright, 1982). Administration patterns also vary

among athletes within a particular sport, based on each athlete’s

training goals and response to the drugs, as well as on the

biological activity of different anabolic steroids ( Kochakian &

Yesalis, 2000; Wright, 1982). Women, regardless of sport, are

generally thought to use lower dosages of anabolic steroids than

men (Elliot & Goldberg, 2000). 

While it appears that many elite athletes obtain pharmaceuticalgrade drugs from medical professionals, the large majority of

anabolic steroid users are not elite athletes and use

black market steroids produced by clandestine labs

in the United States and by companies outside the

U.S. that do not adhere to the rigid industry

standards that ensure each dosage form contains a

predictable and consistent amount of active

ingredient(s) (See Table 3). These products may

be contaminated and/or may not be what they are

purported to be. Regardless of the source, the use

of anabolic steroids for purposes of performance

enhancement is illegal and unethical.

How prevalent is anabolic steroid use?

High levels of use of anabolic steroids have been

attributed to professional football players, weight

lifters, power lifters, bodybuilders, and throwers in track and

field events since the 1960s (Yesalis, Courson, & Wright, 2000).

Use by high school athletes was rumored as early as 1959

(Frazier, 1973; Gilbert, 1969a,b,c). However, until the mid1970s, information on the incidence of non-medical use of

steroids was based on anecdotes, testimonials, and rumors

(Yesalis & Bahrke, 1995). Although rumors still abound,

estimates of the incidence of steroid use are now based on the

results of systematic surveys. Surveys of steroid use are

categorized here as those of (1) adolescent school-age students,

(2) college students, and (3) athletes not falling into categories 1

or 2.

Use among adolescent school-age students 

In 1987 the first U.S. national study of anabolic steroid use at

2

Table 1.

Examples of Anabolic Agents Identified by the 31 IOC/WADA

Accredited Laboratories in 2003

Testosterone Nandrolone Stanozolol

Methandienone Mesterolone Boldenone

Tetrahydrogestrinone (THG) Methyltestosterone Methenolone

Oxandrolone Androstenedione (Andro) Clostebol

Fluoxymesterone Danazol Oxymetholone

DHEA Norethandrolone Drostanolone

Oxymesterone Trenbolone

Source: World Anti-Doping Agency, http://www.wada-ama.org/en/t1.asp, WADA

Statistics, 2003.

Table 2.

Examples of Oral and/or Injectible Anabolic Steroids

Steroid Oral* Injectible**

Testosterone cypionate X

Nandrolone decanoate X

Stanozolol X X

Methandienone X

Mesterolone X

Boldenone undecylenate X

Tetrahydrogestrinone (THG) X X 

(may also be a gel or injectible)

Methyltestosterone X

Methenolone acetate X

Methenolone enanthate X

Oxandrolone X

Androstenedione (Andro) X

Clostebol acetate X X

Fluoxymesterone X

Danazol X

Oxymetholone X

DHEA X

Norethandrolone X

Drostanolone proprionate X X

Oxymesterone X

Trenbolone acetate X 

*Adverse effects of oral steroids–liver disease, decreased

HDL, increased LDL.

**Adverse effects of injecting anabolic steroids (i.e.,

“needle sharing”): infections, AIDS, hepatitis.

Sources: adapted from Llewellyn, W. Anabolics 2000, Aurora,

CO: Anabolics.com, Inc., 2000; Grunding, P. and Bachmann,

M. World Anabolic Review 1996, Houston, TX: MB Muscle

Books, 1995; and Phillips, W.N. Anabolic Reference Guide

Sixth Issue, Golden, CO: Mile High Publishing, 1991.
(Newman, 1994; Yesalis, Ortner, & Bahrke, 1996). Three

Canadian studies (Adalf & Smart, 1992; Canadian Centre

for Drug-Free Sport, 1993; Killip & Stennett, 1990), four

Swedish surveys (Kindlundh, Isacson, Berglund, & Nyberg,

1999; Nilsson, 1995; Nilsson, Baigi, Marklund, & Fridlund,

2001a & b), two South African investigations (Lambert,

Titlestad, & Schwellnus, 1998; Schwellnus, Lambert, &

Todd, 1992), one British study (Williamson, 1993), and one

Australian investigation (Handelsman & Gupta, 1997) have

reported overall prevalence rates for high school-aged

students to range between 1.2–5.9% for males and

0.0–1.5% for females. Although these rates are slightly

lower, they approximate those reported for the U.S., and

reflect the cross-cultural impact of anabolic steroids on

performance and physical appearance.

