Designer steroids - over-the-counter supplements and their androgenic component: review of an increasing problem

Contaminants in Dietary Supplements: Toxicity, Doping Risk, and Current Regulation

Athletes, both amateur and professional, often resort to the consumption of nutritional supplements without professional supervision and without being aware of the risks they may entail. We conducted an exhaustive literature search to determine the most common substances found as contaminants in dietary supplements. For each substance, we analyzed its mechanism of action, clinical indication, health risk, and putative use as doping agent. In addition, we evaluated the current regulation of these supplements. Contamination of nutritional supplements (accidental or intentional), especially with steroids and stimulants, is a hazardous situation. The prolonged consumption of these products without being aware of their composition can cause serious health risks and, in the case of professional athletes, a possible sanction for doping.

Do "testosterone boosters" really increase serum total testosterone? A systematic review

Testosterone boosters are heavily marketed on social media and marketplaces to men with claims to significantly increase testosterone. Lax industry regulation has allowed sales of supplements to thrive in the absence of verification of their purported benefits. Our primary objective was to systematically review all data published in the last two decades on testosterone boosters and determine their efficacy. Our outcome of interest was total testosterone increase versus placebo in four different populations: male athletes, men with late-onset hypogonadism infertile men and healthy men. Following search and screening, 52 studies were included in our review, relating to 27 proposed testosterone boosters: 10 studies of cholecalciferol; 5 zinc/magnesium; 4 Tribulus terrestris and creatine; 3 Eurycoma longifolia and Withania somnifera; 2 betaine, D-aspartic acid, Lepidium meyenii and isoflavones; while the remainder were single reports. Our findings indicate that most fail to increase total testosterone. The exceptions were β-hydroxy β-methylbutyrate and betaine, which can be considered effective for male athletes. Eurycoma longifolia, a blend of Punica granatum fruit rind and Theobroma cacao seed extracts (Tesnor™) and purified Shilajit extract (PrimaVie™) can be considered possibly effective for men with late-onset hypogonadism; Eurycoma longifolia and Withania somnifera possibly effective for healthy men; and a non-hormonal aromatase inhibitor (Novadex XT™) possibly effective for male athletes.

Fear, misinformation, and pharmaceutical messianism in the promotion of compounded bioidentical hormone therapy

Compounded bioidentical hormone therapy (cBHT) for menopausal symptoms maintains popularity in western countries despite the availability of hormone products in different formulations and dosages produced by pharmaceutical companies with federal oversight. Akin to many populist therapeutic trends in the history of medicine, cBHT advocates tend to capitalize on consumer fears about existing FDA-approved hormone treatments. Unsubstantiated, exaggerated, or outright false claims are commonplace in promoting cBHT. Given these elements, the basic elements of pharmaceutical messianism continue to drive the cBHT movement.

Notifications and Health Consequences of Unauthorized Pharmaceuticals in Food Supplements

Health concerns associated with the consumption of food supplements rise in parallel with the rise in the popularity and market availability of these products. In pursuit of data related to the unauthorized presence of pharmaceuticals in food supplements, the Rapid Alert System for Food and Feed (RASFF) database was searched for the 2011-2022 period. The most "popular" pharmaceuticals for the adulteration of food supplements were phosphodiesterase-5 inhibitors (235 records); anorexics and laxatives (76), including sibutramine and its active metabolite N-didesmethyl sibutramine, phenolphthalein and 2,4-dinitrophenol; stimulants, among which 1,3-dimethylamine (97), and synephrine (53) were the most numerous; nootropic drugs (24); anabolics and prohormones (16); and cannabinoid cannabidiol (14) (pending authorization as a novel food ingredient). Over 65% of notifications of interest were classified as serious risks, and over 80% of these were alert or border rejection notifications, mainly generated as a result of official control on the market. The alarming number of RASFF notifications should be considered a public health issue, demanding clear and targeted recommendation for action for the legislature and authorities. A harmonized nutrivigilance system should be considered as a tool to detect and scrutinize the adverse health effects of food supplements, along with measures to improve their safety, quality, and testing.

The in vivo metabolism of Jungle Warfare in greyhounds

Δ6-Methyltestosterone was reported as the main active ingredient of the purported "dietary supplement" Jungle Warfare. This compound is structurally similar to 17α-methyltestosterone, containing an additional Δ6 double bond, and is reported to possess notable androgenic activity, raising concerns over the potential for abuse of Jungle Warfare in sport. The in vivo metabolism of Δ6-methyltestosterone in greyhounds was investigated. Urinary phase I (unconjugated) and phase II (glucuronide) metabolites were detected following oral administration using liquid chromatography-mass spectrometry. No phase II sulfate metabolites were detected. The major phase I metabolite was confirmed as 16α,17β-dihydroxy-17α-methylandrosta-4,6-dien-3-one by comparison with a synthetically-derived reference material. Minor amounts of the parent drug were also confirmed. Glucuronide conjugated metabolites were also observed, but were found to be resistant to hydrolysis using the Escherichia coli β-glucuronidase enzyme. Qualitative excretion profiles, limits of detection, and extraction recoveries were determined for the parent drug and the major phase I metabolite. These results provide a method for the detection of Jungle Warfare abuse in greyhounds suitable for incorporation into routine screening methods conducted by anti-doping laboratories.

A study to demonstrate the potential of Anabolic Androgen Steroid to activate oxidative tissue damage, nephrotoxicity and decline endogenous antioxidant system in renal tissue of Adult Wistar Rats

Anabolic Androgenic steroids (AAS) are abused and reports have been made on their deleterious effects on various organs. It is imperative to report the mechanism of inducing oxidative tissue damage even in the presence of an intracellular antioxidant system by the interaction between lipid peroxidation and the antioxidant system in the kidney. Twenty (20) adult male Wistar rats used were grouped into: A- Control, BOlive oil vehicle, C- 120 mg/kg of AAS orally for three weeks, and D- 7 days withdrawal group following 120 mg/kg/ 21days of AAS intake. Serum was assayed for lipid peroxidation marker Malondialdehyde (MDA) and antioxidant enzyme -superoxide Dismutase (SOD). Sectioned of kidneys were stained to see the renal tissue, mucin granules, and basement membrane. AAS-induced oxidative tissue damage, in the presence of an endogenous antioxidant, is characterized by increased lipid peroxidation and decreased SOD level which resulted in the loss of renal tissue cells membrane integrity which is a characteristic of the pathophysiology of nephron toxicity induced by a toxic compound. However, this was progressively reversed by a period of discontinuation of AAS drug exposure.

