Anabolic steroids, also known more properly as anabolic–androgenic steroids (AAS), are steroidal androgens that include naturalandrogens like testosterone as well as synthetic androgens that are structurally related and have similar effects to testosterone. They are anabolic and increase protein within cells, especially in skeletal muscles, and also have varying degrees of androgenic and virilizingeffects, including induction of the development and maintenance of masculine secondary sexual characteristics such as the growth of facial and body hair. The word anabolic, referring to anabolism, comes from the Greek ἀναβολή anabole, “that which is thrown up, mound”. Androgens or AAS are one of three types of sex hormone agonists, the others being estrogens like estradiol and progestogenslike progesterone.
AAS were synthesized in the 1930s, and are now used therapeutically in medicine to stimulate muscle growth and appetite, induce male puberty and treat chronic wasting conditions, such as cancer and AIDS. The American College of Sports Medicine acknowledges that AAS, in the presence of adequate diet, can contribute to increases in body weight, often as lean mass increases and that the gains in muscular strength achieved through high-intensity exercise and proper diet can be additionally increased by the use of AAS in some individuals.
Health risks can be produced by long-term use or excessive doses of AAS. These effects include harmful changes in cholesterollevels (increased low-density lipoprotein and decreased high-density lipoprotein), acne, high blood pressure, liver damage (mainly with most oral AAS), and dangerous changes in the structure of the left ventricle of the heart. Conditions pertaining to hormonal imbalances such as gynecomastia and testicular size reduction may also be caused by AAS. In women and children, AAS can cause irreversible masculinization.
Ergogenic uses for AAS in sports, racing, and bodybuilding as performance-enhancing drugs are controversial because of their adverse effects and the potential to gain unfair advantage in physical competitions. Their use is referred to as doping and banned by most major sporting bodies. For many years, AAS have been by far the most detected doping substances in IOC-accredited laboratories. In countries where AAS are controlled substances, there is often a black market in which smuggled, clandestinely manufactured or even counterfeit drugs are sold to users.
Since the discovery and synthesis of testosterone in the 1930s, AAS have been used by physicians for many purposes, with varying degrees of success. These can broadly be grouped into anabolic, androgenic, and other uses.
- Bone marrow stimulation: For decades, AAS were the mainstay of therapy for hypoplastic anemias due to leukemia or kidney failure, especially aplastic anemia. AAS have largely been replaced in this setting by synthetic protein hormones (such as epoetin alfa) that selectively stimulate growth of blood cell precursors.
- Growth stimulation: AAS can be used by pediatric endocrinologists to treat children with growth failure. However, the availability of synthetic growth hormone, which has fewer side effects, makes this a secondary treatment.
- Stimulation of appetite and preservation and increase of muscle mass: AAS have been given to people with chronic wasting conditionssuch as cancer and AIDS.
- Stimulation of lean body mass and prevention of bone loss in elderly men, as some studies indicate. However, a 2006 placebo-controlled trial of low-dose testosterone supplementation in elderly men with low levels of testosterone found no benefit on body composition, physical performance, insulin sensitivity, or quality of life.
- Prevention or treatment of osteoporosis in postmenopausal women. Nandrolone decanoate is approved for this use. Although they have been indicated for this indication, AAS saw very little use for this purpose due to their virilizing side effects.
- Androgen replacement therapy for men with low levels of testosterone; also effective in improving libido for elderly males.
- Induction of male puberty: Androgens are given to many boys distressed about extreme delay of puberty. Testosterone is now nearly the only androgen used for this purpose and has been shown to increase height, weight, and fat-free mass in boys with delayed puberty.
- Masculinizing hormone therapy for transgender men, other transmasculine people, and intersex people, by producing masculine secondary sexual characteristics such as a voice deepening, increased bone and muscle mass, masculine fat distribution, facial and body hair, and clitoral enlargement, as well as mental changes such as alleviation of gender dysphoria and increased sex drive.
- Treatment of breast cancer in women, although they are now rarely used for this purpose due to virilizing side effects.
- In low doses as a component of hormone therapy for postmenopausal and transgender women, for instance to increase energy, well-being, libido, and quality of life, as well as to reduce hot flashes. Testosterone is usually used for this purpose, although methyltestosterone is also used.
- Male contraception, in the form of testosterone enanthate; potential for use in the near-future as a safe, reliable, and reversible male contraceptive.
Most steroid users are not athletes. Between 1 million and 3 million people (1% of the population) are thought to have used AAS in the United States. Studies in the United States have shown that AAS users tend to be mostly middle-class heterosexual men with a medianage of about 25 who are noncompetitive bodybuilders and non-athletes and use the drugs for cosmetic purposes. “Among 12- to 17-year-old boys, use of steroids and similar drugs jumped 25 percent from 1999 to 2000, with 20 percent saying they use them for looks rather than sports, a study by insurer Blue Cross Blue Shield found.”(Eisenhauer) Another study found that non-medical use of AAS among college students was at or less than 1%. According to a recent survey, 78.4% of steroid users were noncompetitive bodybuilders and non-athletes, while about 13% reported unsafe injection practices such as reusing needles, sharing needles, and sharing multidose vials,though a 2007 study found that sharing of needles was extremely uncommon among individuals using AAS for non-medical purposes, less than 1%. Another 2007 study found that 74% of non-medical AAS users had post-secondary degrees and more had completed college and fewer had failed to complete high school than is expected from the general populace. The same study found that individuals using AAS for non-medical purposes had a higher employment rate and a higher household income than the general population. AAS users tend to research the drugs they are taking more than other controlled-substance users; however, the major sources consulted by steroid users include friends, non-medical handbooks, internet-based forums, blogs, and fitness magazines, which can provide questionable or inaccurate information.
AAS users tend to be unhappy with the portrayal of AAS as deadly in the media and in politics. According to one study, AAS users also distrust their physicians and in the sample 56% had not disclosed their AAS use to their physicians. Another 2007 study had similar findings, showing that, while 66% of individuals using AAS for non-medical purposes were willing to seek medical supervision for their steroid use, 58% lacked trust in their physicians, 92% felt that the medical community’s knowledge of non-medical AAS use was lacking, and 99% felt that the public has an exaggerated view of the side-effects of AAS use. A recent study has also shown that long term AAS users were more likely to have symptoms of muscle dysmorphia and also showed stronger endorsement of more conventional male roles. A recent study in the Journal of Health Psychology showed that many users believed that steroids used in moderation were safe.
AAS have been used by men and women in many different kinds of professional sports to attain a competitive edge or to assist in recovery from injury. These sports include bodybuilding, weightlifting, shot put and other track and field, cycling, baseball, wrestling, mixed martial arts, boxing, football, and cricket. Such use is prohibited by the rules of the governing bodies of most sports. AAS use occurs among adolescents, especially by those participating in competitive sports. It has been suggested that the prevalence of use among high-school students in the U.S. may be as high as 2.7%. Male students used AAS more frequently than female students and, on average, those that participated in sports used steroids more often than those that did not.
There are four common forms in which AAS are administered: oral pills; injectable steroids; creams/gels for topical application; and skin patches. Oral administration is the most convenient. Testosterone administered by mouth is rapidly absorbed, but it is largely converted to inactive metabolites, and only about one-sixth is available in active form. In order to be sufficiently active when given by mouth, testosterone derivatives are alkylated at the 17α position, e.g. methyltestosterone and fluoxymesterone. This modification reduces the liver’s ability to break down these compounds before they reach the systemic circulation.