Performance & Image Enhancing Drugs (PIEDs)

Performance and image enhancing drugs (PIEDs) refer to a heterogeneous group of substances used to improve physical performance, muscle mass or appearance. The most widely recognised and used PIEDs are anabolic androgenic steroids (AAS) — synthetic derivatives of testosterone that exert anabolic and androgenic effects.

See also Male hypogonadism — AAS use is an exogenous-androgen cause of HPT axis suppression, and long-term recovery after cessation is an endocrinological issue.

Background and epidemiology

Historically associated with elite sport and bodybuilding, patterns of use now also include recreational gym goers, occupational users, older men seeking perceived anti-ageing benefits, and women using PIEDs for bodybuilding, mood and libido effects.

Prevalence:

• 2.3% of Australian secondary school students have used anabolic steroids.
• Global lifetime use in men is estimated at 6–7%.

Most AAS and other PIEDs used outside clinical settings are non-prescribed and commonly obtained through informal networks, online suppliers or imported products, with uncertain composition creating additional safety concerns. There is some prescribing of PIEDs by some clinics and doctors for non-medical purposes, which is considered illegal and inappropriate by regulatory authorities.

Common agents and concurrent use

Anabolic androgenic steroids (AAS) are the most widely recognised PIED class; they may be injected or taken orally. Many people who use AAS also use additional substances concurrently, including:

• Ancillary drugs to manage AAS side effects (eg tamoxifen or anastrozole for gynaecomastia).
• Weight-loss or definition agents.
• Peptides and growth-hormone related agents.
• Other products obtained online or through informal networks.

Patterns of use

Patterns of use vary considerably.

• Cycling — periods of AAS use followed by periods of abstinence; thought to help preserve the HPT axis.
• Blast and cruise — prolonged exposure with alternating higher and lower doses without full cessation.

Both strategies lack evidence. Continuous use patterns might result in greater cumulative dosing and prolonged suppression of endogenous testosterone production, with different implications for endocrine suppression, cardiovascular risk and psychological effects.

Take a detailed substance-use history covering which agents are used, doses, duration, route (oral, intramuscular or subcutaneous injection), stacking, ancillary drugs and any previous adverse effects.

Health risks of AAS

Known adverse effects include:

• Cardiovascular: hypertension, cardiomyopathy and dyslipidaemia, conduction abnormalities.
• Haematological: polycythaemia, leading to thrombosis, stroke or myocardial infarction.
• Hepatic: hepatic inflammation and hepatic failure (particularly with oral androgens).
• Endocrine and reproductive: HPT axis suppression (hypogonadism from withdrawal), infertility (sometimes irreversible) and gynaecomastia.
• Renal: secondary renal failure.
• Psychiatric: mood disorders (eg depression, mania, hypomania), aggression, insomnia and AAS dependence.
• Other: local infection and blood-borne virus risk, tendon rupture, acne and balding, benign prostatic hyperplasia, sleep-disordered breathing.

Peptides and novel agents

Peptides are short chains of amino acids that influence biological processes such as hormone signalling, metabolism and tissue repair. They are increasingly marketed for goals such as muscle growth, fat loss, recovery from injury, anti-ageing, tanning or “health optimisation”.

Many of these substances have limited clinical evidence and have not undergone the rigorous testing required for approved medicines. A harm reduction approach involves creating opportunities for patients to discuss peptide use openly as well as providing education about potential risks, product uncertainty and safer injecting practices.

Other agents encountered include selective androgen receptor modulators (SARMs) marketed as AAS alternatives with fewer side effects — a claim lacking empirical evidence — and weight-loss agents including GLP-1 receptor agonists, which are increasingly used off-label.

Engaging patients without judgement

People who use PIEDs rarely disclose use spontaneously during clinical consultations. This reluctance might reflect previous negative experiences with healthcare providers, concerns about stigma or fears about legal consequences.

Ask directly but non-judgementally:

• Incorporate screening questions into routine lifestyle or substance use histories.
• Consider asking when clinical indicators are present, such as hypertension, dyslipidaemia, abnormal liver function tests, polycythaemia or requests for hormone testing.
• Explain the reason for the enquiry, emphasising that the purpose is to support health monitoring rather than to judge or discourage patients from seeking care.
• Normalise the discussion (eg by asking about supplements, gym training practices and performance enhancing substances alongside other lifestyle factors) to reduce stigma and increase the likelihood of disclosure.

Women might present with some of the adverse effects of PIED use, so do not limit screening to male patients.

Baseline investigations and monitoring

Table 4 of the AJGP article suggests the following investigations:

• Hormones: testosterone (serum), SHBG, LH — useful for tracking recovery after cessation, less useful while still using.
• Cholesterol profile (HDL, LDL, triglycerides).
• FBC (haemoglobin, haematocrit — polycythaemia risk).
• Urea, electrolytes or cystatin-C.
• Liver function tests (ALT, AST, ALP, LDH, GGT).
• Semen analysis if fertility is a concern — normal sperm counts lag behind testosterone recovery.
• ECG ± echocardiogram (left ventricular hypertrophy or cardiomyopathy).
• Hepatitis B/C and HIV testing based on injecting and sexual risk.
• PSA — testosterone might stimulate prostate cancer growth.
• Fasting glucose or HbA1c if GH use is suspected.
• Pregnancy test in women — AAS might affect the fetus, and use should stop immediately if positive.

Harm reduction counselling

Harm reduction strategies minimise the health risks associated with AAS and other PIED use without requiring immediate cessation.

For people considering starting AAS or other PIEDs, discussing potential adverse effects might discourage initiation. For those already using, this approach can lead to meaningful behaviour change, including improved health monitoring, treatment of adverse effects and modifications to patterns of use.

For people who continue to use, harm reduction strategies include regular health monitoring; management of emerging adverse effects; cardiovascular risk assessment and advice; safer injecting education and reducing blood-borne virus transmission risk (injecting and sexual).

Motivational interviewing using the FRAMES approach (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) is useful in encouraging behaviour change in the long term. Clarify that harm reduction does not involve prescribing medications solely to support non-medical PIED use — it is about monitoring health and managing complications when they arise.

Withdrawal and recovery

Stopping AAS use should be encouraged, but might result in androgen induced hypogonadism, characterised by fatigue, reduced libido, depression, and signs of loss of muscle mass and testicular atrophy. These symptoms take several months to recover, and discussion with patients helps manage expectations, reducing the risk of relapse.

Some people use “post-cycle therapy” (eg HCG, clomiphene) to stimulate endogenous testosterone production after stopping AAS. Limited observational evidence suggests these might alleviate some withdrawal-related symptoms, but robust clinical evidence of effectiveness and safety is lacking, and the substances used might carry additional health risks outside a medical setting.

If endogenous testosterone production does not recover or menses does not resume after 3 to 6 months, referral to an endocrinologist with experience managing AAS-related complications might be appropriate. Relapse is common, and ongoing GP support with longitudinal care is important. There are currently no guidelines available for management of AAS withdrawal.

When to refer

Referral to other health professionals is encouraged once trust is gained, including:

• Endocrinology — for non-recovery of the HPT axis or menses.
• Mental health — for psychiatric complications or dependence.
• Cardiology and sleep physicians — as indicated.

Legal context (Australia)

Legislation regarding possession and supply of AAS and other PIEDs varies between Australian jurisdictions. While trafficking offences apply to large quantities, there is currently no mandatory reporting requirement for PIED use, and maintaining patient confidentiality remains essential to effective clinical engagement.