Use among college athletes 

Since 1985, Anderson et al. (1985, 1991, 1993) and the

National Collegiate Athletic Association (NCAA) (1997,

2001) conducted five surveys of male and female student

athletes at selected NCAA member colleges and universities

regarding substance abuse, including anabolic steroids. In the

five surveys, the heaviest anabolic steroid use (defined as use in

the past 12 months) was reported in 1985—4.9% among all

athletes. Thereafter, steroid use decreased to its lowest level in

1997 (1.1%); in 2001 the level of use increased to 1.4%. In all

five surveys, the pattern of self-reported use was fairly

consistent among Division I-III schools. In the 2001 survey,

there was no striking difference in anabolic steroid use by race.

The level of use in men’s sports ranged from 0.2% in swimming

to 3.0% in football and a high of 5.0% among water polo

participants. In women’s sports, self-reported steroid use was

highest in lacrosse (1.6%); there were five women’s sports that

reported no steroid use in the 2001 survey. Of the student

athletes who acknowledged use of anabolic steroids, over half

reported first using these drugs in junior high or high school.

Not surprisingly, the predominant reason (42.7%) given for their

use of anabolic steroids was the improvement of athletic

performance. 

Yesalis, Buckley, Anderson, Wang, Norwig, Ott, Puffer, &

Strauss (1990) employed projected response survey techniques

with collegiate athletes, using indirect questions. Thus,

respondents were asked to estimate the level of their

competitors’ anabolic steroid use. Over 1600 male and female

athletes at five NCAA Division I institutions participated in this

study during the 1989-1990 academic year. The mean overall

projected rate of any prior use of anabolic steroids across all

sports surveyed was 14.7% for male and 5.9% for female

athletes. Among men’s sports, football showed the highest

projected lifetime steroid use rates with 29.3%, followed by

track and field events with 20.6%. The greatest projected use

rate for women’s sports was 16.3% for track and field events.

The reported overall projected rate of anabolic steroid use

the high school level was conducted by Buckley and associates

(Buckley et al., 1988). The investigators found that 6.6% of

male high school seniors reported having used these drugs.

There was no difference in the level of reported steroid use

between urban and rural areas, but there was a small, yet

significant, difference by size of enrollment: students at larger

high schools had a higher rate of reported steroid use. In

addition, among the self-reported steroid users, 38% had

initiated use before 16 years of age; and more than one-third of

the steroid users did not intend to participate in interscholastic

sports.

During the early to mid 1990s multiple U.S. local-, state-, and

national-level studies confirmed the findings of Buckley et al.

(1988), and showed that 4% to 6% (with a range of 3% to 12%)

of high school males admit to using anabolic steroids at some

time in their life (Yesalis, Barsukiewicz, Kopstein, & Bahrke,

1997). Some of these studies also examined the use of anabolic

steroids among high school females, generally showed that 1%

to 2% reported having used anabolic steroids (Yesalis, Bahrke,

Kopstein, & Barsukiewicz, 2000). Likewise, several of the

studies confirmed that substantial percentages of steroid users

do not participate in traditional school-sponsored sports.

Since 1991, steroid use by males as measured by U.S. national

surveys has generally increased (Grunbaum et al. 2004; Hewitt,

Smith-Akin, Higgins, Jenkins, 1998; Johnston, Bachman,

O’Malley, & Schulenberg, 2004; Kann, Warren, Harris, Collins,

Douglas, et al., 1995; Feyrer-Melk, Corbin, & Lewis, 1994)

(Table 4). Furthermore, since 1991, data from these U.S.

national surveys point to an increase in anabolic steroid use

among adolescent females as well as a sharp drop in the

perceived dangers of using steroids (Johnston, Bachman,

O’Malley, & Schulenberg, 2004). What is more troubling is the

2003 Youth Risk and Behavior Surveillance

System data (Grunbaum et al. 2004) showed that

among 9th- to 12th-grade students (ages 13-19) in

public and private high schools in the United

States, 6.8% of males and 5.3% of females (up

from 4.1% and 2.0% respectively in 1997) had

used anabolic steroids at least once in their lives.

