Evidence-Based Reviews

Bodybuilding’s dark side: Clues to anabolic steroid use

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Table 2

Clues to possible AAS use in men

Estimated fat-free mass index (FFMI) >26 (see Box 2)
Recent rapid muscle gains (>8 lb/month)
Striae over pectoralis muscles caused by rapid hypertrophy of underlying muscle
Other physical signs
Testicular atrophy
Psychiatric signs
Uncharacteristically aggressive behavior
Uncharacteristic hypomanic symptoms
  • Grandiosity
  • Decreased sleep
  • Hypersexuality
  • Recklessness
Uncharacteristic depressive symptoms
  • Sudden depression onset
  • Anhedonia
  • Hypersomnia

To overcome these treatment obstacles, we recommend that you:

  • Become as knowledgeable about AAS use as you are about other forms of substance abuse (see Related resources).
  • Approach AAS users as you would any other substance abusers—as individuals at risk for potentially serious medical and psychiatric consequences.
  • Maintain a high index of suspicion when evaluating any muscular young male patient, even if he initially denies AAS use.

AAS use can often be suspected by looking at the patient as he walks in the door. Using what we call the “fat-free mass index” (FFMI) to calculate muscularity (Box 2), we have shown that a lean man can achieve only a certain amount of muscularity without using drugs.5 Although this finding needs to be replicated elsewhere, in our experience a man is almost certainly lying if he:

  • is relatively lean (with approximately 10% body fat)
  • displays an FFMI >26
  • and claims he has not used drugs.

If a patient has an elevated FFMI and other cues suggesting AAS use (Table 2), gently but persistently question him if he denies using these drugs.


When you have established a history of AAS use, you will be far better prepared to anticipate and possibly treat its associated syndromes. Discussion of these effects is beyond the scope of this paper; for details, see reviews of AAS-associated medical effects,3,6 psychiatric effects,6,7 and general treatment principles.8 We focus here on the four scenarios clinicians encounter most often in practice and offer some pragmatic suggestions.

Forensic cases. AAS users almost never voluntarily seek help to stop their drug use. Such a request would be somewhat analogous to a girl with anorexia nervosa voluntarily asking for help to gain weight. We are unaware of any rehabilitation centers, clinics, 12-step programs, or the like for AAS users—there is no demand for them.

Thus, an AAS user may first come to clinical attention through legal channels. For example, if an AAS user committed a violent crime while experiencing hypomanic effects from these drugs, he might be required to undergo random urine testing as a condition of probation. This may be reasonable, provided that the tests are unannounced and urine is always collected under direct observation.

Monitoring clinicians may serve as little better than policemen, although sometimes it is possible to forge an alliance with the patient.

Depression. Exogenous AAS administration suppresses endogenous testosterone production through feedback mechanisms involving the hypothalamic-pituitary-testicular axis.3,6 Thus, during a long cycle, the user’s testes may shrink to half their normal size and stop producing testosterone and spermatozoa.

If the user then stops AAS rapidly, he may plunge into a profoundly hypogonadal state associated with symptoms of major depression. In a field study of 77 steroid users (71 male and 6 female), 6 (7.8%) reported they attempted suicide during AAS withdrawal.9 Depression associated with AAS withdrawal may prompt users to resume AAS quickly, triggering a syndrome of AAS dependence.6,10,11

Fortunately, AAS-withdrawal depression is usually self-limited and responds—in our experience and that of others12—to standard antidepressants. We recommend aggressively treating such depressions, as doing so may prevent resumption of AAS use and eventual AAS dependence.

Body-image disorders. AAS users often report body-image disorders, especially muscle dysmorphia—a form of body dysmorphic disorder where individuals become preoccupied with the belief that they are not adequately muscular.13,14 Anxieties about muscularity are a risk factor for subsequent AAS use15 and a major contributor to AAS dependence.8,11

Body dysmorphic disorder responds to pharmacologic and cognitive-behavioral interventions.3,16 Young men showing pathologic concerns about their muscularity or displaying related body-image pathology may benefit from prompt treatment before they are tempted to use AAS.

Progression to opioid dependence. An ominous development among American17 and British18 AAS users is a growing tendency to use opioids. In two studies of individuals with opioid dependence,19,20 7% to 9% reported beginning as AAS users, then learning about opioids from fellow bodybuilders and often buying their first illicit opioids from the person who had sold them AAS. Most learned as teenagers to use needles to inject AAS intramuscularly, so beginning to using opioids intravenously was only a small step.

In the last 5 years, we have become anecdotally aware of numerous AAS users who developed heroin addiction requiring repeated inpatient detoxification or who died of unintentional opioid overdoses. We suspect this phenomenon is under-recognized and urge clinicians to watch for it.

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