Anabolic Steroids in Fattening Food-Producing Animals—A Review

Simple Summary

Anabolic steroids significantly affect animal tissues and cause morphological and histological changes, which are often irreversible. This issue is currently a very hot topic, as the answers to the questions concerning the health of endangered animals and humans vary greatly from country to country. There is a need to further investigate whether the use of anabolic steroids in animal fattening threatens consumer health and to develop new tools for the detection of anabolic steroids in meat. One possibility for detection could be to observe histological changes in the tissues, which form a typical pattern of anabolic abuse. This review gathered information on the anabolic steroids most commonly used in animal fattening, the legislation governing this issue, and the main effects of anabolics on animal tissues.

Abstract

Anabolic steroids are chemically synthetic derivatives of the male sex hormone testosterone. They are used in medicine for their ability to support muscle growth and healing and by athletes for esthetic purposes and to increase sports performance, but another major use is in fattening animals to increase meat production. The more people there are on Earth, the greater the need for meat production and anabolic steroids accelerate the growth of animals and, most importantly, increase the amount of muscle mass. Anabolic steroids also have proven side effects that affect all organs and tissues, such as liver and kidney parenchymal damage, heart muscle degeneration, organ growth, coagulation disorders, and increased risk of muscle and tendon rupture. Anabolic steroids also have a number of harmful effects on the developing brain, such as brain atrophy and changes in gene expression with consequent changes in the neural circuits involved in cognitive functions. Behavioral changes such as aggression, irritability, anxiety and depression are related to changes in the brain. In terms of long-term toxicity, the greatest impact is on the reproductive system, i.e., testicular shrinkage and infertility. Therefore, their abuse can be considered a public health problem. In many countries around the world, such as the United States, Canada, China, Argentina, Australia, and other large meat producers, the use of steroids is permitted but in all countries of the European Union there is a strict ban on the use of anabolic steroids in fattening animals. Meat from a lot of countries must be carefully inspected and monitored for steroids before export to Europe. Gas or liquid chromatography methods in combination with mass spectrometry detectors and immunochemical methods are most often used for the analysis of these substances. These methods have been considered the most modern for decades, but can be completely ineffective if they face new synthetic steroid derivatives and want to meet meat safety requirements. The problem of last years is the application of “cocktails” of anabolic substances with very low concentrations, which are difficult to detect and are difficult to quantify using conventional detection methods. This is the reason why scientists are trying to find new methods of detection, mainly based on changes in the structure of tissues and cells and their metabolism. This review gathered this knowledge into a coherent form and its findings could help in finding such a combination of changes in tissues that would form a typical picture for evidence of anabolic misuse.

Anabolic androgenic steroid-induced liver injury: An update

Anabolic androgenic steroids (AASs) are a group of molecules including endogenous testosterone and synthetic derivatives that have both androgenic and anabolic effects. These properties make them therapeutically beneficial in medical conditions such as hypogonadism. However, they are commonly bought illegally and misused for their anabolic, skeletal muscle building, and performance-enhancing effects. Supraphysiologic and long-term use of AASs affects all organs, leading to cardiovascular, neurological, endocrine, gastrointestinal, renal, and hematologic disorders. Hepatotoxicity is one of the major concerns regarding AASs treatment and abuse. Testosterone and its derivatives have been most often shown to induce a specific form of cholestasis, peliosis hepatis, and hepatic benign and malignant tumors. It is currently believed that mechanisms of pathogenesis of these disorders include disturbance of antioxidative factors, upregulation of bile acid synthesis, and induction of hepatocyte hyperplasia. Most toxicity cases are treated with supportive measures and liver function normalizes with discontinuation of AAS. However, some long-term consequences are irreversible. AAS-induced liver injury should be taken in consideration in patients with liver disorders, especially with the increasing unintentional ingestion of supplements containing AAS. In this paper, we review the most current knowledge about AAS-associated adverse effects on the liver, and their clinical presentations, prevalence, and pathophysiological mechanisms.

D-aspartic Acid Supplementation Effects on Body Composition: A Systematic Review of Randomized Clinical Trials on Trained Males

Context: D-Aspartic acid (DAA) is an amino acid found in the brain and reproductive system. Some investigations have reported beneficial effects of DAA on brain function and reproductive system health by increasing testosterone through the hypothalamic-pituitary-gonadal axis. However, its effect on body composition is unknown. Given testosterone's role in muscle growth, this study aimed to evaluate the effect of DAA supplementation on the body composition of trained males. Evidence Acquisition: PubMed, Scopus, Embase, and Web of Science (until 1 August 2021) were searched for this systematic review. Inclusion criteria assumed as clinical trials assessed the effect of DAA on body composition in trained males. After including articles by keywords, the articles were reviewed for meeting the eligibility criteria. Three independent researchers conducted the search and full-text review. Results: Among 134 articles located during the primary search, five articles (47 interventions and 43 controls) were included in the study based on eligibility criteria. All included clinical trials had a low risk of bias. A review of the relevant literature concludes that different doses of DAA (three grams, six grams, 7.12, and 12 grams) in different intervention periods (two weeks, four weeks, and 12 weeks) have no effects on body composition in trained males. Conclusions: DAA supplementation is a low-level booster of testosterone and has no significant effect on the testosterone level in professional male athletes, and cannot alter the body composition.

