Androgen use by athletes: a reevaluation of the health risks

Misadventures in Toxicology: Concentration Matters for Testosterone-Induced Neurotoxicity

Testosterone is the predominant androgen in men and has important physiological functions. Due to declining testosterone levels from a variety of causes, testosterone replacement therapy (TRT) is increasingly utilized, while testosterone is also abused for aesthetic and performance-enhancing purposes. It has been increasingly speculated that aside from more well-established side effects, testosterone may cause neurological damage. However, the in vitro data utilized to support such claims is limited due to the high concentrations used, lack of consideration of tissue distribution, and species differences in sensitivity to testosterone. In most cases, the concentrations studied in vitro are unlikely to be reached in the human brain. Observational data in humans concerning the potential for deleterious changes in brain structure and function are limited by their inherent design as well as significant potential confounders. More research is needed as the currently available data are limited; however, what is available provides rather weak evidence to suggest that testosterone use or abuse has neurotoxic potential in humans.

Doping and Urologic Tumors

Several substances such as growth hormone (GH), erythropoietin (Epo), and anabolic steroids (AS) are improperly utilized to increase the performance of athletes. Evaluating the potential cancer risk associated with doping agents is difficult since these drugs are often used at very high doses and in combination with other licit or illicit drugs.

The GH, via its mediator, the insulin-like growth factor 1 (IGF-1), is involved in the development and progression of cancer. Animal studies suggested that high levels of GH/IGF-1 increase progression of androgen-independent prostate cancer. Clinical data regarding prostate cancer are mostly based on epidemiological studies or indirect data such as IGF-1 high levels in patients with prostate cancer. Even if experimental studies showed a correlation between Epo and cancer, no clinical data are currently available on cancer development related to Epo as a doping agent. Androgens are involved in prostate carcinogenesis modulating genes that regulate cell proliferation, apoptosis and angiogenesis. Most information on AS is anecdotal (case reports on prostate, kidney and testicular cancers). Prospective epidemiologic studies failed to support the hypothesis that circulating androgens are positively associated with prostate cancer risk.

Currently, clinical and epidemiological studies supporting association between doping and urological neoplasias are not available. Nowadays, exposure to doping agents starts more prematurely with a consequent longer exposition period; drugs are often used at very high doses and in combination with other licit or illicit drugs. Due to all these elements it is impossible to predict all the side effects, including cancer; more detailed studies are therefore necessary.

Synergistic effect of DHT and IGF-1 hyperstimulation in human peripheral blood lymphocytes

The abuse of mixed or combined performance-enhancing drugs is widespread among athletes and amateurs, adults and adolescents. Clinical studies demonstrated that misuse of these doping agents is associated with serious adverse effects to many organs in human. Previously, we demonstrated in human peripheral blood lymphocytes that high doses of anabolic androgenic steroids, such as dihydrotestosterone (DHT) and growth factors, such as insulin-like growth factor-1 (IGF-1), have effects at gene and protein levels. Supraphysiological treatments of DHT and IGF-1 affected the expression of genes involved in skeletal muscle disorders as well as in cell-mediated immunological response. At protein level, DHT hyperdosage affects cell motility and apoptosis; IGF-1 hyperstimulation triggers an active cytoskeletal reorganization and an overproduction of immune response- and inflammation-related cytokines. In this study, we investigate the combined effects of DHT and IGF-1 hyperdosage in peripheral blood lymphocytes using a differential proteomic approach. DHT and IGF-1 combined treatment affects cell adhesion, migration, and survival through modulation of expression levels of cytokines and paxillin-signaling-related proteins, and activation of several pathways downstream focal adhesion kinase. Our results indicate a synergistic effect of DHT and IGF-1 which has potential implications for health risk factors.

