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Review
, 35 (3), 341-75

Adverse Health Consequences of Performance-Enhancing Drugs: An Endocrine Society Scientific Statement

Affiliations
Review

Adverse Health Consequences of Performance-Enhancing Drugs: An Endocrine Society Scientific Statement

Harrison G Pope Jr et al. Endocr Rev.

Abstract

Despite the high prevalence of performance-enhancing drug (PED) use, media attention has focused almost entirely on PED use by elite athletes to illicitly gain a competitive advantage in sports, and not on the health risks of PEDs. There is a widespread misperception that PED use is safe or that adverse effects are manageable. In reality, the vast majority of PED users are not athletes but rather nonathlete weightlifters, and the adverse health effects of PED use are greatly underappreciated. This scientific statement synthesizes available information on the medical consequences of PED use, identifies gaps in knowledge, and aims to focus the attention of the medical community and policymakers on PED use as an important public health problem. PED users frequently consume highly supraphysiologic doses of PEDs, combine them with other PEDs and/or other classical drugs of abuse, and display additional associated risk factors. PED use has been linked to an increased risk of death and a wide variety of cardiovascular, psychiatric, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders. Because randomized trials cannot ethically duplicate the large doses of PEDs and the many factors associated with PED use, we need observational studies to collect valid outcome data on the health risks associated with PEDs. In addition, we need studies regarding the prevalence of PED use, the mechanisms by which PEDs exert their adverse health effects, and the interactive effects of PEDs with sports injuries and other high-risk behaviors. We also need randomized trials to assess therapeutic interventions for treating the adverse effects of PEDs, such as the anabolic-androgen steroid withdrawal syndrome. Finally, we need to raise public awareness of the serious health consequences of PEDs.

Figures

Figure 1.
Figure 1.
An example of the combined search sets researchers used for each category of PEDs.
Figure 2.
Figure 2.
An historical timeline of the evolution of image- and PED use.
Figure 3.
Figure 3.
The estimates of the prevalence of AASs, cocaine, heroin, and amphetamine use among 12th-grade students from the Monitoring the Future study. The Monitoring the Future survey question states, “Steroids, or anabolic steroids, are sometimes prescribed by doctors to treat certain conditions. Some athletes, and others, have used them to try to increase muscle development. On how many occasions (if any) have you taken steroids on your own—that is, without a doctor telling you to take them?” The limitations of these data include the potential for false positives from a respondent's lack of understanding of the question as well as the potential underestimation of the problem because AAS users do not begin using steroids until they reach their early 20s.
Figure 4.
Figure 4.
The types of PEDs used by competitive athletes based on the WADA's 2011 testing data (A) and by nonathlete weightlifters from a recently published study by Dr Pope (B). A, The types of PEDs used by competitive athletes based on WADA's 2011 testing data. B, The types of PEDs used by nonathlete weighlifters. Because WADA tests only athletes participating in certain competitive sports events, the data in A do not provide information about the frequency of use of various PEDs by nonathlete weightlifters. The distribution of AAS use by nonathlete weightlifters shown in B differs substantially from that among athletes tested by WADA in A. Although testosterone, stanazolol, and nandrolone were the AASs most frequently found in WADA's tests of athletes, testosterone, boldenone, trenbolone, and nandrolone were the AAS most frequently found in nonathlete weightlifters (19).
Figure 5.
Figure 5.
Structure-activity relationships of steroidal androgens. AAS compounds are derivatives of testosterone. Structural modifications of the testosterone molecule based on rational structure-activity relationships have yielded numerous derivatives that differ in their affinity for the androgen receptor, coactivator recruitment, susceptibility to presystemic metabolism, aromatization, metabolism and duration of action, and anabolic to androgenic activity. Novel orally active nonsteroidal SARMs are being developed for their clinical applications in sarcopenia associated with aging and chronic illnesses, although these compounds have not yet been approved for any indication. These oral nonsteroidal SARMs are not widely abused by nonathlete weightlifters because of their relative inaccessibility.

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