Body Image Disorders and Anabolic Steroid Withdrawal Hypogonadism in Men

Hypogonadism commonly occurs during withdrawal from anabolic-androgenic steroid (AAS) use, particularly when users have been taking AAS for prolonged periods. Mounting evidence now suggests that AAS-induced hypogonadism may persist for months or even years after last AAS use, and in some cases may be partially or completely irreversible. Treatment with human chorionic gonadotropin and clomiphene may help to restore hypothalamic-pituitary-testicular axis function, and these substances are widely used illicitly by AAS users at the end of a course of AAS as so-called postcycle therapy. Many endocrinologists still have only limited experience in diagnosing and treating AAS-induced hypogonadism.

Testosterone Replacement Therapy in Hypogonadal Men

All approved testosterone replacement methods, when used according to recommendations, can restore normal serum testosterone concentrations, and relieve symptoms in most hypogonadal men. Selection of the method depends on the patient's preference with advice from the physician. Dose adjustment is possible with most delivery methods but may not be necessary in all hypogonadal men. The use of hepatotoxic androgens must be avoided. Testosterone treatment induces reversible suppression of spermatogenesis; if fertility is desired in the near future, human chronic gonadotropin, selective estrogen receptor modulator, estrogen antagonist, or an aromatase inhibitor that stimulates endogenous testosterone production may be used.

Relative safety and quality of various dietary supplement products U.S. Service Members ask about

CONTEXT

The purpose of this project was to determine types of dietary supplement products U.S. Service Members frequently ask about and identify risks associated with select products that consumers should be aware of when considering their use.

METHODS

Forty-one dietary supplement products frequently asked about through the Operation Supplement Safety's (OPSS.org) Ask-the-Expert portal were selected. Product analysis was performed to verify whether select products were accurately labeled and to identify any risky ingredients contained in these products. Operation Supplement Safety Risk Assessment Scorecard criteria were additionally used as a screening tool to assess a product's relative safety potential.

RESULTS

Among the select dietary supplements, 12 (29.3%) were marketed as pre-workout products; 14 (34.1%) for weight loss; four (9.8%) for male enhancement/testosterone boosters; and 11 (26.8%) as body building supplements. Eleven (26.8%) products had accurate labels; only eight of these had accurate labels plus no risky ingredients listed on the labels. Twenty-six (63.4%) products were misbranded; 10 (24.4%) were adulterated, and six (14.6%) were both misbranded and adulterated. Risky ingredients appeared on 23 (56%) of all product labels. Eight of these 23 products also had additional risky ingredients not listed on the labels but detected through analysis. According to the Scorecard based on label claims, 35 (85.4%) received a rating of "no-go/risky".

CONCLUSIONS

U.S. Service Members and the public at large should be aware that dietary supplements may contain risky ingredients and know how to identify ingredients on the label to evaluate potential risk.

Differences in Nervous Autonomic Control in Response to a Single Session of Exercise in Bodybuilders Using Anabolic Androgenic Steroids

Considering the role of autonomic nerve activity in blood pressure control, this study aimed to investigate the cardiac autonomic nerve responses after an aerobic exercise session in Anabolic Androgenic Steroids (AAS) users. Twenty men (AAS, n = 9; control group, n = 11) performed an aerobic exercise session (60 min, 70 to 80% of HR_max). Heart rate variability (HRV) was assessed before and during a 60-min post-exercise recovery period. RMSSD (root mean square successive difference of the RR intervals) and the LF/HF ratio (low frequency/high frequency spectra) were also evaluated. The Student's t-test for independent samples was used to compare differences between initial group characteristics. Repeated measures ANOVA was used to compare pre- and post-exercise HRV recovery (p < 0.05). AAS had a lower SDNN (standard deviation of the intervals) (40.8 ± 16.8 vs. 71.6 ± 24.7 ms; p = 0.04, d = 1.4) and a higher LF/HF (3.4 ± 2.1 vs. 1.8 ± 0.9%; p = 0.03, d = 0.9) before exercise. AAS and controls had similar RMSSD (14.0 ± 15.8 vs. 18.9 ± 12.1 ms; p = 0.20) and a LF/HF (2.8 ± 1.6 vs. 2.4 ± 1.2 ms; p = 0.41) immediately post-exercise. The between-groups comparison revealed a higher HF/LF at 30 min (4.3 ± 1.4 vs. 2.5 ± 1.3%; p = 0.008, d = 1.3) and 60 min (5.0 ± 2.2 vs. 2.3 ± 0.8%; p = 0.001, d = 1.6) for the AAS group in the recovery time. This study demonstrated impaired parasympathetic activity at rest and immediately after the exercise session as an adverse effect of AAS usage, but similar behavior regarding the restoration of sympathetic activity.

Use, Misuse and Abuse of Testosterone and Other Androgens

INTRODUCTION

For several decades, testosterone and its synthetic derivatives have been used for anabolic and androgenic purposes. Initially restricted to professional bodybuilders, these substances gradually became more popular with recreational weightlifters. Considering its increasing prevalence, the consumption of anabolic androgenic steroids (AAS) has become a matter of great concern. Although most side effects are mild and reversible, some of them can cause permanent damage or can be potentially life threatening.

OBJECTIVES

To review and summarize medical literature regarding misuse and abuse of testosterone and other androgens, in order to provide evidence-based information on the main topics related to this subject, such as how to identify and how to deal with these patients, and to elucidate the multiple possible adverse effects secondary to this practice.

METHODS

Key studies were retrieved from PubMed (1989-2021) with reference searches from relevant articles. Search terms included "hypogonadism", "anabolic androgenic steroids", "androgens", "misuse AND testosterone", "abuse AND testosterone", and "side effects AND testosterone".

RESULTS

There is a significant lack of information in the peer-reviewed literature describing demographic data, implications for different organ systems and the management of current or former AAS users; however, androgen abuse has been already linked to a wide variety of cardiovascular diseases, metabolic, endocrine, neurological, psychiatric and liver disorders. Despite all this, most physicians still feel uncomfortable and hesitate to discuss the issue with patients.