Anabolic steroids after total knee arthroplasty. A double blinded prospective pilot study

Background

Total knee arthroplasty is reported to improve the patient's quality of life and mobility. However loss of mobility and pain prior to surgery often results in disuse atrophy of muscle. As a consequence the baseline functional state prior to surgery may result in poorer outcome "post surgery" and extended rehabilitation may be required. The use of anabolic steroids for performance enhancement and to influence muscle mass is well established. The positive effects of such treatment on bone and muscle could therefore be beneficial in the rehabilitation of elderly patients. The purpose of this study was to investigate the effects of small doses of Nandrolone decanoate on recovery and muscle strength after total knee replacement and to establish the safety of this drug in multimorbid patients.

Methods

This study was designed as a prospective double blind randomized investigation. Five patients (treatment group) with a mean age of 66.2 (58-72), average BMI of 30.76 (24.3-35.3) received 50 mg nandrolone decanoate intramuscular bi-weekly for 6 months. The control group (five patients; mean age 65.2, range 59-72; average BMI 31.7, range 21.2-35.2) was injected with saline solution. "Pre-operatively" and "post-operatively" (6 weeks, 3,6,9 and 12 months) all patients were assessed using the knee society score (KSS), isokinetic strength testing and functional tests (a sit-to-stand and timed walking tests). In addition, a bone density scan was used preoperatively and 6 month postoperatively to assess bone mineral density.

Results

Whilst the steroid group generally performed better than the placebo group for all of the functional tests, ANOVA failed to reveal any significant differences. The steroid group demonstrated higher levels of quadriceps muscle strength across the postoperative period which reached significance at 3 (p = 0.02), 6 (p = 0.01), and 12 months (p = 0.02). There was a significant difference for the KSS at 6 weeks (p = 0.02), 6 (p = 0.02) and 12 month (p = 0.01). The steroid group demonstrated a reduction in the amount of bone mineral density at both the femur and lumbar spine from "pre-" to "post-surgery", however, these results did not reach significance (p < 0.05) using one-way ANOVA.

Conclusions

This project strongly suggests that the use of anabolic steroids result in an improved outcome as assessed by the KSS and significantly increases extensor strength. No side effects were seen in either the study or control group.

Trial Registration Number

Regional Health District: Register No. 03.05

Human Research Ethics Committee University: Clearance Number: 04/03-19

Anabolic-Androgenic Steroid Abuse by Physicians

Physicians are not immune to the rising popularity of anabolic-androgenic steroid (AAS) abuse. We present three cases of physician-patients who recently required inpatient substance abuse treatment stemming from the abuse of AAS or related compounds. These individuals shared a number of clinical and psychological features that led to or resulted from their abuse of ergogenic substances. Each incurred severe professional, legal, domestic and/or health consequences as a result of their abuse. The common features identified in these patients suggest the presence of an overriding "risk behavior syndrome" that may predispose susceptible individuals to AAS abuse. The reinforcing properties of AAS and the potential for dependence remains an active area of research. Effective treatment of these individuals requires recognition of the causative factors as well as the high likelihood of other substance abuse that must also be addressed. With proper support and monitoring, these individuals can resume productive professional careers.

The Effects of Anabolic Androgenic Steroid Abuse on Gingival Tissues

BACKGROUND

Anabolic androgenic steroid (AAS) is the familiar name for synthetic derivatives of the male sex hormone, testosterone. A large number of young adults abuse AAS to enhance performance and physical appearance. The aim of this study was to evaluate the effects of AAS abuse on the gingival tissues in a group of bodybuilders and weight lifters.

METHODS

The test group was composed of 24 athletes aged between 17 and 29 years who had been using AAS for >1 year. All subjects were clinically examined for plaque levels (plaque index), gingival inflammation (gingival index), and gingival enlargement. The results were compared to a control group of 20 bodybuilders who had never used AAS drugs and who matched for age, educational level, and oral habits according to the data obtained from the test group.