Based on 2000 Census estimates of high school

students, these period prevalence rates translate to

well over one million young people in the United

States who have used (cycled) anabolic steroids at

least once during their lifetime. 

We should also note the use of anabolic steroids

by adolescents is not limited to the U.S.

3

Table 3.

Sources of Anabolic Steroids

Countries Medical Professionals Sports Personnel

United States Physicians Sport Coaches

Mexico Pharmacists Conditioning Coaches

Russia Veterinarians Nutrition Consultants

Poland Dentists

Hungary Athletic Trainers

Spain Physical Therapists

Italy

Greece

Canada

Netherlands

Thailand 

Source: Adapted from Bahrke, M.S. and Yesalis, C.E. PerformanceEnhancing Substances in Sport and Exercise. Champaign, IL: Human

Kinetics, 2002.

Table 4.

Trends in Lifetime Prevalence of Use of Anabolic Steroids

for Eighth, Tenth, and Twelfth Graders

Year

Grade 91 92 93 94 95 96 97 98 99 00 01 02 03

8th 1.9 1.7 1.6 2.0 2.0 1.8 1.8 2.3 2.7 3.0 2.8 2.5 2.5

10th 1.8 1.7 1.7 1.8 2.0 1.8 2.0 2.0 2.7 3.5 3.5 3.5 3.0

12th 2.1 2.1 2.0 2.4 2.3 1.9 2.4 2.7 2.9 2.5 3.7 4.0 3.5

Source: Monitoring the Future Study, the University of Michigan.
4

during the past 12 months was approximately three times

greater than the rate obtained from self-reports in the 1991

NCAA survey (NCAA Staff 2001). 

The true level of steroid use among athletes probably lies

between the lower-bound estimates from self-reports and the

upper-bound estimates obtained from the projective response

techniques (Yesalis, Buckley, Anderson, Wang, Norwig, Ott,

Puffer, & Strauss, 1990). While the response of adolescents to

anonymous surveys of drug use is considered generally valid,

the results of this projective response study as well as those of

other validation studies of elite athletes (Yesalis, Bahrke,

Kopstein, & Barsukiewicz, 2000) call into question the validity

of surveys of elite athletes and argue that there is a substantial

underreporting bias.

Use by Olympic athletes

Track and field event athletes who participated in the 1972

Olympics were surveyed (Silvester, 1973): and 68% of the

participants reported prior steroid use, with 61% having used

steroids within six months of the Games. In 1975, Ljungqvist

surveyed elite Swedish male track and field event athletes and

found that 31% admitted prior anabolic steroid use. None of the

middle- or long-distance runners admitted to anabolic steroid

use, but 75% of the throwers did.

In a survey of 155 U.S. Olympians who participated in the 1992

Winter Games, 80% of the athletes classified steroid use among

Olympic competitors as a very serious or somewhat serious

problem; just 5% thought that it was not a problem (Pearson &

Hansen, 1992). When asked to estimate the level of steroid use

in their own sport, 43% of the respondents estimated use by

10% or more of competitors, while 34% estimated use at 1% to

9%. Only 23% of the athletes surveyed believed that there was

no steroid use in their sport. In another survey of former

Olympians (Pearson, 1994), 75% of the medalists and 63% of

the nonmedalists stated that more athletes were using

performance-enhancing drugs than when they themselves had

competed. 

An intensive two-year investigation of doping in Olympic sport

conducted for the U.S. Office of National Drug Control Policy

concluded that while estimates of the magnitude of the doping

epidemic vary widely (from 10% to 90% of athletes), there

exists an atmosphere in our society that fosters drug use by

athletes:

the high financial stakes for Olympic athletes,

corporate sponsors, the TV broadcast and cable

industries and sport governing bodies, coupled with

the pharmacopoeia of performance-enhancing

substances, the athlete’s drive to win and the absence

of an effective policing mechanism, create an

environment that encourages doing anything –

including doping – to win (National Center on

Addiction and Substance Abuse, 2000: 2).