CONCLUSIONS

The chronic use of high doses of AAS is associated with adverse effects in several organ systems; however, there are still many gaps in our knowledge about the long-term consequences of this practice and how to deal with these patients. Healthcare professionals have a crucial role in combating this public health problem, recognizing and preventing the spread of androgen abuse. Linhares BL, Miranda EP, Cintra AR, et al. Use, Misuse and Abuse of Testosterone and Other Androgens. Sex Med Rev 2021;XX:XXX-XXX.

Identification of the designer steroid 17β-hydroxy 5α-androst-1-en-3-one cypionate in an injectable liquid

In the screening of an injectable liquid marketed for body building, a steroid resembling 1-testosterone was found. The compound of interest was isolated using HPLC-UV detection coupled to an analytical scale fraction collector and subsequently characterized using HRAM-MS, NMR spectrometry, and GC-MS. The designer steroid was identified as 17β-hydroxy 5α-androst-1-en-3-one cypionate, an analog of 1-testosterone that had not been reported.

Androgen Misuse and Abuse

Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.

The in vivo metabolism of Furazadrol in greyhounds

Samples of the 'dietary supplement' Furazadrol sourced through the internet have been reported to contain the designer anabolic androgenic steroids [1',2']isoxazolo[4',5':2,3]-5α-androstan-17β-ol (furazadrol F) and [1',2']isoxazolo[4',3':2,3]-5α-androstan-17β-ol (isofurazadrol IF). These steroids contain an isoxazole fused to the A-ring and were designed to offer anabolic activity while evading detection, raising concerns over the potential for abuse of this preparation in sports. The metabolism of Furazadrol (F:IF, 10:1) was studied by in vivo methods in greyhounds. Urinary phase II Furazadrol metabolites were detected as glucuronides after a controlled administration. These phase II metabolites were subjected to enzymatic hydrolysis by Escherichia coli β-glucuronidase to afford the corresponding phase I metabolites. Using a library of synthetically derived reference materials, the identities of seven urinary Furazadrol metabolites were confirmed. Major confirmed metabolites were isofurazadrol IF, 4α-hydroxyfurazadrol 4α-HF and 16α-hydroxy oxidised furazadrol 16α-HOF, whereas the minor confirmed metabolites were furazadrol F, 4β-hydroxyfurazadrol 4β-HF, 16β-hydroxyfurazadrol 16β-HF and 16β-hydroxy oxidised furazadrol 16β-HOF. One major hydroxyfurazadrol and two dihydroxyfurazadrol metabolites remained unidentified. Qualitative excretion profiles, limits of detection and extraction recoveries were established for furazadrol F and major confirmed metabolites. These investigations identify the key urinary metabolites of Furazadrol following oral administration, which can be incorporated into routine screening by anti-doping laboratories to aid the regulation of greyhound racing.

Undeclared Doping Substances are Highly Prevalent in Commercial Sports Nutrition Supplements

Sports nutrition supplements have previously been reported to contain undeclared doping substances. The use of such supplements can lead to general health risks and may give rise to unintentional doping violations in elite sports. To assess the prevalence of doping substances in a range of high-risk sports nutrition supplements available from Dutch web shops. A total of 66 sports nutrition supplements - identified as potentially high-risk products claiming to modulate hormone regulation, stimulate muscle mass gain, increase fat loss, and/or boost energy - were selected from 21 different brands and purchased from 17 web shops. All products were analyzed for doping substances by the UK life sciences testing company LGC, formerly known as the Laboratory of the Government Chemist, using an extended version of their ISO17025 accredited nutritional supplement screen. A total of 25 out of the 66 products (38%) contained undeclared doping substances, which included high levels of the stimulants oxilofrine, β-methylphenethylamine (BMPEA) and N,β-dimethylphenethylamine (NBDMPEA), the stimulant 4-methylhexan-2-amine (methylhexaneamine, 1,3-dimethylamylamine, DMAA), the anabolic steroids boldione (1,4-androstadiene-3,17-dione) and 5-androstene-3β,17α-diol (17α-AED), the beta-2 agonist higenamine and the beta-blocker bisoprolol. Based upon the recommended dose and the potential variability of analyte concentration, the ingestion of some products identified within this study could pose a significant risk of unintentional doping violations. In addition to inadvertent doping risks, the prescribed use of 3 products (4.5%) could likely impose general health risks.

Nontargeted detection of designer androgens: Underestimated role of in vitro bioassays

Androgens, both steroidal and nonsteroidal in nature, are among the most commonly misused substances in competitive sports. Their recognized anabolic and performance enhancing effects through short- and long-term physiological adaptations make them popular. Androgens exist as natural steroids, or are chemically synthesized as anabolic androgenic steroids (AAS) or selective androgen receptor modulators (SARMs). In order to effectively detect misuse of androgens, targeted strategies are used. These targeted strategies rely heavily on mass spectrometry, and detection requires prior knowledge of the targeted structure and its metabolites. Although exquisitely sensitive, such approaches may fail to detect novel structures that are developed and marketed. A nontargeted approach to androgen detection involves the use of cell-based in vitro bioassays. Both yeast and mammalian cell androgen bioassays demonstrate a clear ability to detect AAS and SARMS, and if paired with high resolution mass spectrometry can putatively identify novel structures. In vitro cell bioassays are successfully used to characterize designer molecules and to detect exogenous androgens in biological samples. It is important to continue to develop new and effective detection approaches to prevent misuse of designer androgens, and in vitro bioassays represent a potential solution to nontargeted detection strategies.