RESULTS

Although there were no statistical differences between the plaque index (P>0.05) and gingival index (P>0.05) scores of the study group and the control group, the AAS abusers had statistically higher scores of gingival thickness, extent of gingival encroachment, and total gingival enlargement scores (P<0.001 each) compared to non-users.

CONCLUSIONS

The results of this study have revealed that the prolonged use of AAS is closely associated with significant levels of gingival enlargement. Because recreational abuse and abuse in non-competitive sports seem to increase despite legislation, dentists and periodontists should be familiar with the adverse effects of these synthetic derivatives of testosterone on the gingival tissues.

Current concepts in anabolic-androgenic steroids

Anabolic-androgenic steroids (AAS) are synthetic derivatives of testosterone. According to surveys and media reports, the legal and illegal use of these drugs is gaining popularity. Testosterone restores sex drive and boosts muscle mass, making it central to 2 of society's rising preoccupations: perfecting the male body and sustaining the male libido. The anabolic effects of AAS have been questioned for decades, but recent scientific investigation of supraphysiologic doses supports the efficacy of these regimens. Testosterone has potent anabolic effects on the musculoskeletal system, including an increase in lean body mass, a dose-related hypertrophy of muscle fibers, and an increase in muscle strength. For athletes requiring speed and strength and men desiring a cosmetic muscle makeover, illegal steroids are a powerful lure, despite the risk of subjective side effects. Recent clinical studies have discovered novel therapeutic uses for physiologic doses of AAS, without any significant adverse effects in the short term. In the wake of important scientific advances during the past decade, the positive and negative effects of AAS warrant reevaluation. Guidelines for the clinical evaluation of AAS users will be presented for sports medicine practitioners.

Effects of androgen manipulation on postprandial triglyceridaemia, low-density lipoprotein particle size and lipoprotein(a) in men

Although androgenic hormones decrease HDLC concentration, no direct evidence has linked them to atherosclerosis. The present study was undertaken to extend our ability to assess risk associated with androgen induced lipoprotein(Lp) changes by simultaneously gathering information about postprandial triglyceridaemia (PPT), LDL particle size, HDL and Lp(a) in men either taking exogenous androgens or with suppressed endogenous androgen concentrations. The experimental groups comprised nine male bodybuilders who self-administered anabolic-androgenic steroids (AAS) for a mean period of 6.5 weeks, and 10 healthy men whose testosterone concentration had been reversibly suppressed for 5 weeks using the GnRH agonist triptorelin (Decapeptyl; D-Trp-6-LHRH). A separate group receiving no hormonal treatment provided analytical control (n=7). Lipoprotein size was assessed by gradient gel electrophoresis categorisation (GGE), lipoprotein concentrations by immuno and enzymatic assays and PPT by a standardised oral fat tolerance test (65g /m(2)). Testosterone concentration was significantly reduced on triptorelin from 7.32+/-1.92 to 1.15+/-0.57 ng/ml (P=0.002). High dose AAS use was confirmed by urinalysis. With AAS use, mean HDLC and Lp(a) concentrations and PPT decreased from 0.9+/-0.3 to 0.7+/-0.3 mmol/l (P=0.004), 125+/-128 to 69+/-73 U/l (P=0.008) and 11.6+/-10.0 mmol/l h to 7.5+/-5.4 mmol/l h (P=0.027) respectively. Mean total cholesterol and LDLC were unchanged. LDL size was unchanged in six AAS users, decreased in one but remaining in the normal size range, and increased in two from small LDL to the normal range. Size changes in the latter two subjects were associated with 42 and 58% reductions in PPT respectively. In the triptorelin group, mean total cholesterol, HDLC and Lp(a) were increased from 4.8+/-0.8 mmol/l to 5.2+/-1.0 mmol/l (P=0.039), 1.1+/-0.2 to 1.4+/-0.3 mmol/l (P=0.002) and 278+/-149 to 377+/-222 U/l (P=0.004) respectively. Mean LDLC concentration and PPT were unchanged. LDL particle size increased in four, decreased in two, and was unchanged in four subjects. LDL size decreased in two and showed no change in the other five control subjects. Other lipid measures were unchanged in the control group. Thus, apart from lowering HDLC concentrations, no other potentially atherogenic effects of endogenous androgens or AAS were observed. A suppression of Lp(a) as well as a reduced PPT and increased LDL size in predisposed individuals may be antiatherogenic effects of AAS.