While testing and education programs have been in effect for

some time, new efforts to reduce steroid use have recently been

implemented. On October 1, 2000 the U.S. Anti-Doping Agency

(USADA) was formed as the independent anti-doping agency

for Olympic sports in the United States. It was created as the

result of recommendations set forth by the U.S. Olympic

Committee’s Select Task Force on Externalization. They have

full authority for testing, education, and research, as well as

adjudication for U.S. Olympic, Pan Am and Paralympic athletes. 

Use by Weight Lifters

Weight trainers in three gymnasiums in the Chicago area were

questioned (Frankle, Cicero, & Payne, 1984); 44% reported

prior steroid use. In a study of amateur competitive bodybuilders

(Tricker, O’Neil, & Cook, 1989), over half of the men and 10%

of the women reported that they had used anabolic steroids at

some time in their life. In 1993, of the 185 members of

gymnasiums and health clubs, 18% of men and 3% of women

acknowledged having used or currently using anabolic steroids

(Kersey, 1993). In 1988, Yesalis et al. surveyed elite power

lifters using both questionnaires and follow-up telephone

interviews. One-third of the questionnaire respondents admitted

prior anabolic steroid use; however, 55% of those interviewed

later by telephone conceded steroid use.

The level of steroid use appears to have increased significantly

over the past three decades (Johnston, Bachman, O’Malley, &

Schulenberg, 2004; Yesalis, Anderson, Buckley, & Wright,

1990; Yesalis, Kennedy, Kopstein, & Bahrke, 1993.), and is no

longer limited to elite athletes or to men. Although higher rates

of steroid use are reported by competitive athletes, a significant

number of recreational athletes and non-athletes appear to be

using these drugs, probably to “improve” their appearance.

Looking at elite sport in the 20th Century through the eyes of

historians and journalists as well as the athletes themselves, an

unmistakable picture emerges of a sustained doping pandemic

of huge proportions in elite sport (Yesalis & Bahrke, 2003). Of

greater concern is that the use of anabolic steroids has cascaded

down from the Olympic, professional, and college levels to the

high schools and junior high schools, and there are significantly

more adolescents using anabolic steroids than elite athletes.

Ergogenic effects: Do anabolic steroids improve

performance? 

While the vast majority of the athletic community accepts that

anabolic steroids enhance exercise capacity and performance

(Yesalis, Anderson, Buckley, & Wright, 1990), from 1977 to

1984, the American College of Sports Medicine (1977, 1984)

regarded anabolic steroids as ineffective, sending mixed

messages to the athletic community concerning the potential of

anabolic steroids to enhance performance. As recently as 1992,

other scientists (Celotti & Negri-Cesi, 1992) remained skeptical,

also reporting that anabolic steroids were ineffective. However,

a study by Bhasin and his colleagues in 1996 quelled much of

the residual doubt concerning the effectiveness of anabolic

steroids in humans. Using a relatively high dose of an anabolic

steroid (600 mg/wk of testosterone enanthate for 10 weeks),

Bhasin et al. (1996) found a 13 lb (6 kg) weight gain and 48.5 lb

(22 kg) improvement in the one-repetition maximum (1-RM)

bench press in experienced lifters. The results of the Bhasin

study (1996) also suggested additive effects of exercise and

steroids, with a bench press improvement of approximately 22

lb (10 kg) produced by exercise or steroid, and 44 lb (20 kg)

produced by exercise and steroid.

Thus, anabolic steroids, as a class, produce lean mass gain in

normal healthy, adult men with a reciprocal decrease in total

body adipose tissue. In addition, a dose response effect has been

demonstrated (Forbes, 1985; Herbst and Bhasin, 2004). Typical

weight gains are 6.6 to 11 lb (3-5 kg) after several weeks of

high-dose steroid use. The effects of steroids on strength

performance are mostly seen with experienced weight lifters and

when strength training is performed concurrently with the

steroid administration. Most studies demonstrating strength

gains also demonstrate weight gains. 

At least one study has demonstrated a threshold response of

body composition to anabolic steroids, as well as variations in

response according to type of steroid (Friedl, Dettori, Hannan,

Patience, & Plymate, 1991). The mechanisms of action for an
effect on muscle mass have been increasingly elucidated and

involve multiple mechanisms including increased protein

anabolism and differentiation of pluripotent stem cells toward

the myogenic lineage (Herbst and Bhasin, 2004). Furthermore,

the resultant muscle hypertrophy and regeneration is associated

with an increase in myoblast differentiation or the number of

satellite cells (Herbst and Bhasin, 2004). 