Anabolic steroid misuse and male infertility: management and strategies to improve patient awareness

Introduction: Anabolic androgenic steroid use is an uncommon but important cause of male infertility. As paternal age and anabolic steroid use increases, providers are more likely than ever to encounter men with infertility and prior or concurrent anabolic steroid use. In this review, we outline the background, epidemiology and pathophysiology of anabolic steroid induced male infertility and provide recommendations regarding the diagnosis, management, and future prevention of this condition.Areas covered: Male reproductive physiology is a tightly regulated process that can be influenced by exogenous sources such as anabolic steroids and selective androgen receptor modulators (SARMs). Data suggest that a combination of selective estrogen receptor modulators (SERMs), human chorionic gonadotropin (hCG), aromatase inhibitors (AIs), and recombinant follicle-stimulating hormone (rFSH) may lead to spermatogenesis recovery.Expert opinion: Anabolic steroid and SARM users continue to exhibit lack of understanding regarding the potential side effects of their use on male fertility. Current literature suggests that spermatogenesis can be safely recovered using a combination of SERMs, hCG, AIs and rFSH although additional studies are necessary. While anabolic steroid prevention strategies have largely been focused on the individual level, further investigation is necessary and should be approached in a socioecological manner.

Adverse Effects of Anabolic-Androgenic Steroids: A Literature Review

Anabolic-androgenic steroids (AASs) are a large group of molecules including endogenously produced androgens, such as testosterone, as well as synthetically manufactured derivatives. AAS use is widespread due to their ability to improve muscle growth for aesthetic purposes and athletes’ performance, minimizing androgenic effects. AAS use is very popular and 1–3% of US inhabitants have been estimated to be AAS users. However, AASs have side effects, involving all organs, tissues and body functions, especially long-term toxicity involving the cardiovascular system and the reproductive system, thereby, their abuse is considered a public health issue. The aim of the proposed review is to highlight the most recent evidence regarding the mechanisms of action of AASs and their unwanted effects on organs and lifestyle, as well as suggesting that AAS misuse and abuse lead to adverse effects in all body tissues and organs. Oxidative stress, apoptosis, and protein synthesis alteration are common mechanisms involved in AAS-related damage in the whole body. The cardiovascular system and the reproductive system are the most frequently involved apparatuses. Epidemiology as well as the molecular and pathological mechanisms involved in the neuropsychiatric side-effects of AAS abuse are still unclear, further research is needed in this field. In addition, diagnostically reliable tests for AAS abuse should be standardized. In this regard, to prevent the use of AASs, public health measures in all settings are crucial. These measures consist of improved knowledge among healthcare workers, proper doping screening tests, educational interventions, and updated legislation.

Spectral trends in GC-EI-MS data obtained from the SWGDRUG mass spectral library and literature: A resource for the identification of unknown compounds

Rapid identification of new or emerging psychoactive substances remains a critical challenge in forensic drug chemistry laboratories. Current analytical protocols are well-designed for confirmation of known substances yet struggle when new compounds are encountered. Many laboratories initially attempt to classify new compounds using gas chromatography-electron ionization-mass spectrometry (GC-EI-MS). Though there is a large body of research focused on the analysis of illicit substances with GC-EI-MS, there is little high-level discussion of mass spectral trends for different classes of drugs. This manuscript compiles literature information and performs simple exploratory analyses on evaluated GC-EI-MS data to investigate mass spectral trends for illicit substance classes. Additionally, this work offers other important aspects: brief discussions of how each class of drugs is used; illustrations of EI mass spectra with proposed structures of commonly observed ions; and summaries of mass spectral trends that can help an analyst classify new illicit compounds.

Periodontal clinical status, microbial profile, and expression of interleukin-1β in men under androgenic anabolic steroids abuse

OBJECTIVES

Androgenic anabolic steroids (AAS) abuse is a serious health problem associated to several systemic complications. Here, we evaluated the periodontal clinical status, microbial profile, and expression of total protein (TP) and interleukin (IL)-1β in men using AAS.

MATERIALS AND METHODS

Men using AAS were recruited (case group) and matched for age with men who had never used AAS (control group) but also performed physical activities. Plaque index (PI), marginal bleeding (MB), probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BoP) were evaluated. Crevicular fluid and subgingival biofilm were collected from healthy and diseased sites (PD ≥ 4 mm with CAL ≥ 1 mm and BoP) and evaluated for TP, IL-1β, and proportions of 40 bacterial species.

RESULTS

Thirty patients were included (n = 15/group). AAS consumers had significantly higher mean PD and higher percentage of diseased sites; sites with PD ≥ 4 mm or with CAL ≥ 1 mm than non-consumers. Also, AAS users showed a more dysbiotic biofilm containing lower proportions of host-compatible species and higher proportions of pathogens. IL-1β expression was statistically higher in diseased than in healthy sites only in the control group. A statistically positive correlation was detected between periodontal pathogens and IL-1β expression. The number of AAS cycles was positively associated with higher percentages of periodontal pathogens, but not with IL-1β or total protein concentrations.

CONCLUSIONS

AAS intake can worsen clinical and immunological periodontal conditions and the biofilm composition in healthy sites.

CLINICAL RELEVANCE

Dental care professionals should perform full mouth periodontal screening and schedule regular follow-up appointments for patients under AAS use.

Screening for twenty-eight target anabolic-androgenic steroids in protein supplements using QuEChERS extraction followed by liquid chromatography-tandem mass spectrometry

Anabolic-androgenic steroids (AASs) are very potent muscle builders, and professional sportsmen often take protein supplements to improve their performance. Several studies have emphasised that protein supplements may contain undeclared AASs banned by the International Olympic Committee/World Anti-Doping Agency. The widespread occurrence and abuse of contaminated protein supplements is extremely dangerous because of their side effects. To minimise the chances of an unattended positive doping test or to avoid serious health problems, adequate screening methods for the detection of a wide range of steroids is essential. To address this requirement, a rapid and effective modified QuEChERS (quick, easy, cheap, effective, rugged and safe) method was developed and validated to screen and quantify the simultaneous analysis of twenty-eight AASs in protein supplements using LC-MS/MS. The validated method was applied to 198 protein supplements collected from on-line and, off-line markets, and direct purchase from overseas between 2019 and 2020. Of the 198 samples, two samples contained testosterone and stanozolol at concentrations of 0.27 μg/g and 0.023 μg/g, respectively. In addition, 5α-hydroxylaxogenin was detected for the first time in three products purchased in Korea from overseas. The modified QuEChERS method was established and successfully applied to screen and determine AASs as a measure of continuous control and supervision in protein supplements.

