The editors and current author would like to thank and acknowledge the significant contribution of the previous author of this chapter from the 2004 first edition, Dr. Robert J. Bidwell. This current third edition chapter is a revision and update of the original author’s work.

A 17-year old male visits for his annual well-teen sports health evaluation. As with all such patients, he is interviewed alone about his physical and psychosocial health and development over the past year. He acknowledges no significant physical illness and feels he is developing appropriately. He reports getting along well with his parents and he is generally a B student at school. He is involved in his school's track team and belongs to a paddling club. He denies any substance use. He is sexually active with his 16-year old girlfriend and reports using condoms consistently. He denies any major mood changes or suicidal ideation. His physical exam is completely normal.

The patient is unaware that his father recently called the clinic, saying he had found pills in his son's room. He believes they may be steroids since he had overheard his son talking with other teammates about someone dealing steroids at school. He requests the physician to bring this up with his son. When steroid use is specifically addressed during the adolescent interview, he admits that he and several of his friends on the track team have been injecting steroids regularly for the past 4 months and they are planning on taking steroid pills in the near future. He believes it has increased his muscle mass and improved his appearance but admits he knows little about the potential side effects of steroid use.

Anabolic steroids, which are synthetic derivatives of testosterone, have legitimate uses in the treatment of male hypogonadism, chronic illness, and other starvation or catabolic states. However, they also belong to a group of drugs known as performance enhancing drugs (PEDs) (1). Their first use among athletes was in the early 1950s, most notably among male and female Soviet athletes competing internationally. The anabolic (tissue-building) effects of these steroids are attributed to their binding to specific cellular receptors resulting in increased protein synthesis (2,3). In addition, they have an anti-catabolic effect by competitively binding to glucocorticoid receptors (2,3). The net result is increased lean body mass (muscle) as well as increased muscle strength, especially if accompanied by a rigorous exercise regimen and adequate diet. These, in turn, are thought to result in enhanced athletic performance, though there is little data to support significant gains over those undergoing the natural puberty process and utilizing proper nutrition and training regimens (1,3). Anabolic steroids may not improve and can actually limit aerobic capacity, agility and athletic skill. Some male adolescents take anabolic steroids not to enhance athletic performance but to improve their physical appearance through increased muscle mass and definition, a problem exacerbated by appearance-focused social media (3,4). Other PEDs include human growth hormone (hGH), stimulants, diuretics and a variety of protein, vitamin and mineral supplements (1). Blood doping (intravenous infusion of blood) is another technique used by athletes to improve performance (1).

The demographic of anabolic steroid use is typically a heterosexual male in their late 20s to early 30s (4). Anabolic steroid use in adolescents appears to increase with age and shows a prevalence rate of 1% to 12% for males and 0.5% to 3% for females (1,2,5). The highest rates of use are in male athletes in football, wrestling, and weight lifting (1).

Anabolic steroids and their prohormones are classified as Schedule III drugs, therefore possession or use without a physician’s prescription is prohibited by state and federal laws (3). Despite this, anabolic steroids are not difficult to obtain, even for high school students. Sources of the drug have been cited as friends, coaches, veterinarians, physicians, or on deceptive supplement and nutrition websites. Anabolic steroids can be purchased over the counter in many foreign countries and brought back into the U.S. for distribution. Anabolic steroids generally come in oral pills or liquid preparations intended for intramuscular injection. Often both routes are employed simultaneously with more than one drug, a process known as stacking, blending, or shotgunning (6). Another pattern of use is megadosing, with doses up to forty times greater than therapeutic doses. Pyramiding is a third technique in which doses are increased then decreased on a cyclic basis (6). Plateauing refers to when a drug becomes ineffective at a particular level, prompting switching to another drug (6).

Steroid use is associated with harmful side effects in many organ systems (see Table 1 below). These primarily relate to effects on growth and the endocrine and hepatic systems (2). Despite increased strength, anabolic steroids may cause dysplastic collagen that can increase the risk of strains and sprains (2,6). Additionally, anabolic steroids may cause premature epiphyseal plate closure despite initial acceleration of bony growth (2,7). Exogenous steroids provide feedback inhibition on luteinizing and follicle-stimulating hormone, causing testicular atrophy and possible infertility (7,8). The excess steroids also undergo conversion to estrogen, which can then lead to male gynecomastia (7,8). The liver is most susceptible to oral preparations, and common adverse effects include cholestasis and increases in liver enzymes (2,7,8). Steroid abuse has also been linked to rarer events such as peliosis hepatis (hepatic capillary proliferation resulting in cystic blood filled cavities) and hepatocellular carcinoma (2,7). Anabolic steroids can also have serious effects on a patient's psychological state, typified by violent mood swings, mania, and aggression colloquially termed "roid rage" (4,7). 25% to 33% of users who inject steroids have shared needles, raising the concern for hepatitis B, hepatitis C, and HIV (2,4). Studies have also shown that anabolic steroid users are also more likely to use other drugs, therefore early intervention of the adolescent athlete is critical (3-5). Because anabolic steroid use can have multisystemic effects as described above, the differential diagnosis would at first appear to be a lengthy one. However, a history of athletic involvement in sports where muscle mass is important coupled with an unusual degree of muscle development should narrow the differential diagnosis. Testosterone-producing tumors may have masculinizing effects on both males and females, but usually result in muscle-wasting and other signs of chronic illness (9).

Table 1. Negative effects of anabolic steroid use (7).

