N A T I O N A L I N S T I T U T E O N D R U G A B U S E
ResearchReport
S E R I E S
Since the 1950s, some athletes
have been taking anabolic steroids
to build muscle and boost their
athletic performance. Increasingly,
other segments of the population
also have been taking these com-
pounds. The Monitoring the Future
study, which is an annual survey
of drug abuse among adolescents
across the country, showed a signifi-
cant increase from 1998 to 1999 in
steroid abuse among middle school
students. During the same year,
the percentage of 12th-graders who
believed that taking these drugs
steroids will be used through-
causes  great risk to health, de- What are
out this report because of its
clined from 68 percent to 62 percent.
anabolic steroids?
Studies show that, over time,
familiarity, although the proper
anabolic steroids can indeed take a
term for these compounds is
nabolic steroids is the
heavy toll on a person s health. The
 anabolic-androgenic steroids.

abuse of oral or injectable steroids
familiar name for synthetic
is associated with higher risks for
Anabolic steroids were devel-
Asubstances related to the
heart attacks and strokes, and the
oped in the late 1930s primarily
male sex hormones (androgens).
abuse of most oral steroids is associ-
to treat hypogonadism, a condi-
They promote the growth of
ated with increased risk for liver
problems. Steroid abusers who share tion in which the testes do not
skeletal muscle (anabolic effects)
needles or use nonsterile techniques
produce sufficient testosterone
and the development of male
when they inject steroids are at risk
for normal growth, development,
sexual characteristics (androgenic
for contracting dangerous infec-
tions, such as HIV/AIDS, hepatitis B effects), and also have some and sexual functioning. The
and C, and bacterial endocarditis.
other effects. The term  anabolic primary medical uses of these
Anabolic steroid abuse can also
cause undesirable body changes.
These include breast development
From 1998 to 1999, the Monitoring the Future Survey
and genital shrinking in men,
masculinization of the body in reported an increase in lifetime use of steroids
women, and acne and hair loss
among 10th-graders and a decrease in perceived risk
in both sexes.
of harm among seniors.
These and other effects of steroid
abuse are discussed in this Research
Report, which is one of a series of
Lifetime Use Perceived Risk of Harm
reports on drugs of abuse. NIDA (10th-Graders) (Seniors)
produces this series to increase
4% 70%
understanding of drug abuse and
68%
addiction and the health effects
62%
associated with taking drugs.
50
We hope that this compilation of
2.7%
scientific information on anabolic
2
30
steroids will help the public recog- 2%
nize the risks of steroid abuse.
Alan I. Leshner, Ph.D.
Director 0 0
1998 1999 1998 1999
National Institute on Drug Abuse
U. S. De p a r t me n t o f He a l t h a n d Hu ma n Se r v i c e s Na t i o n a l I n s t i t u t e s o f He a l t h
"
from the director
2NIDA RESEARCH REPORT SERIES
compounds are to treat delayed
puberty, some types of impo-
Commonly Abused Steroids
tence, and wasting of the body
caused by HIV infection or other
diseases. Oral Steroids Injectable Steroids
During the 1930s, scientists
Anadrol Deca-Durabolin
discovered that anabolic steroids
(oxymetholone) (nandrolone
could facilitate the growth of
decanoate)
skeletal muscle in laboratory Oxandrin
Durabolin
animals, which led to use of the (oxandrolone)
(nandrolone
compounds first by bodybuilders
Dianabol
phenpropionate)
and weightlifters and then by
(methandrostenolone)
athletes in other sports. Steroid
Depo-Testosterone
abuse has become so wide-
Winstrol
(testosterone
spread in athletics that it affects
(stanozolol)
cypionate)
the outcome of sports contests.