While the ergogenic effects of anabolic steroids have been

established, the effects of high doses or prolonged

administration of anabolic steroids on physique or physiological

capacities have not been documented. Likewise, the residual

effects of anabolic steroids on physiological capacities after the

termination of use have not been established. Furthermore,

results of any dose on physical/physiological capacities or

performance in females are unknown.

Although the evidence is incomplete, anabolic steroids may also

inhibit or block the catabolic effects of glucocorticoids that are

released during intense training (Kuhn, 2002). Theoretically, this

anti-catabolic effect would allow athletes to train more

frequently and more intensely, and this may be the most

important factor concerning the performance-enhancing effects

of anabolic steroids. Furthermore, while there is little evidence

to support a beneficial role of anabolic steroids in other types of

exercise performance such as muscular endurance or aerobic

endurance, anabolic steroids increase the number of red blood

cells (RBCs). With the anti-catabolic effect and an increase in

RBCs, endurance athletes may be able to train more frequently,

for longer periods of time, and with greater intensity. In turn,

this could produce improved aerobic capacity resulting in

quicker running times or in more repetitions of a particular

activity.

What are the short- and long-term health

effects of anabolic steroid use? 

Physical and Physiological Effects

The short-term health effects of anabolic-androgenic steroids

have been increasingly studied, and several authors have

reviewed the physiological and health effects of these drugs

(Friedl, 2000b; Haupt & Rovere, 1984; Lamb, 1984; Wilson,

1988; Wright, 1980) (See Table 5). Although anabolic steroid

use has been associated (mainly through case reports) with a

number of adverse and even fatal effects, the incidence of

serious effects thus far reported has been extremely low (Friedl,

2000b). However, for several decades experts have consistently

stated that the long-term health effects of anabolic steroid use

are unknown (Yesalis, Wright, &

Bahrke, 1989). Specifically, the longterm health effects as related to type of

steroid, dose, frequency of use, age at

initiation, and concurrent drug use

have not been elucidated. Confounding

the assessment of health consequences

is the fact that some individuals use

large doses of anabolic steroids for

prolonged periods of time, while

others use therapeutic doses

intermittently (Buckley et al., 1988;

Duchaine, 1989; Grundig &

Bachmann, 1995; Llewellyn, 2000). 

Although the role of anabolic steroids

in the etiology of various diseases in

both animals and humans is still

uncertain, steroid use in clinical trials

and in laboratory studies has been

associated with numerous deleterious

changes in risk factors and in the physiology of various organs

and body systems, suggesting potential for subsequent health

problems (American College of Sports Medicine, 1984;

Kruskemper, 1968; Wright, 1980; Freidl, 2000b). The bestdocumented effects are those on the liver, serum lipids, and the

reproductive system. Other suspected areas of concern include

the psyche and behavior, coronary artery disease,

cerebrovascular accidents, prostatic changes, and the immune

function (Friedl, 2000b).

Steroid use has been related to cardiovascular risk factors. The

most important are changes in lipoprotein fraction, increased

triglyceride levels and concentrations of several clotting factors,

and hyperinsulinism and diminished glucose tolerance (Friedl,

2000b; Glazer, 1991; Haupt & Rovere, 1984; Sullivan,

Martinez, Gennis, & Gallagher, 1998; Wright, 1980). It should

be noted, however, that although these effects vary significantly

between types and doses of anabolic steroids, and between

individuals and situations (Kruskemper, 1968), all of the effects

have been demonstrated to be fully reversible within several

months after cessation of steroid use (Friedl, 2000b; Haupt &

Rovere, 1984; Wright, 1980). 

Anabolic steroids have been shown to be cardiotoxic in animals

(Hartgens, Cherlex, & Kulpers, 2003). In addition, some studies

in humans, but not all, have shown that anabolic steroid use is

associated with left ventricular (LV) hypertrophy (Karila et al.,

2003; Hartgens, Cherlex, & Kulpers, 2003; Urhausen, Albers, &

Kindermann, 2004). Furthermore, one study demonstrated that

the increases in LV mass persist several years after

discontinuation of anabolic steroid use (Urhausen, Albers, &

Kindermann, 2004). 

