Intended for healthcare professionals

Practice 10-Minute Consultation

Anabolic steroid use

BMJ 2016; 355 doi: (Published 13 October 2016) Cite this as: BMJ 2016;355:i5023
  1. John H M Brooks, academic foundation year 2 doctor1,
  2. Imtiaz Ahmad, general practitioner and trainer, and sports medicine physician2,
  3. Graham Easton, general practitioner and programme director3
  1. 1Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
  2. 2South Lambeth Road Practice, London SW8 1UL, and Guy’s and St Thomas’ Hospital, London SE1 7EH
  3. 3Imperial GP Specialty Training, Department of Primary Care and Public Health, Imperial College London, London, W6 8RP
  1. Correspondence to: J Brooks JohnBrooks{at}

What you need to know

  • Ask about anabolic steroid use in a non-judgemental way, strongly encourage cessation, and explain the side effects and long term health risks

  • Male patients (<2% female) may present with local infection at injecting sites or stress related mood changes

  • Initially, offer annual monitoring for cardiac (electrocardiogram and echocardiogram) and hepatic (liver function tests) complications

A 27 year old man weight-trains five times a week and has used anabolic steroids orally for six months. He is concerned about long term health consequences.

Anabolic steroids are synthetic testosterone derivatives usually taken without medical advice to increase muscle mass or improve athletic performance. Risk factors include male sex (<2% female),1 body dysmorphic disorder,2 competitive sport participants, and bodybuilders. Steroid induced muscle gain is possible even without training.4 There are an estimated three million users in Europe.5

What you should cover

Establish the substances involved and pattern of use. Testosterone derivatives are known as “roids” or “juice”. Some nutritional supplements may also contain steroids.7

Ask about duration and pattern of use, including “cycling” of different combinations of drugs over 6-12 weeks, “stacking” of more than one different steroid, and “pyramiding” by using variable doses to improve effectiveness and reduce side effects. Users may periodically abstain to allow normal hormonal production to return (“post-cycle therapy”) to try and prevent hypothalamic-pituitary-gonadal axis dysfunction.

Ask about oral or injected use, commonly directly into muscles. Associated symptoms include8:

  • Reversible—Increased appetite, gastrointestinal dysfunction, mood swings, anxiety, aggression, acne, oedema, libido change, scrotal pain and impotence, menstrual irregularities

  • Irreversible—Hirsutism, voice pitch changes, male pattern baldness or hairline recession, skin straie or keloid, chest pain or other symptoms of cardiac disease, clitoral hypertrophy, and short stature or premature masculinisation or feminisation in adolescents

  • Testicular atrophy, gynaecomastia, and infertility—These may be reversible. Studies are scarce, but sperm anomalies have been observed in anabolic steroid users,9 with normal sperm production and return of fertility reported four months and up to five years after cessation of anabolic steroid use.9 10

Ask about the use of other medications to tackle side effects, including tamoxifen for gynaecomastia, human chorionic gonadotropin for testicular atrophy, diuretics for oedema, opioids for pain relief, and anxiolytics for anxiety.11

What you should do


Look for signs associated with steroid use or long term complications:

  • Body composition (height, weight, body mass index), particularly rapid increase in lean body mass, and for ongoing monitoring

  • Skin (acne, male pattern baldness, needle marks, hirsutism, gynaecomastia, striae or keloids)

  • Breasts (lactation, gynaecomastia)

  • Genitourinary (testicular atrophy, clitoromegaly, enlarged prostate)

  • Systemic signs of cardiac or liver disease

  • Depression screening and mood assessment.

Consider steroid use in patients presenting with suggestive signs or symptoms: regular weight trainers with a rapid increase in muscle mass, those suspected of violent crime,3 and polydrug users. Ask non-judgemental questions (“Have you ever been offered steroids?”) and consider other diagnoses, including ovarian carcinoma, polycystic ovarian syndrome, adrenal neoplasm, Cushing’s syndrome, drug induced jaundice, hepatitis, and cirrhosis.


Table 1 lists the investigations to consider in cases of suspected or confirmed use of anabolic steroids.

Table 1

Investigations to consider in suspected or confirmed use of anabolic steroids

View this table:

Consider longer term risks

The magnitude of health risks is not known. Side effects and risks are potentially higher with oral ingestion,13 although injection risks HIV infection, hepatitis, and local infections. Refer patients to appropriate specialists if you suspect long term complications.

  • Cardiac complications and premature death with double the morbidity and mortality risk being reported14: the underlying cause is unclear.8

  • Hepatic complications—Cholestasis and chronic vascular injury to the liver. Hepatocellular carcinoma and hepatic adenomas have been reported 2-15 years after initial use.13

  • Psychiatric—Obsessive compulsive disorder, body dysmorphic disorder, mood instability, and anxiety in persistent use. Patients may develop anabolic-androgenic steroid dependence2 due to muscle dysmorphia. Increased aggression (“roid rage”) has been reported in up to 44% of users. It is not clear if users of anabolic steroids are predisposed to aggression or if the substance increases aggressive behaviour.15

  • Tendon rupture 16

  • Reproductive—Testicular atrophy, impotence and infertility.


Assess the patient’s understanding and outline the potential short and long term risks. Strongly encourage cessation; no tapering is required. A loss of muscle tone may trigger relapse of steroid use, but continued resistance and endurance exercise may limit these losses. Consider psychological services for body dysmorphia and any withdrawal depression. Continued exercise can help alleviate depressive symptoms.17 Reassure patients that many side effects are reversible, including changes in lipid profile, hormones, blood pressure, and electrolytes. Expert opinion suggests lifelong monitoring for complications. Consider annual monitoring initially, which can be reduced if examination and biochemical results remain normal.

For patients continuing to use anabolic steroids, aim for harm reduction:

  • A minimum of annual monitoring for complications, advice about not sharing needles, provision of clean needles, and advice about avoiding multiple agents and reducing doses.

  • Advise of legal and probably safe alternatives to improve muscle mass and performance such as regular resistance exercise, eating a balanced diet, creatine18 or hydroxymethylbutyrate (HMB) supplementation,19 and caffeine use.

  • Advise that anabolic steroids are banned by sports governing bodies.6

  • Document discussions about the risk of serious long term damage to the heart and liver.

Patient involvement

We sought comments from an online forum, and an anabolic steroid user kindly read and commented on the article. It was clear there was a range of knowledge and experience of users: some believed that “steroids” were all the same and that the corticosteroids regularly prescribed by doctors for conditions such as asthma were what they were using, while others were knowledgeable and sensible about managing their use as safely as possible.

Legal considerations

In the UK, anabolic steroids are a class C drug; a prescription is required to obtain them. Possession and import for personal use is legal, but importing to supply or supplying them is illegal. Most sporting bodies ban anabolic steroid use, although usually only elite competitors are tested.6


  • This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

  • We thank Professor Aseem Majeed, who helped change the original proposal into a 10-minute consultation article; the anabolic steroid user who commented on the article and wished to remain anonymous; and the other anabolic steroid users whose forum comments were used to shape this article.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.


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