Equipoise
More than 100 different
(boldenone
anabolic steroids have been
undecylenate)
developed, but they require a
prescription to be used legally
in the United States. Most
Whether such conversion pro- middle and high schools across
steroids that are used illegally
duces sufficient quantities of the United States, estimated
are smuggled in from other
testosterone to promote muscle that 2.7 percent of 8th- and
countries, illegally diverted from
growth or whether the supple- 10th-graders and 2.9 percent of
U.S. pharmacies, or synthesized
ments themselves promote mus- 12th-graders had taken anabolic
in clandestine laboratories.
cle growth is unknown. Little is steroids at least once in their
known about the side effects of lives. For 10th-graders, that is a
steroidal supplements, but if significant increase from 1998,
What are steroidal
large quantities of these com- when 2.0 percent of 10th-graders
supplements?
pounds substantially increase said they had taken anabolic
n the United States, supple- testosterone levels in the body, steroids at least once. For all
ments such as dehydroepian- they also are likely to produce three grades, the 1999 levels rep-
Idrosterone (DHEA) and
the same side effects as anabolic resent a significant increase from
androstenedione (street name
steroids. 1991, the first year that data on
Andro) can be purchased legally
steroid abuse were collected from
without a prescription through
the younger students. In that
What is the
many commercial sources includ- year, 1.9 percent of 8th-graders,
scope of steroid
ing health food stores. They are 1.8 percent of 10th-graders, and
often referred to as dietary sup- 2.1 percent of 12th-graders
abuse in the
plements, although they are not reported that they had taken
United States?
food products. They are often anabolic steroids at least once.
taken because the user believes ecent evidence suggests Few data exist on the extent
they have anabolic effects. that steroid abuse among of steroid abuse by adults. It has
Steroidal supplements can be Radolescents is on the rise. been estimated that hundreds of
converted into testosterone (an The 1999 Monitoring the Future thousands of people aged 18 and
important male sex hormone) or study, a NIDA-funded survey of older abuse anabolic steroids at
a similar compound in the body. drug abuse among adolescents in least once a year.
NIDA RESEARCH REPORT SERIES3
Among both adolescents and tion think that they look small stronger would discourage fur-
adults, steroid abuse is higher and weak, even if they are large ther attacks because men would
and muscular. Similarly, women find them either intimidating or
among males than females.
However, steroid abuse is grow- with the syndrome think that unattractive.
they look fat and flabby, even Finally, some adolescents
ing most rapidly among young
though they are actually lean and
abuse steroids as part of a pat-
women.
muscular.
tern of high-risk behaviors. These
Some people who abuse
adolescents also take risks such
Why do people
steroids to boost muscle size
as drinking and driving, carrying
abuse anabolic
have experienced physical or
a gun, not wearing a helmet on
sexual abuse. They are trying to
a motorcycle, and abusing other
steroids?
increase their muscle size to pro-
illicit drugs.
ne of the main reasons
tect themselves. In one series of
While conditions such as
people give for abusing
interviews with male weight-
muscle dysmorphia, a history of
Osteroids is to improve their
lifters, 25 percent who abused
physical or sexual abuse, or a
performance in sports. Among
steroids reported memories of
history of engaging in high-risk
competitive bodybuilders, steroid
childhood physical or sexual
behaviors may increase the risk
abuse has been estimated to be
abuse, compared with none who
of initiating or continuing steroid
very high. Among other athletes,
did not abuse steroids. In a study
abuse, researchers agree that
the incidence of abuse probably
of women weightlifters, twice as
most steroid abusers are psycho-
varies depending on the specific
many of those who had been
logically normal when they start
sport. raped reported using anabolic
abusing the drugs.
Another reason people give steroids and/or another purport-
for taking steroids is to increase ed muscle-building drug, com-
their muscle size and/or reduce pared to those who had not How are anabolic
their body fat. This group been raped. Moreover, almost
steroids used?
includes some people who have all of those who had been raped
ome anabolic steroids are
a behavioral syndrome (muscle reported that they markedly
dysmorphia) in which a person increased their bodybuilding taken orally, others are
has a distorted image of his or activities after the attack. They Sinjected intramuscularly, and
her body. Men with this condi- believed that being bigger and still others are provided in gels
Lifetime Use of Steroids: 8th-Graders, 10th-Graders, and Seniors (1991-1999)
3.0%
8th Grade
10th Grade
2.5
12th Grade
2.0
1.5
1.0
0.5
0
1991 1992 1993 1994 1995 1996 1997 1998 1999
Percentage Who Ever Used Steroids
4NIDA RESEARCH REPORT SERIES
or creams that are rubbed on
the skin. Doses taken by abusers
can be 10 to 100 times higher
than the doses used for medical
conditions.
