Muscle dysmorphia (MD) is a body image disorder characterized by an obsessive preoccupation with muscularity and compulsive behaviors such as excessive exercise, rigid dieting, and frequent body checking. MD has been linked to obsessive-compulsive traits and the use of anabolic-androgenic steroids (AASs), yet these associations have not been comprehensively synthesized. This systematic review and meta-analysis examined the relationships between MD, obsessive-compulsive symptomatology, and AASs or performance-enhancing drug use. Following PRISMA 2020 guidelines and PROSPERO preregistration (CRD42025640206), we searched four major databases for peer-reviewed studies published between 2015 and 2025. Ten studies (five quantitative, five qualitative) met the inclusion criteria. Meta-analytic findings revealed a moderate positive correlation between MD symptom severity and obsessive-compulsive traits ( ≈ 0.24), and significantly higher MD symptoms among AAS users compared to non-users (Cohen's ≈ 0.45). Odds of MD were markedly higher in steroid-using populations. Thematic synthesis of qualitative studies highlighted compulsive training routines, identity conflicts, motivations for AAS use, and limited engagement with healthcare services. These findings suggest that MD exists at the intersection of obsessive-compulsive psychopathology and substance-related behavior, warranting integrated interventions targeting both dimensions. The study contributes to understanding MD as a complex, multi-faceted disorder with significant clinical and public health relevance.