Athletes Using Performance Enhancers

Lee A. Mancini

INTRODUCTION

In 1987 a poll of Olympic-level power athletes offered the following scenario: the athletes were offered a banned substance with two guarantees—you would not get caught and you would win the gold medal. Out of 198 athletes, 195 said yes and only 3 said no. Another question posed in that 1987 poll was, would you take a banned substance if it would let you win every competition you entered for the next 5 years, but would kill you in the sixth year? Over half of these athletes responded yes, that is, they would take the substance.¹ It is estimated that between one to three million athletes in the United States have used steroids. Nearly 60% of all high school students play on formal sports teams.² There is enormous pressure on athletes to gain any sort of competitive advantage. This chapter will review the most common types of performance enhancers used by athletes and help the medical provider approach this challenging issue in an organized fashion with their patients.

PATHOPHYSIOLOGY/PHARMACOLOGY

Erythropoietin

Erythropoietin is an alternative to blood doping. It is a hormone naturally produced in the kidney. The recombinant form is used to artificially increase hematocrit mass and to increase oxygen-carrying capacity of blood. It has been proven to increase hematocrit, Vo₂max, and time to exhaustion. Side effects of erythropoietin are an increased risk of cerebral vascular accident, myocardial infarction, and pulmonary embolism. Erythropoietin is banned by the International Olympic Committee (IOC), the International Cycling Union, and the International Ski Federation. The governing bodies have adopted an upper limit of hemoglobin as a rule for competition.³

Blood Doping

Blood doping is an autologous transfusion of blood into an athlete. Blood doping artificially increases the hematocrit mass and increases oxygen-carrying capacity of blood. It has been shown to increase hematocrit, Vo₂max, and time to exhaustion in athletes. Side effects of blood doping are an increased risk of cerebral vascular accident, myocardial infarction, pulmonary embolism, and blood pathogens such as HIV, hepatitis B, and hepatitis C. Blood doping is banned by the IOC, the International Cycling Union, and the International Ski Federation. Governing bodies have adopted an upper limit of hemoglobin as a rule for competition.³

Anabolic-Androgenic Steroids (AAS)

The goal of synthetic steroids is to maximize anabolic effects while minimizing androgenic effects. Synthetic steroids have alkylation of the 17-α position on sterol D ring and carboxylation of the 17-β hydroxyl group on the sterol D ring. Stacking is taking multiple steroids at the same time. Pyramiding is increasing the doses to peak toward the middle of a cycle.

Synthetic steroids have been proven to increase fat-free mass. Most studies have shown increases in lean body mass (LBM) of an average of 2 to 5 kg in a 10-week period.⁴ Steroids have been proven to increase strength.² The effects of steroids are dose related, with higher doses leading to greater gains.

Steroids have been shown to have a wide array of side effects that range from nuisances to life threatening. The side effects of steroids affect every organ system in the body.

Cardiovascular Effects

Steroid use by athletes causes a significant decrease in highdensity lipoprotein (HDL) cholesterol and an increase in low-density lipoprotein (LDL) and very low density lipoprotein (VLDL) cholesterol. Athletes taking steroids have a greater risk of myocardial ischemia and infarction, hypertension, and cerebral vascular accident.⁵ Chronic steroid use can cause left ventricular hypertrophy and left ventricular wall thickness.²,⁶ All cardiovascular effects reversed when examined 3 months after cessation of steroids.¹

Psychologic Effects

Steroid use has been shown to increase the risk of aggressive behavior. There have been reports of steroids causing mood disturbances.⁴

Toxicologic Effects

There have been documented cases of steroid users contracting hepatitis B, hepatitis C, and HIV.⁷ There have also been documented cases of fungal and bacterial abscesses from injection of steroids.⁸ As with any injectable substances, athletes are at risk if they are sharing needles.

Musculoskeletal Effects

There is an increased risk of tendon ruptures in athletes using steroids. There is evidence of premature closure of growth plates in younger athletes using steroids.

Dermatologic Effects

Steroid use has been shown to cause alopecia, striae distensae (stretch marks), and acne.

Male Reproductive Effects

Male athlete steroid use decreases testes size, sperm count, and sperm quality and can cause gynecomastia.

Female Reproductive Effects

Female athlete steroid use causes voice deepening, sterilization, enlargement of clitoris, menstrual irregularities, hirsutism, male pattern baldness, and breast atrophy. Sterilization is irreversible in women after discontinuing steroids.

TABLE 26.1 Adverse Effects of Steroid Use

CNS	Derm	Musculoskeletal	Liver	Men	Women	Cardiac	Immune
Increased aggression	Oily hair and skin	Premature closure of growth plates	Increased LFTs	Gynecomastia	Hirsutism	Increased total cholesterol, LDL, VLDL, and triglycerides	Increased risk of HIV
Mood swings	Alopecia	Increased risk of tendon ruptures	Peliosis hepatis (blood-filled liver cysts)	Increased risk of prostate cancer	Voice deepening	Increased risk of stroke	Increased risk of hepatitis B
Increased sexual aggression	Striae distensae (stretch marks)			Decreased testicle size	Clitoral hypertrophy	Decreased HDL	Increased risk of hepatitis C
Increased major mood disorders	Acne on the face and back			Decreased sperm count	Decrease in breast size and amenorrhea	Increased risk of myocardial infarction
	Increased sebaceous cysts			Decreased fertility	Male pattern baldness	Hypertension
LFTs, liver function tests; LDL, low-density lipoprotein; VLDL, very low density lipoprotein; HDL, high-density lipoprotein.

Hepatic Effects

Steroid use elevates liver enzymes, can create peliosis hepatis (blood-filled cysts in the liver) and cholestatic jaundice, and can cause hepatocellular carcinoma (Table 26.1).⁴,⁸

Legal Issues

Steroids are banned by the IOC, the National Collegiate Athletic Association (NCAA), the National Football League (NFL), the National Basketball Association (NBA), and Major League Baseball (MLB). A positive test has a testosterone-to-epitestosterone ratio greater than 6:1 for both men and women. The normal ratio in healthy male is 1.3:1, and only one male in 1,000 has a ratio of 4:1.

Possession of steroids carries both a 1-year prison sentence and minimum $1,000 fine. Selling or the intent to sell steroids carries a 5-year prison sentence and $250,000 fine.²

Prohormones

Prohormones are the androgenic testosterone precursors. Examples of prohormones are androstenedione and dehydroepiandrosterone (DHEA). The proposed mechanism is that prohormones would increase serum testosterone.

Performance Effects

There are no proven performance effects of androstenedione. DHEA has been shown to decrease body fat in some studies and no effect in others. DHEA has shown no increase in testosterone levels.⁹

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