Consider common reasons for presentation – a patient may present:

• • Requesting to be monitored and tested because they have stopped their non-prescribed AAS use (they may or may not be aware of adverse effects from their use).
  • Requesting for their testosterone levels to be tested because the patient suspects that their levels are low and wants to discuss the option of hormone replacement therapy, especially in older men.
  • Requesting information and advice when already using or when contemplating the use of AAS for non-prescribed reasons, particularly around minimising harms.
  • With adverse effects from their non-prescribed AAS use, including related to their injecting practices (e.g. abscess).
  • With signs or symptoms of AAS withdrawal (e.g. decreased or absent libido, fatigue and low energy), often related to hypogonadism.
  • Presenting with symptoms such as gynaecomastia or severe acne – possibly requesting specific treatments (e.g. tamoxifen or Isotretinoin).

Consider whether the patient may be using non-prescribed AAS or other PIEDs when the patient is:

• • A muscular, toned man – particularly if he presents with infertility, loss of libido, erectile dysfunction, low mood, severe acne, or gynaecomastia.
  • A muscular, toned woman – particularly if she presents with abnormal menstruation, deepening of voice, clitoral enlargement, or increase growth of body hair (hirsutism).
  • Someone whose blood tests show high haemoglobin or other relevant abnormal results, such as high testosterone levels, liver and kidney abnormalities.

Note that not all patients will have evident features of PIED use, for example, older men who will use non-prescribed AAS for anti-aging purposes as opposed to obtaining a muscular physique. It is therefore important to include AAS in general history taking when updating the patient’s alcohol and other drug history in the general adult population.

How to ask about AAS and other enhancement drug use?

• Avoid asking patients directly if they are using non-prescribed AAS or other PIEDs, as there is the risk that patient will be offended. Instead ask about this as part of regular assessment/history taking.

Useful questions:

• As part of a comprehensive assessment a GP could ask:
  • Do you use or take anything to help with your workouts or muscle gain?; or
  • Can you tell me about supplements you are using, including any use of pills, powders or injectables?
• When asking, a GP could note:
  • I am asking this because am interested to see if we need to be checking for any other related health issues.

History – ask about:

• Current and past use of non-prescribed PIEDs:

  • Age of initiation
  • Route of administration
  • Reason for commencement and specific goals;
    • It is important to examine why patients are using and what their relationship is with the substance. There may be underlying issues such as anxiety, depression or lack of body confidence.
  • How long has the patient been using AAS and other PIEDs, what regimen(s) have they used in the past and the duration of the cycles?
  • Current use including duration of cycle and amount.
  • What adverse effects or withdrawal symptoms has the patient experienced during or after a previous cycle of AAS? Particularly check for signs and symptoms that may indicate AAS-induced hypogonadism (see withdrawal section)

• Relevant personal medical history including co-morbidities, and alcohol and other drug use (see background section)

  • Comorbidities – check for pre-existing conditions as well as conditions potentially caused by AAS use (list not exhaustive)
    • Cardiovascular disease including high blood pressure or high cholesterol;
    • Reduced kidney function or liver disease (particularly when patients are using oral AAS);
    • Sexual dysfunction: e.g. heightened or reduced libido
    • Psychiatric:
      • Depression or anxiety (particularly when patient stops using AAS)
      • Body dysmorphic (particularly muscle dysmorphia) and eating disorders may also be present (not common).
      • Psychosis (rare but may occur with prolonged use)
    • Sleeping disturbances (may be caused by disturbances on hypothalamic-pituitary-adrenal axis) – consider using the Sleep Disorders Questionnaire to screen for a sleep disorder
  • Current medications; and
  • Current dietary supplement use.
  • Alcohol and other substance use – people who use AAS may also use other illicit substances like cocaine, cannabis and amphetamines to further enhance training and for relaxation. The use of alcohol and other substances also increases the risk of behaviour and mood disturbances as well as end-organ damage (e.g., heart, liver).

• Family/social history

  • Family history:

• • • Medical history (particularly premature heart disease and prostate cancer[13]);
    • Psychiatric history (particularly check for depression, anxiety and major psychiatric conditions).

• • Social history: e.g. profession, occupation, spare-time activities, relationship status, and checking if the patient wants a family.

Although the majority of adverse effects may be mild or may go unnoticed by the person using these substances[14], all people who use AAS experience some form of adverse effect and some of these may be long-term (even after stopping).

Note: The adverse effects in bold are well recognised in the literature and probably of serious concern.

Check for features of dependence. Consider using the Diagnostic Criteria for Anabolic-Androgenic Steroid Dependence to assess for dependence.

Dependence is defined as the problematic pattern of non-prescribed AAS use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

• Tolerance, as defined by either of the following:
  • A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
  • Markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
  • A characteristic withdrawal syndrome, characterized for AAS by two or more of the following features: depressed mood, prominent fatigue, insomnia or hypersomnia, decreased appetite, and loss of libido.
  • AAS are used to relieve or avoid withdrawal symptoms.
• Using larger amounts or over a longer period than intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent obtaining the substance, using the substance, or recovering from its effects.
• Important social, occupational, or recreational activities are given up or reduced.
• Continued use despite persistent or recurrent physical or psychological problem caused or exacerbated by use.

Check for withdrawal symptoms following cessation of non-prescribed AAS use.

Withdrawal symptoms

• Withdrawal is characterised by psychiatric and neuroendocrine symptoms, with the patient ultimately re-initiating non-prescribed AAS to alleviate or avoid their onset.
• Withdrawal symptoms typically appear upon discontinuation of AAS use due to AAS-induced hypogonadism (deficiency in testosterone), especially if they have used AAS for prolonged periods[15].
  • In some patients these symptoms can also be a result of underlying mental health disorders, such as depression, dependence and/or a body dysmorphic disorder.
• Although hypogonadism may gradually resolve after AAS use is discontinued, in some cases patients will exhibit hypothalamic–pituitary–testicular (HPT) suppression that persists for many months after AAS are discontinued and in some there is the risk that it becomes permanent.
• Common symptoms are:
  • Depressed mood
  • Prominent fatigue
  • Insomnia or hypersomnia
  • Decreased appetite
  • Loss of libido

Physical examination

Conduct a targeted examination based on any signs and symptoms:

• General appearance.
• Height, weight and BMI.
• Chest (gynaecomastia).
• Heart (blood pressure, pulse, signs of heart failure, cardiac murmurs).
• Abdomen/rectal examination (hepatic enlargement, prostatic hypertrophy).
• Urogenital examination (testicular atrophy) and measuring of testes
• Skin/hair (acne, premature baldness, striae/stretch marks).
• Musculoskeletal (musculoskeletal injuries).

Mental health assessment

Check for:

• Depressed mood or other symptoms of depression.
• Symptoms of anxiety.
• Behavioural changes including aggression.
• Sleep patterns.
• Body dysmorphic disorders.

• In case a patient is still on an AAS cycle, it is worth checking their hormone levels 6 weeks after they have stopped their cycle.
• In case a patient has halted their use and hormone levels have not returned to normal, check again in 3 and 6 months.
• In case of ‘blast and cruise’ usage, use should be discouraged but if patient is not willing to halt their use do base-line testing and test again 3 and 6 months to monitor adverse effects.

Please note that most people who use AAS will have abnormal results – this however does not mean that there is any (permanent) damage.

Consider investigations on a case by case basis taking into account presenting signs and symptoms, and risk factors (e.g. co-morbidities, use of injectables):

Use motivational interviewing techniques to assess patient’s motivation and willingness to change. Discuss with the patient if they intend to withdraw or continue using.