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If smaller, statistically not significant studies tend to remain unpublished, then an asymmetrical shape may be observed. For "over-concentrated" preparations however, active ingredients could go as much as 200% above that indicated on the label (e.g. 221% or 225% ) if quantitative data was available. In seven articles (37%), both main endpoints were presented simultaneously. In the case of Europe, the studies are divided among several countries. The authors provided sufficient information in the methods section so that, by consensus between the reviewers (RM/PB/LF), we were confident to include the study for extraction and analysis. For one study, the study design (retrospective database analysis) did not qualify for the analysis by ToxRtool and was individually assessed by the study team . A total of 20 full-text articles were included for quality appraisal by the ToxRTool. The full-text screening stage of 24 articles led to 21 potential articles relevant in this systematic review and were thus eligible for quality appraisal. Qualitative and quantitative analysis according to the suggested classification of Neves , and Weber and colleagues into original, substandard or counterfeit and subclassifications with some adaptions for analysis They often lack any form of quality control and are run by individuals with limited knowledge of steroid manufacturing. Mid-tier labs may operate in areas with some regulatory oversight but often lack access to the best raw materials and cutting-edge equipment. Operating from countries with lenient steroid regulations, they manage to produce near-pharmaceutical-grade products. These steroids are known for their high purity, potency, and safety. This evolution has introduced a spectrum of quality and safety concerns that users need to navigate. Furthermore, we assessed the different analytical methods used to determine the quality and quantity of AAS on the black market. We used a subclassification of "counterfeit" substances to comprise "adulterated", "substituted" and "inert"; and "substandard" substances to comprise "over- and under- concentrated" (Table 3). • to increase the homogeneity, article with mixed samples (e.g., if the analysis includes different classes of IPED) in which data on AAS are This often leads to products that may be subpar, with issues such as powdery tablets or inconsistently filled multi-dose vials—signs of poor manufacturing practices. Quality control is completely in the hands of the people operating the labs without any oversight. 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