Acute thrombotic risk has been linked to steroid use in 17 case

reports of nonfatal myocardial infarction and stroke in athletes

who were using anabolic steroids (Rockhold, 1993; Wu &

Eckardstein, 2003). Although there is no direct evidence

anabolic steroids are thrombogenic in humans (Ansell, Tiarks, &

Fairchild, 1993), the clinical circumstances of these reports

suggest a possible causal relationship. These reports further

suggest that, if a causal relationship exists, anabolic steroids

could have serious short-term effects. 

Liver structure and function have also been altered by

administration of anabolic steroids; associated conditions

include cholestatic jaundice, peliosis hepatitis, hepatocellular

hyperplasia, and hepatocellular adenomas (Dickerman, Pertusi,

Zachariah, Dufour, & McConathy, 1999; Soe, Soe, & Gluud,

1992). Peliosis hepatitis is clearly associated with the use of 17-

5

Table 5

Potential Adverse Effects of Anabolic Steroids

Males Females Both Males and Females

Baldness Breast Shrinkage Acne

Prostate changes Clitoral Enlargement Aggression

Gynecomastia Increased Facial/Body Hair Brittle connective tissue

Impotence/Sterility Menstrual Irregularities Cardiovascular Disease

Premature Hair Loss Cerebrovascular incidents

Deepened Voice Dependency

(Vocal cord thickening) Headaches

Hypertension

Liver Disease

Psyche and behavior changes

Short Stature

(Premature growth-plate closure)

Source: Adapted from Bahrke, M.S. and Yesalis, C.E. Performance-Enhancing Substances in Sport

and Exercise. Champaign, IL: Human Kinetics, 2002.
between the use of anabolic steroids by athletes and increased

levels of irritability, aggression, personality disturbance, and

psychiatric diagnoses, others do not (Bhasin et al., 1996; Millar,

1996; Yates, Perry, MacIndoe, Holman, & Ellingrod, 1999).

Only a few prospective, blinded studies documenting aggression

and adverse overt behavior resulting from steroid use have been

reported (Hannan, Friedl, Zold, Kettler, & Plymate, 1991; Pope,

Kouri, & Hudson, 2000; Kouri, Lukas, Pope, & Oliva, 1995; Su

et al., 1993). As Bjorkqvist and colleagues (1994) point out,

much of the psychological and behavioral effect of steroid

intake may be placebo. In a double-blind experiment, human

males (n = 27) were given either testosterone, placebo, or no

treatment, over a one-week period. The results revealed a

significant placebo effect. After treatment, the placebo group

scored higher than both the testosterone and the control groups

on self-estimated anger, irritation, impulsivity, and frustration.

Observer-estimated mood yielded similar results. Anticipation

of the aggressiveness related to steroid use may lead to actual

violent acts and become, in effect, an excuse for aggression.

Although anabolic steroid dependency may be a problem, its

prevalence and symptomatology are difficult to reliably

establish based on the existing literature. There is some evidence

that testosterone is mildly reinforcing (relative to the classic

reinforcers, cocaine and heroin) in male rats and hamsters selfadministering (Wood et al., 2004). Brower (2002) in his review

found no evidence that anabolic steroids lead to dependence

(i.e., meeting the Diagnostic and Statistical Manual of Mental

Disorders criteria for dependence) with therapeutic use.

However, he noted 165 instances of dependence among

weightlifters and bodybuilders using supraphysiologic doses of

anabolic steroids. 

It is interesting to note that with a million or more steroid users

in the United States (Yesalis, Kennedy, Kopstein, & Bahrke,

1993), only an extremely small percentage of users appear to

experience mental disturbances that result in clinical treatment.

Also, of the few individuals who do experience significant

changes, most apparently recover without additional problems

when the use of steroids is terminated. 

Conclusion

Anabolic steroids are synthetic derivatives of testosterone. They

are usually administered orally and by injection. Anabolic

steroids are used by athletes to enhance performance and nonathletes to enhance appearance. Strong evidence now exists

demonstrating that anabolic steroid use results in increased body

weight and muscular strength. There is also an increasing body

of evidence that anabolic steroid use is associated with a variety

of health problems. While the long-term effects of anabolic

steroids remain unclear, the best-documented physiological

effects are those on the liver, serum lipids, and the reproductive

system. A pattern of association between the use of anabolic

steroids and increased levels of irritability, aggression,

personality disturbance, dependence, and psychiatric diagnoses

has been revealed in a number of reports. 