Steroid abusers typically
 stack the drugs, meaning that
they take two or more different
anabolic steroids, mixing oral
and/or injectable types and
sometimes even including com-
pounds that are designed for
veterinary use. Abusers think that
the different steroids interact to
produce an effect on muscle size
that is greater than the effects
of each drug individually, a
theory that has not been tested
scientifically.
Often, steroid abusers also
effects ranging from some that
Hormonal system
 pyramid their doses in cycles
are physically unattractive, such
Steroid abuse disrupts the normal
of 6 to 12 weeks. At the begin-
as acne and breast development
production of hormones in the
ning of a cycle, the person starts
in men, to others that are life
body, causing both reversible
with low doses of the drugs
threatening, such as heart attacks
and irreversible changes.
being stacked and then slowly
and liver cancer. Most are
Changes that can be reversed
increases the doses. In the sec-
reversible if the abuser stops
include reduced sperm produc-
ond half of the cycle, the doses
taking the drugs, but some are
are slowly decreased to zero. tion and shrinking of the testicles
permanent.
This is sometimes followed by (testicular atrophy). Irreversible
Most data on the long-term
a second cycle in which the
changes include male-pattern
person continues to train but effects of anabolic steroids
baldness and breast development
without drugs. Abusers believe on humans come from case
(gynecomastia). In one study of
that pyramiding allows the body
reports rather than formal epi-
male bodybuilders, more than
time to adjust to the high doses
demiological studies. From the
half had testicular atrophy, and
and the drug-free cycle allows
case reports, the incidence of
more than half had gynecomastia.
the body s hormonal system time
life-threatening effects appears
Gynecomastia is thought to
to recuperate. As with stacking,
to be low, but serious adverse
occur due to the disruption of
the perceived benefits of pyra-
effects may be under-recognized
normal hormone balance.
miding and cycling have not
or under-reported. Data from
In the female body, anabolic
been substantiated scientifically.
animal studies seem to support
steroids cause masculinization.
this possibility. One study found
Breast size and body fat decrease,
What are
that exposing male mice for the skin becomes coarse, the
the health one-fifth of their lifespan to clitoris enlarges, and the voice
steroid doses comparable to deepens. Women may experi-
consequences of
those taken by human athletes ence excessive growth of body
steroid abuse?
caused a high percentage of hair but lose scalp hair. With
premature deaths. continued administration of
nabolic steroid abuse has
steroids, some of these effects
been associated with a
are irreversible.
Awide range of adverse side
NIDA RESEARCH REPORT SERIES5
Musculoskeletal system Liver
Possible Health
Rising levels of testosterone and Steroid abuse has been associat-
Consequences of
other sex hormones normally
ed with liver tumors and a rare
trigger the growth spurt that
condition called peliosis hepatis, Anabolic Steroid Abuse
occurs during puberty and ado- in which blood-filled cysts form
lescence. Subsequently, when
in the liver. Both the tumors and
Hormonal system
these hormones reach certain
the cysts sometimes rupture,
men
levels, they signal the bones to
causing internal bleeding.
stop growing, locking a person " infertility
into his or her maximum height.
" breast development
Skin
When a child or adolescent takes
" shrinking of the
Steroid abuse can cause acne,
anabolic steroids, the resulting
testicles
cysts, and oily hair and skin.
artificially high sex hormone
women
levels can signal the bones to
" enlargement of
Infection
stop growing sooner than they
the clitoris
Many abusers who inject ana-
normally would have done.