Use of ergogenic aids by athletes

"Ergogenic aid" is defined as any means of enhancing energy utilization, including energy production, control, and efficiency. Athletes frequently use ergogenic aids to improve their performance and increase their chances of winning in competition. It is estimated that between 1 and 3 million male and female athletes in the United States alone have used anabolic steroids. In response to the problem of drug use, many athletic organizations have established policies prohibiting the use of certain pharmacologic, physiologic, and nutritional aids by athletes and have implemented drug testing programs to monitor compliance. Therefore, it is important for physicians to be knowledgeable about the available ergogenic aids so they can appropriately treat and counsel the athletic patient.

Effects of castration and androgen treatment on androgen-receptor levels in rat skeletal muscles

The effects of castration and dihydrotestosterone (DHT) treatment on levels of skeletal muscle androgen receptor (AR) were examined in three groups of adult male rats: 1) intact normal rats, 2) rats castrated at 16 wk of age, and 3) rats castrated at 16 wk of age and given DHT for 1 wk starting at week 17. All animals were killed at 18 wk of age. Castration caused a decrease (P < 0.05) in the weights of the levator ani and bulbocavernosus muscles. The administration of DHT to the castrated rats increased (P < 0.05) the weights of the levator ani and bulbocavernosus muscles. Castration caused a significant downregulation of AR levels in the bulbocavernosus (P < 0.05) but had no significant effect on AR levels in the levator ani muscle. DHT administration to the castrated group upregulated AR levels in the bulbocavernosus and levator ani muscles. The plantaris muscle did not significantly (P > 0.05) change for any of the treatments. These findings suggest that the effects of castration and androgen replacement differentially affect skeletal muscle mass and AR levels.

Intratesticular leiomyosarcoma in a young man after high dose doping with Oral-Turinabol: a case report

BACKGROUND

Androgenic anabolic steroids have been suspected of activity as carcinogens in the development of carcinoma and angiosarcoma of the liver and adenocarcinoma of the prostate. Although the proliferation of smooth muscle cells is stimulated by sexual steroids, to the authors' knowledge a possible relation between androgenic anabolic steroids and the development of leiomyosarcoma has not previously been reported in humans.

METHODS

A 32-year-old man underwent right radical orchiectomy for a tumor of the upper pole of the right testicle. Routine histopathologic examination and immunohistochemical staining were performed.

RESULTS

The tumor was identified as an intratesticular leiomyosarcoma based on its typical growth pattern and the characteristic immunohistochemical staining profile. The patient reported a 5-year history of systematic use of high dose Oral-Turinabol (4-chloro-1-dehydro-17alpha-methylteststerone) that began at age 18 years and stopped approximately 9 years before presentation.

CONCLUSIONS

The rarity of intratesticular leiomyosarcoma, the experimental induction of similar tumors in animals by androgens and estrogens, and the unusually young age at presentation of the patient in the current study support the hypothesis that high dose doping with androgenic anabolic steroids could have played a cocarcinogenic role in the development of the tumor in this case.

Steroids and steroid-like compounds

Athletes have been searching for an "edge" in competition as long as there has been a reward for success. Anabolic-androgenic steroids have been the most popular of these ergogenic aids when winning is the only goal. The authors present a concise review of these substances, their prevalence, efficacy, adverse effects, and legality. This article also presents a steroid user profile and discusses physician perception and management of a patient who uses these drugs. The popular precursors of testosterone, dehydroepiandrosterone, and androstenedione are discussed with a review of the limited available data on these substances.