Designer drugs: mechanism of action and adverse effects

Psychoactive substances with chemical structures or pharmacological profiles that are similar to traditional drugs of abuse continue to emerge on the recreational drug market. Internet vendors may at least temporarily sell these so-called designer drugs without adhering to legal statutes or facing legal consequences. Overall, the mechanism of action and adverse effects of designer drugs are similar to traditional drugs of abuse. Stimulants, such as amphetamines and cathinones, primarily interact with monoamine transporters and mostly induce sympathomimetic adverse effects. Agonism at μ-opioid receptors and γ-aminobutyric acid-A (GABA_A) or GABA_B receptors mediates the pharmacological effects of sedatives, which may induce cardiorespiratory depression. Dissociative designer drugs primarily act as N-methyl-d-aspartate receptor antagonists and pose similar health risks as the medically approved dissociative anesthetic ketamine. The cannabinoid type 1 (CB₁) receptor is thought to drive the psychoactive effects of synthetic cannabinoids, which are associated with a less desirable effect profile and more severe adverse effects compared with cannabis. Serotonergic 5-hydroxytryptamine-2A (5-HT_2A) receptors mediate alterations of perception and cognition that are induced by serotonergic psychedelics. Because of their novelty, designer drugs may remain undetected by routine drug screening, thus hampering evaluations of adverse effects. Intoxication reports suggest that several designer drugs are used concurrently, posing a high risk for severe adverse effects and even death.

Non-testosterone management of male hypogonadism: an examination of the existing literature

Testosterone deficiency is defined as a total testosterone level <300 ng/dL confirmed on two early morning lab draws. Testosterone therapy has historically been offered to men with symptomatic testosterone deficiency in the form of injections, gels, or pellets. However, these treatments are invasive or have undesirable effects including the risk of drug transference. Additionally, testosterone therapy has been associated with increases in hematocrit and controversy remains regarding the risk of cardiovascular and thromboembolic events while on testosterone therapy. As such, much interest has recently been focused on alternative treatment options for testosterone deficiency in the form of orally-administered medications with more favorable side effect profiles. Lifestyle modifications and varicocelectomy have been shown to raise endogenous testosterone production. Similarly, SERMs and aromatase inhibitors (AIs) have been shown to raise testosterone levels safely and effectively. Human chorionic gonadotropin (hCG) remains the only FDA-approved non-testosterone treatment option for testosterone deficiency in men. However, this medication is expensive and requires patient-administered injections. Over the counter herbal supplements and designer steroids remain available though they are poorly studied and are associated with the potential for abuse as well as increased hepatic and cardiovascular risks. This review aims to discuss the existing treatment alternatives to traditional testosterone therapy, including efficacy, safety, and side effects of these options. The authors suggest that the SERM clomiphene citrate (CC) holds the greatest promise as a non-testosterone treatment option for testosterone deficiency.

Separation of Structurally Similar Anabolic Steroids as Cation Adducts in FAIMS-MS

Novel synthetic anabolic androgenic steroids have been developed not only to dodge current antidoping tests at the professional sports level, but also for consumption by noncompetitive bodybuilders. These novel anabolic steroids are commonly referred to as "designer steroids" and pose a significant risk to users because of the lack of testing for toxicity and safety in animals or humans. Manufacturers of designer steroids dodge regulation by distributing them as nutritional or dietary supplements. Improving the throughput and accuracy of screening tests would help regulators to stay on top of illicit anabolic steroids. High-field asymmetric-waveform ion mobility spectrometry (FAIMS) utilizes an alternating asymmetric electric field to separate ions by their different mobilities at high- and low-fields as they travel through the separation space. When coupled to mass spectrometry (MS), FAIMS enhances the separation of analytes from other interfering compounds with little to no increase in analysis time. Here we investigate the effects of adding various cation species to sample solutions for the separation of structurally similar or isomeric anabolic androgenic steroids. FAIMS-MS spectra for these cation-modified samples show an increased number of compensation field (CF) peaks, some of which are confirmed to be unique for one steroid isomer over another. The CF peaks observed upon addition of cation species correspond to both monomer steroid-cation adduct ions and larger multimer ion complexes. Notably, the number of CF peaks and their CF shifts do not appear to have a straightforward relationship with cation size or electronegativity. Future directions aim at investigating the structures for these analyte-cation adduct ions for building a predictive model for their FAIMS separations.

Drug-induced Liver Injury Secondary to Herbal and Dietary Supplements

The use of herbal and dietary supplements (HDS) is increasing in the United States and worldwide. Its significant association with liver injury has become a concern, particularly because rates of hepatotoxicity caused by HDS are increasing. There are variety of HDS available, ranging from multi-ingredient substances, to anabolic steroids for bodybuilding purposes, to individual ingredients for purposes of supplementing a diet. This article reviews the impact of liver injury cause by HDS and explores the hepatotoxic potential of such products and their individual ingredients.

Contaminants: a dark side of food supplements?

Food supplements (FS) are often consumed as one of the strategies to fight ageing-associated pathologies, especially in the case of oxidative stress-related diseases. Despite the popularity of FS, some concerns about their quality and safety have been raised, especially regarding the presence of contaminants. This paper reviews and discusses the occurrence of contaminants in marketed samples of FS in the last two decades, considering both scientific literature and notifications registered on RASFF portal. The most relevant classes of contaminants were included namely metals, toxins, pesticides, dioxins and PCBs, as well as pharmacologically active ingredients. Variable amounts of contaminants were reported in a significant number of commercially available FS. Although the presence of contaminants does not necessarily mean that their levels exceed the regulatory limits or that the FS intake constitutes a risk to human health, it alerts for the need to further monitor FS safety. The evaluation of the risk associated to the consumption of FS, especially in the elderly population, is particularly challenging due to the frequent exposure to multiple toxicants and to different exposure sources, as well as due to possible pre-existing diseases and respective therapeutics. Therefore, improved quality control procedures and monitoring programs should be pursued in order to avoid undesirable products and assure the safety of FS.