" excessive growth
bolic steroids use nonsterile
of body hair
injection techniques or share
Cardiovascular system
both sexes
contaminated needles with
Steroid abuse has been associated
" male-pattern
other abusers. In addition, some
with cardiovascular diseases
baldness
steroid preparations are manu-
(CVD), including heart attacks
factured illegally under non-
and strokes, even in athletes
Musculoskeletal system
sterile conditions. These factors
younger than 30. Steroids con-
short stature
put abusers at risk for acquiring
tribute to the development of
tendon rupture
life-threatening viral infections,
CVD, partly by changing the
such as HIV and hepatitis B
levels of lipoproteins that carry
Cardiovascular system
and C. Abusers also can develop
cholesterol in the blood. Steroids,
heart attacks
infective endocarditis, a bacterial
particularly the oral types, in-
enlargement of the
illness that causes a potentially
crease the level of low-density
heart s left ventricle
fatal inflammation of the inner
lipoprotein (LDL) and decrease
lining of the heart. Bacterial
the level of high-density lipopro-
Liver
infections also can cause
tein (HDL). High LDL and low
cancer
pain and abscess formation
HDL levels increase the risk of
peliosis hepatis
at injection sites.
atherosclerosis, a condition in
which fatty substances are
Skin
deposited inside arteries and
acne and cysts
What effects
disrupt blood flow. If blood is
oily scalp
do anabolic
prevented from reaching the
heart, the result can be a heart
steroids have
Infection
attack. If blood is prevented from
HIV/AIDS
on behavior?
reaching the brain, the result can
hepatitis
be a stroke.
ase reports and small
Steroids also increase the risk
studies indicate that anabolic
Psychiatric effects
that blood clots will form in
Csteroids, particularly in high
homicidal rage
blood vessels, potentially dis-
doses, increase irritability and
mania
rupting blood flow and damag-
aggression. Some steroid abusers
delusions
ing the heart muscle so that it
report that they have committed
does not pump blood effectively.
6NIDA RESEARCH REPORT SERIES
brain but because high steroid doses to volunteers,
the abusers have a minority of the volunteers
been affected developed behavioral symptoms
by extensive
that were so extreme as to dis-
media attention
rupt their ability to function in
to the link
their jobs or in society. In a few
between steroids
cases, the volunteers behavior
and aggression.
presented a threat to themselves
According to
and others.
this theory, the
In summary, the extent to
abusers are using
which steroid abuse contributes
this possible link
to violence and behavioral
as an excuse to
disorders is unknown. As with
commit aggres-
the health complications of
sive acts and
steroid abuse, the prevalence of
property crimes.
extreme cases of violence and
One way
behavioral disorders seems to be
to distinguish
low, but it may be underreported
between these
or underrecognized.
two possibilities
is to administer
Are anabolic
either high
steroids addictive?
steroid doses
or placebo for
n undetermined percentage
days or weeks
of steroid abusers become
to human volun-
Aaddicted to the drugs, as
teers and then
evidenced by their continuing to
ask the people to
take steroids in spite of physical
aggressive acts, such as physical
report on their behavioral symp-
problems, negative effects on
fighting, committing armed rob- toms. To date, four such studies
social relations, or nervousness
bery, or using force to obtain have been conducted. In three,
and irritability. Also, they spend
something. Some abusers also high steroid doses did produce
large amounts of time and
report that they have committed greater feelings of irritability and
money obtaining the drugs and
aggression than did placebo;
property crimes, such as stealing
experience withdrawal symptoms
but in one study, the drugs did
from a store, damaging or
such as mood swings, fatigue,
not have that effect. One possi-
destroying others property, or
restlessness, loss of appetite,
ble explanation, according to
breaking into a house or a build- insomnia, reduced sex drive, and
researchers, is that some but
ing. Abusers who have commit- the desire to take more steroids.
not all anabolic steroids increase
ted aggressive acts or property The most dangerous of the with-
irritability and aggression.