Anabolic steroid use by male and female middle school students

BACKGROUND

The prevalence of anabolic steroid use by high school and college students has been reported in the literature. However, rumors persist regarding the use of steroids by younger populations.

OBJECTIVE

To assess the extent of steroid use by male and female middle school students and to explore their attitudes and perceptions about these drugs. Methods. A confidential self-report questionnaire was administered to 466 male and 499 female students between 9 and 13 years of age (mean +/- SD, 11.4 +/- 0.9 years) in 5th, 6th, and 7th grades from four public middle schools in Massachusetts. The number of students reporting steroid use and differences between users' and nonusers' underlying attitudes and perceptions about these drugs were evaluated.

RESULTS

The response rate was 82% (965/1175 eligible). Results indicated that 2.7% of all middle school students reported using steroids; 2.6% were males and 2.8% were females. When steroid users were compared with nonusers, 47% versus 43% thought that steroids make muscles bigger; 58% versus 31% thought that steroids make muscles stronger; 31% versus 11% thought that steroids improve athletic performance; 23% versus 13% thought that steroids make one look better; 23% versus 9% knew someone their own age who currently took steroids; 38% versus 4% were asked by someone to take steroids; 54% versus 91% thought that steroids were bad for them; and 35% versus 2% indicated that they would take steroids in the future. Additional analyses determined steroid user involvement in sports and activities.

CONCLUSION

The results of this study suggest that the problem of illicit steroid use extends to children and young adolescents and that a segment of this population is mindful of the potential physiologic effects of steroids. This information will be useful to pediatricians, sport authorities, and school teachers whose guidance will become increasingly more important as steroid educational interventions for male and female middle school students are developed.

Medico-legal aspects of doping

Abuse of anabolic steroids is an increasing problem not only among athletes but also body-builders and teenagers. A fast-developing black market has been established since the opening of the borders to eastern Europe. Medico-legal aspects of doping are addressed with particular reference to toxicology and pathology. Constituents of anabolic steroids bought on the black market were identified using gas chromatography/mass spectrometry; the products did not contain the expected ingredients in 35% of cases. Long-term effects and fatalities because of anabolic steroid abuse are reported here based on our own case material and a literature review. In our own cases, severe cardiovascular side-effects developed after long-term abuse of Dianabol (methandrostenolone) and Oral-Turinabol (chlordehydromethyltestosterone), i.e. myocardial infarction, stroke, organomegaly and/or severe atherosclerosis. The pathogenesis of cardiovascular complications (cardiotoxic effect, risk of atherosclerosis, thrombogenic risk) is discussed based on the available literature reports following fatal outcome after the abuse of anabolic steroids.

Uso de esteróides anabolizantes em praticantes de musculação e/ou fisioculturismo

Os hormônios andrógeno-anabolizantes têm seu uso difundido entre os esportistas, usualmente para aumentar a massa e a potência musculares. Assim, através do uso de questionários auto-aplicáveis em um estudo transversal, foram entrevistados 305 atletas (escolhidos aleatoriamente) das academias de Santa Maria, RS, a fim de quantificar diversas variáveis relacionadas ao uso de esteróides anabolizantes (EA). A maioria dos participantes era de homens (81,1%) e a média de idade foi de 22 anos (DP ± 7). Enquanto 29% usavam aditivos alimentares, apenas 2% dos indivíduos admitiram ter usado EA (apesar de 46% dos entrevistados conhecerem algum usuário de EA). Dois terços dos usuários adquiriram a droga em farmácias (sem prescrição médica) e 35,1% desconheciam seus paraefeitos. Dos entrevistados, 28,4% acreditam que doses "adequadas" de EA não causam dano à saúde. Dessa forma, conclui-se que a principal medida preventiva à iniciação ao uso de EA é a educação dos atletas.