PIEDs in your waiting room: a practical guide for GPs and AOD clinicians

Performance and image enhancing drug use has become a routine feature of the Australian clinical landscape. The Kirby Institute's 2024 NSP National Data Report shows anabolic agents accounting for 12% of injecting occasions at needle and syringe programs nationally , the third most common category after stimulants and opioids. Yet most GPs report limited confidence in identifying or managing PIED use, and most patients who use PIEDs don't disclose to their GP.

The gap between prevalence and clinical detection is substantial, and it has health consequences. The Sydney North Health Network's GP Guide to harm minimisation for patients using non-prescribed AAS and other PIEDs , the primary Australian clinical resource in this area, developed by van de Ven, Eu, Jackson, and colleagues , estimates that illicit steroid use may be considerably more widespread among patients than GPs realise.

This article summarises the practical clinical guidance for general practitioners and AOD clinicians encountering PIED-using patients.

Who is using and why

The PIED-using population presenting to Australian primary care is predominantly male, aged 20–40, and often employed in physically demanding occupations , construction, mining, agriculture, security , where physical size and strength carry cultural and professional value. The population also includes gym-goers across socioeconomic groups, fitness influencers, and a smaller but significant proportion of women.

Motivations are primarily image-related rather than competitive. Most non-prescribed PIED use in Australia is about appearance and self-image rather than sporting performance. Understanding this matters for clinical engagement: the patient's investment is often deeply personal and connected to identity, which affects how they respond to harm-focused conversations.

Not all patients will show features of AAS or PIED use such as a muscular body. It is important to include AAS and PIEDs in general history taking when updating the patient's alcohol and other drug history.

Useful opening questions, as outlined in the NSW Health quick reference guide:

"Do you use or take anything to help with your workouts or muscle gain?"
"Can you tell me about supplements you are using, including any pills, powders or injectables?"

These questions normalise the enquiry and avoid the confrontational dynamic that direct questions about steroid use can produce.

What patients are using

The PIED category is broad and expanding. Core substances:

Anabolic-androgenic steroids (AAS): Testosterone in various ester forms (enanthate, cypionate, propionate) remains the foundation of most cycles. Additional compounds include nandrolone, boldenone, trenbolone, stanozolol, and oxandrolone. Most are injectable; some are oral. Polypharmacy is the rule rather than the exception , most AAS users take multiple compounds simultaneously ("stacking").

Peptides and growth hormones: Human growth hormone (HGH) and peptides that stimulate its release , CJC-1295, ipamorelin, GHRP-6, and others , are increasingly common, particularly among older users seeking recovery enhancement rather than muscle growth. BPC-157 and TB-500 are used for injury repair. These are typically subcutaneous injections administered daily or multiple times daily.

SARMs (Selective Androgen Receptor Modulators): Oral compounds marketed as safer alternatives to traditional steroids. Ostarine, RAD-140, LGD-4033, and related compounds. Long-term safety data is essentially absent , these are research chemicals that have never completed human clinical trials.

Ancillary compounds: Aromatase inhibitors (anastrozole, letrozole) to manage oestrogen conversion; SERMs (tamoxifen, clomiphene) for post-cycle recovery of natural testosterone production; hCG to maintain testicular function during a cycle; diuretics for competition cutting.

Understanding the full stack is clinically important because drug interactions and combined effects differ substantially from individual compound risk profiles.

Clinical assessment

History

A structured substance history should cover:

Current compounds and doses
Route of administration and injection technique
Cycle status (on-cycle, post-cycle, or between cycles)
Duration of use and number of previous cycles
Use of ancillary compounds
Concurrent use of other substances , alcohol and cocaine co-use are common in this population
Sourcing (underground lab products carry greater contamination and dose uncertainty)

Examination and investigations

Offering testing to identify emerging health problems will help patients feel more comfortable, more willing to discuss their AAS and PIED use, and more likely to return for follow-up appointments.

The framing of health monitoring as protective rather than judgmental is key to maintaining engagement. The RACGP has endorsed harm minimisation as the appropriate clinical approach for practitioners seeing steroid users in general practice.

Core monitoring investigations:

Cardiovascular: Blood pressure (AAS commonly elevate BP), fasting lipid profile (HDL suppression and LDL elevation are consistent effects of AAS use), ECG for rhythm and signs of LVH in long-term users, and echocardiography if clinically indicated.

Endocrine: Testosterone (total and free), LH, FSH, SHBG, oestradiol, and prolactin. These establish the degree of HPG axis suppression and guide post-cycle management. Thyroid function if growth hormone or T3/T4 are in the stack.

