Box 1.

Clinical signs of AAS use

Clinical factor	Details
Consumption of nutritional supplements	Many users of AAS will simply refer to their usage by referencing protein shakes, for example.
Increased weight gain and muscular build	Steroid use results in fast gains with significant increases in lean body mass, which contributes to increased muscle mass
Increased appetite	Common with chronic use
Aggression and mood swings	Aggression, hostility, mood swings, and irritability (also known as ‘roid rage’) are possible with chronic use and maybe more common with certain AAS (that is, trenbolone)
Disproportionate muscular development of upper torso	Due to predominance of androgen receptors in upper body (that is, thorax, neck, shoulder, and upper arms)
Testicular atrophy	Common with chronic use
Acne and/or oily skin	Possible with chronic use
Striae or keloids	Possible with chronic use
Changes in libido/impotence and infertility	Despite supra-physiological circulating levels of testosterone, suppression of testicular testosterone production results in infertility (reduction in sperm count). Fluctuating hormone levels and raised oestradiol can lead to erectile dysfunction
Cognitive changes	Includes confusion, forgetfulness, and distractibility. Depression and anxiety can develop on cessation of AAS. Steroid use may uncover a narcissistic personality
Gynaecomastia	Possible with acute/chronic use
Enlarged prostate	Possible with chronic use
Muscle and joint issues	Rapid muscle growth and development may lead to musculoskeletal strain. Gout, avascular necrosis, disc herniations, and knee (ligament/meniscal) and elbow injuries are common

AAS = androgenic anabolic steroids.