Stephen Kishner, MD, MHA; Chief Editor: George T Griffing, MD

Steroids are a general class of agents that all have the steroid ring in common. The steroid ring is comprised of three 6-carbon rings and one 5-carbon ring joined, of which cholesterol is the most basic form and, indeed, the precursor. Although the term steroid includes all agents derived from this ringed structure, this discussion includes only testosterone and the anabolic-androgenic steroids (AASs).

Testosterone is the principle hormone in humans that produces male secondary sex characteristics (androgenic) and is an important hormone in maintaining adequate nitrogen balance, thus aiding in tissue healing and the maintenance of muscle mass (anabolic). Testosterone has a dual action and can be described in terms of its androgenic and anabolic capacities.

AASs are drugs derived from the modification of the testosterone molecule in order to augment or limit certain characteristics of testosterone. In general, testosterone has been altered to produce drugs that are more or less anabolic, are more or less androgenic, have differing affinity for the testosterone receptor, have different metabolic breakdown pathways, or are efficacious for oral use; they can also have any combination of these changes.

Well over a thousand different compounds have been synthesized and studied since the 1950s in the hope of producing compounds that have an anabolic or androgenic effect superior to that of testosterone. Biochemists quickly noted that additions or subtractions to the testosterone molecule at specific locations would have a somewhat predictable effect on the inherent qualities of said compound. Specifically, qualities including (but not limited to) anabolic/androgenic ratio, metabolism, receptor affinity, and oral efficacy were noted.

In general, the goal of altering an AAS is to increase its anabolic characteristics and to decrease its androgenic features, thus multiplying the compound's desirable, anabolic, nitrogen-sparing effects and minimizing its generally undesirable, androgenic, virilizing effects. To date, however, complete dissociation of the anabolic effects of an AAS from its androgenic characteristics has not been possible.

Clinically, AASs have been used to treat a host of conditions, including the following:

Many forms of anemia

Acute and chronic wounds

Protein-calorie malnutrition with associated weight loss

Severe burns

Short stature

Osteoporosis

Primary or secondary hypogonadism

Prolonged catabolic state secondary to long-term use of corticosteroids

Human immunodeficiency virus (HIV) wasting syndrome

Almost since their inception, testosterone and anabolic-androgenic analogues have been used and abused by individuals seeking to augment their anabolic and androgenic potential. By doing so, these persons aim to boost their physical performance in athletic endeavors or improve their physique. Stories of Eastern-bloc athletes receiving testosterone and AASs as part of their training regimens as early as the 1950s abound. The Eastern-bloc weightlifters and track athletes subsequently ruled the athletic stage for decades.

The degree to which AASs affect performance enhancement in healthy athletes is widely debated, as are the precise mechanisms of action. Anecdotal evidence, including increases in strength and lean body mass (LBM), has been reported, but steroid effect is difficult to study in a true placebo-controlled, double-blind fashion. Most athletes would notice testicular atrophy if receiving AASs, which would interfere with a study's double-blind structure. Dosing, nutrition, and training parameters would need to be monitored extensively to completely satisfy the most critical review.

Certainly, the use of AASs has become a worldwide phenomenon, slowly trickling down to collegiate, high school, and even junior high levels.[1] The early assertion from the medical community that "anabolic steroids have not been shown to enhance athletic ability," still in print in the 2002 Physicians Desk Reference, contributed to this phenomenon. Technically, the statement is correct; however, people misusing and abusing these drugs quickly realized that the performance-enhancing effects were real and subsequently dismissed the rest of the medical community's contraindications, dosing recommendations, and warnings