Haematological: FBC , polycythaemia (elevated haematocrit) is a common AAS effect with thromboembolic implications. Haematocrit above 52% warrants clinical attention.

Hepatic: LFTs , elevated liver enzymes are common with oral AAS. Significant elevation warrants cessation of oral compounds.

Renal: Urea, creatinine, eGFR , relevant with high-protein diets and some AAS compounds.

Red flags requiring closer monitoring

The following red flag warning signs require closer monitoring: use by a young person under 21 years and women, given high risk of irreversible complications even with short-term use.

Additional red flags include: haematocrit above 52%, significant LFT elevation, symptomatic cardiovascular effects (chest pain, palpitations, exertional dyspnoea), signs of dependence, significant mood disturbance, and injection site complications.

Managing the HPG axis

Hypothalamic-pituitary-gonadal axis suppression is the most clinically significant endocrine consequence of AAS use. Exogenous androgens suppress endogenous testosterone production via negative feedback, and this suppression can persist for months to years after cessation depending on duration and dose of use.

HPG suppression takes several months to resolve when coming off AAS. Coming off AAS can lead to depressed mood, fatigue, sleep disturbance, loss of libido, anxiety, and reduced semen production in men.

This post-cycle syndrome is a common reason users restart before the HPG axis has recovered , creating a cycle of use that can be difficult to interrupt. For patients wanting to stop, managing the post-cycle period with appropriate monitoring and, where indicated, hCG and SERM protocols, significantly improves outcomes. This is territory where specialist referral (endocrinology or a GP with AAS experience, such as the network around Dr Beng Eu in Melbourne) is appropriate for complex cases.

Dependence

PIED dependence is primarily psychological but clinically significant. The diagnostic framework adapted for AAS dependence mirrors standard substance dependence criteria: use of larger amounts or for longer than intended, persistent desire or unsuccessful efforts to cut down, continued use despite awareness of adverse effects, and withdrawal symptoms on cessation.

Body dysmorphia , specifically muscle dysmorphia, the perception that one is insufficiently muscular regardless of objective size , is an important underlying driver for a subset of users and warrants assessment. It is associated with more severe use patterns, greater resistance to cessation, and higher rates of co-occurring mental health conditions.

The disclosure problem

Users of steroids don't often reveal that fact to their GP , but it's vital they feel comfortable to do so.

The barriers to disclosure are well documented: stigma, concern about judgment, fear of legal consequences (AAS are Schedule 4 substances in Australia), and the perception , often accurate , that the GP will not be knowledgeable or helpful.

The clinical response to this is not to push for disclosure but to create conditions where it feels safe. Non-judgmental language, health-focused framing rather than legal or moral framing, and demonstrating knowledge of what patients are actually using all contribute to a clinical environment where disclosure becomes more likely over time.

The harm minimisation approach, as outlined in the SNHN GP Guide and endorsed by the RACGP, explicitly frames the clinical role as reducing risk within the patient's current use pattern rather than as securing a commitment to cessation.

Between-consultation support

Most PIED users manage their cycles with information from online communities, forums, and informal networks. The quality of this information is variable, and the community context has commercial incentives that are not aligned with harm reduction.

Digital self-monitoring tools that track substance use alongside mood, sleep, cardiovascular symptoms, and injection site status provide a structured alternative to informal tracking. For patients who are already tracking their cycles in detail , which many are , extending this to include systematic health and wellbeing data adds clinical value that routine consultations alone cannot provide.

The key features relevant for PIED users are multi-substance support (many PIED users also use alcohol, cannabis, or stimulants), privacy architecture that removes disclosure anxiety, and the ability to generate a structured summary to share with their GP at their discretion.

Key clinical resources

The Sydney North Health Network's GP Guide to Harm Minimisation for patients using non-prescribed AAS and other PIEDs (van de Ven et al., 2020) is freely available at sydneynorthhealthnetwork.org.au and provides comprehensive clinical guidance including monitoring schedules, management algorithms, and local referral pathways. The NSW Health quick reference version is available at health.nsw.gov.au.

Roidsafe (roidsafe.com.au) is an Australian telehealth service providing Medicare-funded pathology referrals for PIED users who are unable or unwilling to disclose to their regular GP , a harm reduction service worth knowing about for patients with significant disclosure barriers.

ayodee includes a dedicated PIED tracking section covering steroids, testosterone, peptides, SARMs, and ancillary compounds. Clinician access codes available. Clients share structured reports at their discretion.