Use of androgens and other performing enhancing drugs by athletes

INTRODUCTION

Some athletes take medications to attempt to improve their performance. They are motivated by a desire to win and the perception that certain medications improve performance. The focus of the general news media is on the athletes who are caught using these medications in popular sporting events, such as the Olympics, baseball, and the Tour de France bicycle race [1]. In comparison, the emphasis of the sports medicine literature is on methods of detection of the newest medications that athletes are using. The focus of this review is on the effects of these compounds that might be encountered by a physician who sees an athlete, competitive or noncompetitive, as a patient. Physicians might also see patients who are taking androgens to improve their appearance [2].

The United States Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for drug abuse in adolescents, including abuse of anabolic steroids [3]. The American Academy of Family Physicians, American Medical Association Guidelines for Adolescent Preventive Services, and the American Academy of Pediatrics all suggest that clinicians discuss the dangers of drug abuse with children and adolescents and include questions about substance abuse as a part of routine adolescent visits. Physicians may also suspect abuse of androgens in adolescents who have problem behavior (eg, fighting, other substance abuse, sexual risk) [4].

HOW THIS AREA OF MEDICINE IS DIFFERENT

This area of medicine differs from most others because athletes who take medications to improve their performance do so surreptitiously. There are several consequences of the clandestine nature of this use:

• Athletes often obtain the medications from sources other than physicians. These preparations are sometimes meant for veterinary use, sometimes from laboratories that are not regulated by government agencies for manufacturing quality.
• Athletes obtain their information about the medications from other athletes, trainers, magazines, underground publications, and the Internet.
• Athletes often take several medications in various patterns, including simultaneously, consecutively ("stacking"), escalating doses ("pyramiding"), intermittently or cyclically in an attempt to increase the overall effect on performance.
• Athletes may attempt to counter a side effect of one medication with another medication. As examples, an athlete might take human chorionic gonadotropin (hCG) to counteract the decrease in testicular size resulting from high-dose androgen use, an aromatase inhibitor or estrogen receptor antagonist to counteract the gynecomastia from administration of high doses of hCG, and a 5 alpha reductase inhibitor to prevent balding and acne.
• Athletes discontinue the medications periodically, often to avoid detection when they know they will be tested just before a competition.
• Physicians who see these athletes are often unaware that they are taking these medications.
• Physicians' knowledge of the possible effects of these medications is poor because the doses and even the medications used have rarely been studied in a controlled fashion.

EPIDEMIOLOGY

It is difficult to know how commonly athletes take these medications since they are so often taken surreptitiously. In fact, athletes use elaborate schemes to avoid detection.