Identification of the designer steroid Androsta-3,5-diene-7,17-dione in a dietary supplement

A liquid chromatography-mass spectrometry (LC-MS) screen for known anabolic-androgenic steroids in a dietary supplement product marketed for "performance enhancement" detected an unknown compound having steroid-like spectral characteristics. The compound was isolated using high performance liquid chromatography with ultraviolet detection (HPLC-UV) coupled with an analytical scale fraction collector. After the compound was isolated, it was then characterized using gas chromatography with simultaneous Fourier Transform infrared detection and mass spectrometry (GC-FT-IR-MS), liquid chromatography-high resolution accurate mass-mass spectrometry (LC-HRAM-MS) and nuclear magnetic resonance (NMR). The steroid had an accurate mass of m/z 285.1847 (error-0.57 ppm) for the protonated species [M + H]⁺ , corresponding to a molecular formula of C₁₉ H₂₄ O₂ . Based on the GC-FT-IR-MS data, NMR data, and accurate mass, the compound was identified as androsta-3,5-diene-7,17-dione. Although this is not the first reported identification of this designer steroid in a dietary supplement, the data provided adds information for identification of this compound not previously reported. This compound was subsequently detected in another dietary supplement product, which contained three additional active ingredients.

The power of hyphenated chromatography-Time of flight mass spectrometry for unequivocal identification of spirostanes in bodybuilding dietary supplements

A previously unidentified purported botanical ingredient was found in dietary supplements marketed for anabolic benefits. In an attempt to assess the 'naturalness' of a group of steroid-like compounds called laxogenins, a UHPLC-QToF method was developed. Several dietary supplements claim to contain 5α-hydroxy laxogenin, which is a derivative of a naturally occurring spirostane-type steroid, laxogenin. Although laxogenin has been isolated from the rhizomes of Smilax sieboldii, 5α-hydroxy laxogenin has not been isolated or reported from any natural source. These derivatives of laxogenins have untested anabolic properties. Due to the low UV absorbance of the spirostanes, a mass spectrometric method in positive ion mode was developed for unambiguous identification of laxogenin and closely related compounds. To show the utility of the developed method, twelve dietary supplements labeled to contain 5α-hydroxy laxogenin or laxogenin as 5α-hydroxy laxogenin were analyzed as a proof-of-concept. Five supplements did not contain any 5α-hydroxy laxogenin, whereas in the remaining seven samples, spirostane-type contaminants were identified along with the labeled 5α-hydroxy laxogenin. The identity of some of these contaminants was established based on reference standards along with mass fragmentation patterns. One of the unlabeled contaminants was identified as the phytosteroid saponin, diosgenin, a common starting precursor of several steroidal drugs. Several synthetic derivatives of diosgenin were identified in the eight products. These findings indicate that the labeled 5α-hydroxy laxogenin along with other spirostanes found in supplements are synthetic and signify a lack of quality controls. Additionally, an unlabeled, anabolic androgenic steroid, arimistane, an aromatase inhibitor, was also identified in one product. Laxogenin, was not detected in any of the samples analyzed during this investigation.

Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To update the "Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2008.

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of seven medical experts and a methodologist.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

Group meetings, conference calls, and e-mail communications facilitated consensus development. Endocrine Society committees, members, and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.

CONCLUSION

We suggest testing for elevated androgen levels in all women with an abnormal hirsutism score. We suggest against testing for elevated androgen levels in eumenorrheic women with unwanted local hair growth (i.e., in the absence of an abnormal hirsutism score). For most women with patient-important hirsutism despite cosmetic measures (shaving, plucking, waxing), we suggest starting with pharmacological therapy and adding direct hair removal methods (electrolysis, photoepilation) for those who desire additional cosmetic benefit. For women with mild hirsutism and no evidence of an endocrine disorder, we suggest either pharmacological therapy or direct hair removal methods. For pharmacological therapy, we suggest oral combined estrogen-progestin contraceptives for the majority of women, adding an antiandrogen after 6 months if the response is suboptimal. We recommend against antiandrogen monotherapy unless adequate contraception is used. We suggest against using insulin-lowering drugs. For most women who choose hair removal therapy, we suggest laser/photoepilation.

Prohibited Contaminants in Dietary Supplements

CONTEXT

With the increasing use of unregulated dietary supplements, athletes are at continued risk from adverse medical events and inadvertent doping.

EVIDENCE ACQUISITION

A review of Clinical Key, MEDLINE, and PubMed databases from 2012 to 2017 was performed using search terms, including dietary supplement, contamination, doping in athletes, inadvertent doping, and prohibited substances. The references of pertinent articles were reviewed for other relevant sources.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Poor manufacturing processes and intentional contamination with many banned substances continue to occur in dietary supplements sold in the United States. Certain sectors, such as weight loss and muscle-building supplements, pose a greater threat because they are more likely to be contaminated.

CONCLUSION

Athletes will continue to be at risk for adverse events and failed doping tests due to contaminated dietary supplements until legislation changes how they are regulated. In the interim, there are several steps that can be taken to mitigate this risk, including improved education of medical staff and athletes and use of third party-certified products.

Heterozygous Inactivation of the Nuclear Receptor PXR/NR1I2 in a Patient With Anabolic Steroid-Induced Intrahepatic Cholestasis

INTRODUCTION

The incidence of liver damage due to steroid consumption is increasing due to the omnipresence of the idealized body image and the widespread availability of drugs via the Internet. The genetic factors underlying individual susceptibility are not presently known.

CASE PRESENTATION

A male patient developed cholestatic liver injury two weeks after a two-month course of anabolic steroids. Next-generation sequencing (NGS) of 24 cholestasis-related genes revealed a heterozygous two-basepair deletion in exon 1 of the pregnane X receptor gene (PXR). Serum bile salt levels showed marked imbalances, strongly resembling the changes observed in patients with biliary obstruction.

