The health risks of anabolic steroids: what the evidence says

Anabolic steroid use is more common than most people assume, and its risks are better studied than the internet suggests. This article sets out what health authorities and the strongest published studies say about those risks, in plain terms and with every figure linked to its source. It is not a guide to using steroids, and it contains nothing about doses or cycles. If you are using or thinking about using them, the most useful thing in it is the last section.

How many people use them

A 2014 meta-analysis of 187 studies estimated a global lifetime prevalence of anabolic steroid use of 3.3%. The figure was 6.4% for men and 1.6% for women.^[9] It is not a rare behaviour, which is part of why the health evidence below matters.

What health authorities say

The US National Institute on Drug Abuse (NIDA) states that steroid misuse can lead to "early heart attacks, strokes, liver tumors, kidney failure, and psychiatric problems".^[1] The NHS lists heart attack or stroke, liver or kidney problems or failure, high blood pressure, deep vein thrombosis, fluid retention and high cholesterol among the risks for both men and women.^[2]

In 2014 the Endocrine Society published a scientific statement reviewing the evidence on performance-enhancing drugs. It concluded that their use "has been linked to an increased risk of death and a wide variety of cardiovascular, psychiatric, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders".^[3]

The heart

The heart is where the evidence is most concerning, because the harm can build without symptoms.

A 2017 study in Circulation compared 140 experienced male weightlifters aged 34 to 54: 86 who had used steroids for at least two years and 54 who had not.^[4]

The authors concluded that long-term use "appears to be associated with myocardial dysfunction and accelerated coronary atherosclerosis": a weaker heart muscle, and arteries furring up earlier than they should.^[4] NIDA's list of cardiovascular effects includes high blood pressure, blood clots, heart attack, stroke and artery damage.^[1]

Mortality and illness over time

The most direct evidence on long-term outcomes comes from Denmark. A 2019 study followed 545 men who had tested positive for anabolic steroids in gym testing programmes and compared them with 5,450 men who had not.^[5]

• Mortality was three times higher among users (hazard ratio 3.0).^[5]
• Users had more than twice as many hospital contacts per year: a median of 0.81, against 0.36.^[5]
• Acne, breast tissue growth in men (gynaecomastia) and erectile dysfunction each affected more than 10% of users.^[5]

These are observational findings. Users and non-users differ in other ways too, so the study shows a strong association rather than proving every excess death was caused by steroids. It is still the kind of association that should be taken seriously.

Hormones and fertility

Anabolic steroids suppress the body's own hormone production. In men, NIDA lists decreased sperm production, shrinking of the testicles, enlarged breasts and male-pattern baldness.^[1] Some changes, including male-pattern baldness and breast development in men, can be irreversible.^[1] In women, NIDA lists a deepening voice, decreased breast size, coarse skin and excessive body hair growth.^[1]

The Dutch HAARLEM study followed men who were about to begin using steroids, through their course and for a year afterwards. Testosterone levels generally returned to normal within three months of stopping, but sperm production took around a year to recover. Recovery was not universal: at the end of follow-up, 11% still had low testosterone and 34% still had a low sperm count.^[7] The Endocrine Society notes that some people "may never regain normal testosterone levels".^[3]

Mental health and dependence

NIDA lists aggression, mania and delusions among the psychiatric effects.^[1] Dependence is common. The Endocrine Society estimates that "about 30% of AAS users may develop AAS dependence", with a pooled estimate from ten studies of 32.5%.^[3]

Stopping carries its own risk. NIDA describes withdrawal symptoms including fatigue, restlessness, loss of appetite, insomnia, reduced sex drive and cravings, and warns that "the most dangerous of the withdrawal symptoms is depression, because it sometimes leads to suicide attempts".^[1]

Injecting and infection

Injecting brings risks of its own. The NHS lists damage to veins leading to ulcers or gangrene, hepatitis B, hepatitis C and HIV.^[2] A UK survey of 395 men who inject image and performance enhancing drugs found that 1.5% had HIV, 9% had antibodies showing past hepatitis B infection and 5% had antibodies to hepatitis C. HIV prevalence was similar to that among people who inject psychoactive drugs.^[8] FRANK, the UK's drug information service, warns that sharing needles, syringes and other equipment can spread HIV, hepatitis C and other infections.^[10]

What one year looks like

The same study group reported on the health effects of 100 men over that year. Every participant reported at least one negative health effect. Four had serious adverse events: congestive heart failure, acute pancreatitis, suicidal thoughts and a flare of ulcerative colitis.^[6] For most of the effects the study measured, prevalence had returned to baseline after a year of follow-up.^[6] That recovery is reassuring as far as it goes, but the heart and mortality studies above describe what happens with longer use.

Getting help and getting checked

The NHS advises seeing a GP if you think you are addicted to anabolic steroids, and says a GP may refer you to a specially trained drugs counsellor.^[2] Telling a doctor what you take is the only way they can check for the things this article describes.

• UK: your GP, or FRANK on 0300 123 6600.^[10]
• United States: SAMHSA's National Helpline, 1-800-662-4357, free and confidential.^[12]
• Australia: the National Alcohol and Other Drug Hotline, 1800 250 015.^[11]

For what the law says about these substances where you live, read anabolic steroids and the law.