Although anabolic steroids are illegal, and their use is banned by

virtually every sport governing body, survey and drug-testing

data indicate continued use by competitive athletes at all levels.

The fact that the level of steroid use appears to have increased

significantly over the past three decades among adolescents,

women, and recreational athletes is also of growing concern.

The use of anabolic steroids presents an interesting public health

challenge. While these drugs are associated with deleterious

physical and psychological outcomes, they are being used to

achieve what many consider socially desirable ends: being

physically attractive and being a winner.

6

a-alkylated (oral) anabolic steroids, but with unknown

frequency. Hepatic tumors are rare in men (1% to 3%), but

nearly half of the discovered tumors rupture, and a larger

proportion may remain undetected. In two cases, rupture proved

fatal (Friedl, 2000b). It has not been convincingly demonstrated

that anabolic steroids can cause, at least with therapeutic doses,

the development of hepatocellular carcinomas. In summary,

virtually all histological changes in the liver have been

associated with the use of 17-a-alkylated (oral) steroids (Friedl,

2000b; Kruskemper, 1968; Wilson, 1988; Wright, 1980); and the

cause-and-effect relationship between oral anabolic steroids and

these conditions is strengthened by the return of normal blood

values and excretory function, the regression of tumors, a

general recovery, and a return toward normal liver function after

cessation of steroid use (Friedl, 2000b).

The effects of anabolic-androgenic steroids on the male

reproductive system include reductions in levels of endogenous

testosterone, gonadotrophic hormones, and sex hormonebinding globulin (SHBG); reductions in testicle size, sperm

count, and sperm motility; and alterations in sperm morphology

(Friedl, 2000b; Wright, 1980). When steroid use is stopped, the

testes resume sperm production and sperm quality usually

recovers spontaneously within four months. However, the

impact of anabolic steroids on spermatogenesis may persist for a

year or more (Dohle, Smit, & Weber, 2003). 

Anabolic steroids have been associated through case reports

with tendon injuries and neuropathies (Friedl, 2000b). While the

results of animal studies support a causal association, to date the

effects of steroids on musculoskeletal injuries in humans cannot

be distinguished from the risks ordinarily faced by strength

athletes not using anabolic steroids. 

In women, anabolic steroids have been associated with a number

of adverse effects, some of which are not reversible upon

discontinuation of steroid use (Elliot & Goldberg, 2000). These

include menstrual abnormalities; deepening of the voice;

shrinkage of the breasts; male-pattern baldness; and an increase

in sex drive, acne, body hair, and clitoris size. In addition,

women using steroids experience dramatically elevated

testosterone levels and lowered levels of SHBG, folliclestimulating hormone, and thyroid-binding proteins (Elliot &

Goldberg, 2000; Malarkey, Strauss, & Leizman, 1991).

Premature halting of growth in younger male and female users

has not been systematically studied, although such effects have

been described in case reports for several decades (Rogol &

Yesalis, 1992).

Psychological Effects

Previous and current research studies have documented

significant positive relationships between testosterone levels,

dominance, and aggressive behavior in various species of

animals, including nonhuman primates (Bahrke, Yesalis, &

Wright, 1996). Relative to the animal literature, fewer studies

have assessed the relationship of endogenous or exogenous

androgens to aggression or violent behavior in humans.

However, a positive pattern of association between endogenous

testosterone levels and aggressive behavior in males has been

increasingly established (Bahrke, 2000). Also, while random

clinical trials using moderate doses of exogenous testosterone

for contraceptive and other purposes reveal few adverse effects

on male sexual and aggressive behavior, other investigations and

case reports of athletes using higher doses suggest the

possibility of affective and psychotic syndromes (some of

violent proportions), psychological dependence, and withdrawal

symptoms.

While several published reports support a pattern of association
7

Please Post

President’s Council on Physical Fitness & Sports

200 Independence Avenue, S.W., Washington, DC 20201

(202) 690-9000 • FAX (202) 690-5211

“The use of performance-enhancing

drugs like steroids in baseball,

football and other sports is

dangerous, and it sends the wrong

message – that there are shortcuts

to accomplishment, and that

performance is more important

than character.”

President George W. Bush, State of the Union address, January 20, 2004 
8

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