CONCLUSIONS

This case of PXR haploinsufficiency reveals transcriptional regulatory functions activated in the liver under xenobiotic stress by steroids, which appear to require two functional copies of the nuclear receptor gene. Deranged bile salt levels outline the central role of PXR in bile acid synthesis, modification, and export.

Liver toxicity related to herbs and dietary supplements: Online table of case reports. Part 2 of 5 series

BACKGROUND

No online current list of potentially life-threatening, hepatotoxic herbs and dietary supplements based on PubMed case reports exists in a summarized tabular form.

METHODS

Documented case reports of herbs or dietary supplements (DS; includes herbs) appearing to contribute to liver injury were used to create an online "DS Toxic Table" of potentially hepatotoxic herbs and dietary supplements (PubMed, 1966 to June, 2016, and cross-referencing). The spectrum of DS induced liver injuries (DSILI) included elevated liver enzymes, hepatitis, steatosis, cholestasis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, veno-occlusive disease, acute liver failure requiring a liver transplant, and death.

RESULTS

Over the past 50 years, approximately 21 herbs (minus germander and usnic acid that are no longer sold) and 12 dietary supplements (minus the nine no longer sold and vitamin A & niacin due to excess intake) posed a possible risk for liver injures in certain individuals. The herbs with the most number of reported publications (but not cases studies) in descending order, were germander, black cohosh, kava extract, and green tea extract.

CONCLUSION

These online DS Toxic Tables will contribute to continued Phase IV post marketing surveillance to detect possible liver toxicity cases and serve to forewarn consumers, clinicians, and corporations.

Scientific and Regulatory Perspectives in Herbal and Dietary Supplement Associated Hepatotoxicity in the United States

In the United States (US), the risk of hepatotoxicity linked to the widespread use of certain herbal products has gained increased attention among regulatory scientists. Based on current US law, all dietary supplements sold domestically, including botanical supplements, are regulated by the Food and Drug Administration (FDA) as a special category of foods. Under this designation, regulatory scientists do not routinely evaluate the efficacy of these products prior to their marketing, despite the content variability and phytochemical complexity that often characterizes them. Nonetheless, there has been notable progress in the development of advanced scientific methods to qualitatively and quantitatively measure ingredients and screen for contaminants and adulterants in botanical products when hepatotoxicity is recognized.

Anabolic steroids abuse and male infertility

For several decades, testosterone and its synthetic derivatives have been used with anabolic and androgenic purposes. These substances were first restricted to professional bodybuilders, but become more and more popular among recreational athletes. Up to date, 3,000,000 anabolic-androgenic steroids (AAS) users have been reported in the United States with an increasing prevalence, making AAS consumption a major public health growing concern. Infertility is defined by the WHO as the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse and a male factor is present in up to 50 % of all infertile couples. Several conditions may be related to male infertility.

Substance abuse, including AAS, is commonly associated to transient or persistent impairment on male reproductive function, through different pathways. Herein, a brief overview on AAS is offered. Steroids biochemistry, patterns of use, physiological and clinical issues are enlightened. A further review about fertility outcomes among male AAS abusers is also presented, including the classic reports on transient anabolic steroid-induced hypogonadism (ASIH), and the more recent experimental reports on structural and genetic sperm damage.

Annual banned-substance review: analytical approaches in human sports drug testing

The aim of improving anti-doping efforts is predicated on several different pillars, including, amongst others, optimized analytical methods. These commonly result from exploiting most recent developments in analytical instrumentation as well as research data on elite athletes' physiology in general, and pharmacology, metabolism, elimination, and downstream effects of prohibited substances and methods of doping, in particular. The need for frequent and adequate adaptations of sports drug testing procedures has been incessant, largely due to the uninterrupted emergence of new chemical entities but also due to the apparent use of established or even obsolete drugs for reasons other than therapeutic means, such as assumed beneficial effects on endurance, strength, and regeneration capacities. Continuing the series of annual banned-substance reviews, literature concerning human sports drug testing published between October 2014 and September 2015 is summarized and reviewed in reference to the content of the 2015 Prohibited List as issued by the World Anti-Doping Agency (WADA), with particular emphasis on analytical approaches and their contribution to enhanced doping controls.

MECHANISMS IN ENDOCRINOLOGY: Medical consequences of doping with anabolic androgenic steroids: effects on reproductive functions

Anabolic androgenic steroids (AASs) are appearance and performance-enhancing drugs (APEDs) used in competitive athletics, in recreational sports, and by body-builders. The global lifetime prevalence of AASs abuse is 6.4% for males and 1.6% for women. Many AASs, often obtained from the internet and dubious sources, have not undergone proper testing and are consumed at extremely high doses and in irrational combinations, also along with other drugs. Controlled clinical trials investigating undesired side effects are lacking because ethical restrictions prevent exposing volunteers to potentially toxic regimens, obscuring a causal relationship between AASs abuse and possible sequelae. Because of the negative feedback in the regulation of the hypothalamic-pituitary-gonadal axis, in men AASs cause reversible suppression of spermatogenesis, testicular atrophy, infertility, and erectile dysfunction (anabolic steroid-induced hypogonadism). Should spermatogenesis not recover after AASs abuse, a pre-existing fertility disorder may have resurfaced. AASs frequently cause gynecomastia and acne. In women, AASs may disrupt ovarian function. Chronic strenuous physical activity leads to menstrual irregularities and, in severe cases, to the female athlete triad (low energy intake, menstrual disorders and low bone mass), making it difficult to disentangle the effects of sports and AASs. Acne, hirsutism and (irreversible) deepening of the voice are further consequences of AASs misuse. There is no evidence that AASs cause breast carcinoma. Detecting AASs misuse through the control network of the World Anti-Doping Agency (WADA) not only aims to guarantee fair conditions for athletes, but also to protect them from medical sequelae of AASs abuse.