Musculoskeletal	Premature epiphyseal closure, short stature, ligament and tendon injuries
Hepatic	Benign and malignant tumors, toxic hepatitis, peliosis hepatis, decreased HDL (high density lipoprotein) cholesterol, increased LDL (low density lipoprotein) cholesterol, and increased total cholesterol
Cardiovascular	Hypertension, stroke, thrombosis
Male reproductive	Decreased testosterone production, decreased testicular size, impotence, enlarged prostate
Female reproductive	Breast atrophy, clitoromegaly, menstrual changes, teratogenicity
Psychological	Severe anger outbursts, hallucinations, paranoia, anxiety, addiction
Other	Deepened voice, acne, alopecia

Once an adolescent who is using anabolic steroids has been identified, the pediatrician assumes the role of educator and counselor. Traditional drug treatment programs do not treat youths using anabolic steroids unless this use is part of a broader spectrum of substance use. Guidelines for the approach to the adolescent using anabolic steroids have been established by the American Academy of Pediatrics (3). In general, counseling should be provided in a confidential and non-judgmental manner. It is appropriate to acknowledge to the patient that anabolic steroids may, in fact, lead to increased muscle mass and strength. It is also appropriate to express an understanding of why athletes and others might want to increase muscle mass, strength and definition. This honest discussion of the benefits of steroid use must then be balanced with an honest review of the risks of harm. Simply citing the negative effects is both dishonest and diminishes the physician's credibility in the adolescent's eyes. There is no evidence that scare tactics work in diminishing steroid use since the drive to excel athletically is so strong.

Pediatricians also have a role in prevention. At the individual patient level, screening questions and anticipatory guidance regarding anabolic steroid use should be a part of each well-teen visit. Adolescents who present with signs or symptoms suggestive of steroid use, even if not related to the presenting complaint, should be asked specifically about the possibility of anabolic steroid use at acute care visits. Adolescents can be counseled about alternatives for improving their strength and appearance through healthier diets and appropriate physical training (3). Discussions about the concept of fair competition and the satisfaction coming from relying on one's natural abilities and hard work are reasonable but will be counterproductive if they sound like lecturing. At a community level, pediatricians can educate parents, schools and coaches about the prevalence and risks of anabolic steroid use among students. Drug screening programs at a school or team level are impractical and expensive.

Questions
1. True/False: Anabolic steroid use can be effective in enhancing athletic performance.
2. Name the two most common routes of anabolic steroid administration. Which is the more hepatotoxic route?
3. What is the growth consequence of adolescents using anabolic steroids?
4. In which patients should pediatricians consider the possibility of anabolic steroid use?
5. What is the role of the pediatrician in addressing anabolic steroid use?

References
1. White ND, Noeun J. Performance-Enhancing Drug Use in Adolescence. Am J Lifestyle Med. 2016;11(2):122-124. doi:10.1177/1559827616680593
2. Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes. Pediatrics. 2006;117(3):e577-589. doi:10.1542/peds.2005-1429
3. LaBotz M, Griesemer BA, Council on Sports Medicine and Fitness, et al. Use of Performance-Enhancing Substances. Pediatrics. 2016;138(1):e20161300. doi:10.1542/peds.2016-1300
4. Mullen C, Whalley BJ, Schifano F, Baker JS. Anabolic androgenic steroid abuse in the United Kingdom: An update. Br J Pharmacol. 2020;177(10):2180-2198. doi:10.1111/bph.14995
5. Schneider KE, Webb L, Boon D, Johnson RM. Adolescent Anabolic-Androgenic Steroid Use in Association With Other Drug Use, Injection Drug Use, and Team Sport Participation. J Child Adolesc Subst Abuse. 2022;0(0):1-6. doi:10.1080/1067828X.2022.2052219
6. Graham MR, Davies B, Grace FM, Kicman A, Baker JS. Anabolic steroid use: patterns of use and detection of doping. Sports Med. 2008;38(6):505-525. doi:10.2165/00007256-200838060-00005
7. Ganesan K, Rahman S, Zito PM. Anabolic Steroids. In: StatPearls. StatPearls Publishing; 2022. Accessed April 2, 2022. http://www.ncbi.nlm.nih.gov/books/NBK482418/
8. Kerr JM, Congeni JA. Anabolic-androgenic steroids: use and abuse in pediatric patients. Pediatr Clin North Am. 2007;54(4):771-785, xii. doi:10.1016/j.pcl.2007.04.010
9. Glintborg D, Altinok ML, Petersen KR, Ravn P. Total testosterone levels are often more than three times elevated in patients with androgen-secreting tumours. BMJ Case Rep. 2015;2015:bcr2014204797. doi:10.1136/bcr-2014-204797

Answers to questions
1. True. One of the reasons it is difficult to dissuade competitive athletes from using anabolic steroids is that it can result in increased lean body mass, muscle strength, and aggressiveness. These may, in fact, contribute to enhanced athletic performance.
2. Anabolic steroids may be taken orally or injected intramuscularly. Oral steroids are more hepatotoxic.
3. An adolescent in early puberty who uses steroids risks premature epiphyseal closure with resultant shorter stature than otherwise would be predicted.
4. Anabolic steroid use should be considered and addressed with all adolescent patients, male or female, athlete or non-athlete. Particular attention should be paid to those adolescents who have greater than expected muscle-mass development or in females with signs of masculinization.
5. On an individual level, pediatricians should, without lecturing, initiate an honest discussion of the risks and benefits of steroid use. They should ask all adolescents, and especially those with signs and symptoms of steroid use, about the possibility of using steroids. They also have a role in educating parents, teachers and coaches about the prevalence and dangers of anabolic steroid use.