crimes generally report that they drawal symptoms is depression,
Anabolic steroids have been
engage in these behaviors more because it sometimes leads to
reported also to cause other
often when they take steroids suicide attempts. Untreated,
behavioral effects, including
some depressive symptoms
than when they are drug-free.
euphoria, increased energy,
associated with anabolic steroid
Some researchers have sug-
sexual arousal, mood swings,
withdrawal have been known
gested that steroid abusers may
distractibility, forgetfulness, and
to persist for a year or more
commit aggressive acts and
confusion. In the studies in
after the abuser stops taking
property crimes not because of
which researchers administered
the drugs.
steroids direct effects on the
NIDA RESEARCH REPORT SERIES7
offers of drugs. They also discuss antidepressants to treat depres-
What can be
how strength training and proper sion, and analgesics for head-
done to prevent
nutrition can help adolescents aches and muscle and joint pains.
build their bodies without the Some patients require assis-
steroid abuse?
use of steroids. Later, special tance beyond simple treatment
arly attempts to prevent
trainers teach the players proper of withdrawal symptoms and are
steroid abuse concentrated
weightlifting techniques. An treated with behavioral therapies.
Eon drug testing and on
ongoing series of studies has
educating students about the
shown that this multicomponent,
Where can I get
drugs adverse effects. A few
team-centered approach reduces
further scientific
school districts test for abuse of
new steroid abuse by 50 percent.
illicit drugs, including steroids,
A program designed for adoles-
information about
and studies are currently under
cent girls on sports teams,
steroid abuse?
way to determine whether such
patterned after the program
testing reduces drug abuse.
designed for boys, is currently act sheets on anabolic
Research on steroid educational
being tested. steroids, other illicit drugs,
programs has shown that simply
Fand related topics can be
teaching students about steroids
ordered free, in English and
What treatments
adverse effects does not con-
Spanish, by calling NIDA
are effective for
vince adolescents that they
Infofax at 1-888-NIH-NIDA
personally can be adversely
(1-888-644-6432) or, for those
anabolic steroid
affected. Nor does such instruc-
with hearing impairment,
abuse?
tion discourage young people
1-888-TTY-NIDA (1-888-889-6432).
from taking steroids in the
ew studies of treatments for Information on steroid abuse
future. Presenting both the risks
anabolic steroid abuse have also can be accessed through
and benefits of anabolic steroid
Fbeen conducted. Current the NIDA Steroid Abuse Web
use is more effective in convinc- knowledge is based largely on Site (www.steroidabuse.org).
ing adolescents about steroids
the experiences of a small num- Information on illicit drugs
negative effects, apparently ber of physicians who have in general can be accessed
because the students find a bal- worked with patients undergoing through NIDA s home page
anced approach more credible steroid withdrawal. The physi- (www.drugabuse.gov) or
and less biased, according to cians have found that supportive by contacting the National
the researchers. However, the therapy is sufficient in some Clearinghouse for Alcohol
balanced approach still does cases. Patients are educated and Drug Information (NCADI)
not discourage adolescents from about what they may experience Web Site (www.health.org).
abusing steroids. during withdrawal and are
A more sophisticated approach evaluated for suicidal thoughts.
has shown promise for prevent- If symptoms are severe or
NIDA Web Sites
ing steroid abuse among players prolonged, medications or
www.drugabuse.gov
on high school sports teams. In hospitalization may be needed.
www.steroidabuse.org
the ATLAS program, developed Some medications that have
for male football players, coach- been used for treating steroid
NCADI
es and team leaders discuss the withdrawal restore the hormonal
Web Site: www.health.org
potential effects of anabolic system after its disruption by
Phone No.: 1-800-729-6686
steroids and other illicit drugs on steroid abuse. Other medications
immediate sports performance, target specific withdrawal
and they teach how to refuse symptoms for example,
8NIDA RESEARCH REPORT SERIES
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Revised April 2000
or stopped. Feel free to reprint this publication.