Doping: Anabolic Steroids

Doping exists always and everywhere – not only in sports, but also in social life. Alcohol, sedatives and stimulants are nowadays the supporting measures not only for personal pleasure, but also for stress management and professional performance enhancement. We live in a competitive society, and competitive sports are a reflection of it. Doping is not a phenomenon of modern times. Doping was already practiced in ancient times by the Greeks and Romans. Even then, it wasn’t just about fame and glory. Attempts were made to improve performance and thereby gain a competitive advantage. One should be aware that in today’s elite sports, doping is widely practiced, but in the meantime the topic of doping is also on the agenda in popular sports. Here, the focus is often less on the idea of performance than on the “visual aspect” of one’s own body. The procurement problem is no longer a problem in the age of the infinite supply of information. Thus, physicians involved in sports medicine are regularly confronted with this issue.

The situation in Germany

The World Anti-Doping Code, which was adopted in Copenhagen on the initiative of the World Anti-Doping Agency, has been in force worldwide since 2004. Unlike other countries such as France, Italy or Belgium, there are no specific anti-doping laws in Germany. Only within the framework of the Medicines Act is the marketing, prescribing and use of medicines for doping purposes in sport subject to criminal law. However, taking and possession of doping substances are not punishable. The sanctioning of doped athletes thus remains in the hands of the sports associations. According to a survey, more than 800,000 Germans admit that they regularly take doping substances in order to be physically and mentally fit and to cope with the ever-increasing stresses at work and in their private lives. Anabolic steroids (anabolic steroids; growth hormones) in sports have a building effect – through increased protein biosynthesis (new formation of proteins) – with an increase in muscle mass and muscle strength. The most commonly used substances are the anabolic androgenic steroids (AAS). These are testosterone and their synthetically produced derivatives (derivatives). Overview of the different classes of anabolic substances.

Substance class Substance class representative
Anabolic androgenic steroids (AAS) Testosterone preparations (T-cypionate, -decanoate, -enanthate, -isocaproate, -phenylproprionate, -proprionate), dehydrochloromethyltestosterone, furazabol, nandrolone, metandienone, metenolone, oralturinabol, stanozolol, and trenbolone)
Selective androgen receptor modulators* (SARM). Andarine (S-4)/S4 Andarine, Ostarine (MK-2866 or GTx-024).
β2-Sympathomimetics(beta-2 agonists). z. E.g., clenbuterol (LABA (“long-acting beta-2 agonists”) – duration of action: 6-12 hours).
Growth factors
Erythropoietin (EPO)
Somatotropin (STH; growth hormone)
Somatomedin/”insulin-like growth factor 1″ (IGF-1)* *

* high binding affinity to the androgen receptor in the musculoskeletal system (10-fold higher than testosterone)* * is often combined with insulinIn addition to testosterone itself, synthetically produced steroids that exhibit an effect similar to the male sex hormone testosterone are used. The most important representatives are listed above in the table.Depending on the duration, dosage and type of application, different side effects occur. These affect the liver, hormonal control circuits, blood lipid levels, the cardiovascular system, the skin and the psyche.Side effects of anabolic androgenic steroids (AAS).

Gynecomastia (enlargement of the mammary glands)
Testicular atrophy (testicular shrinkage)
Steroid acne (face/shoulders)
Reduced HDL cholesterol (reduction of up to 70%).
LDL elevation by up to 20% with consecutive 3- to 6-fold increased risk of CHD (coronary artery disease; coronary artery disease)
Oxidative stress; elevated inflammatory markers.
Arterial hypertension (high blood pressure)
Cardiac hypertrophy (enlargement of the heart)
Impaired left ventricular pump function (systolic as well as diastolic ventricular function) and accelerated coronary sclerosis
Liver cysts/cell adenoma
Mental instability, aggressive behavior

When growth hormones (somatotropic hormone (STH), English “human growth hormone (GH)) such as somatotropin are used, risks such as acromegaly and diabetes mellitus (type 2) occur. Recently, endogenous substances such as somatotropin and somatomedin C (IGF-1) have also been increasingly used to enhance performance. Somatotropin is often used in combination with insulin, since insulin compensates for the reduced glucose uptake into muscle cells caused by somatotropin. The other far more important effect of growth hormones for athletes is the activation of liver synthesis of insulin-like-growth-factor-I (IGF-I, IGF-1; also called somatomedin C (SM-C)) and insulin-like-growth-factor-binding-protein-3 (IGF-BP-3; IGF 3 BP).IGFBP-3 binds IGF-1 (insulin-like-growth-factor) circulating in the blood. In this process, the action of IGF-1 is regulated by IGFBP-3.IGF-1 (somatomedin C) is one of the differentiation and growth factors. This hormone is the effective muscle anabolic and fat catabolic activator. Thus, many doping athletes now know that through the combined use of STH, T3 and T4, high doses of testosterone (up to 1,500 mg ! / Wo) or metandienone (a synthetically produced steroid) and insulin, a maximum growth effect on the muscles occurs. Metandienone is a so-called 17α-alkylated steroid due to its methylation. This alkylation means that metandienone is only subject to a low first-pass effect, i.e. it can be taken orally. At the same time, it has a lower affinity for both androgen receptors and sex hormone binding globulin (SHGB). Since only free androgens, i.e. those not bound to SHGB, are effective, metandienone is still significantly more active than testosterone in sum. In many cases, athletes who take such combined therapies gain weight and muscle, sometimes more than 10 kg, in just a few weeks. Other typical doping agents are β2-sympathomimetics (beta-2 agonists; e.g., clenbuterol), which also have an anabolic effect. These agents were developed as drugs to treat asthmatic symptoms and to inhibit labor. In addition to tocolytic and bronchodilator effects, they exhibit muscle anabolic and lipolytic side effects.β2-Sympathomimetics can enhance sprint and power performance in athletes who do not have asthma. They improve anaerobic exercise performance by 5% in people without asthma compared with placebo treatment.Depending on duration, dosage, and mode of application, different side effects occur. These affect the cardiovascular system and include muscle tremors, muscle cramps, and cephalgia (headache). Users of anabolic androgen steroids (ASA users) treat themselves according to a typical ASA cycle:

  • Week 1 – average 4-12 weeks of diverse ASA 500-1,000 mg/week (combining is referred to as “stacking”).
  • 9th week – additionally hCG + aromatosis inhibitors.
  • Week 16 – 4 weeks post-cycle phase: SERM.

Legend

  • ASS: anabolic androgenic steroids.
  • HCG: human chorionic gonadotropin
  • SERM: selective estrogen receptor modulators.

Gender-specific side effects of anabolic steroids are:

  • Male
    • Hypogonadism (gonadal hypofunction; anabolic steroid-induced hypogonadism (AIH); “anabolic androgenic steroid-induced hypogonadism”); this is associated with:
      • Suppression of spermatogenesis (suppression of spermatogenesis).
      • Gynecomastia (enlargement of the mammary gland).
      • Testicular atrophy (“testicular shrinkage”)
      • Loss of libido
      • Infertility (fertility disorder)
      • erectile dysfunction (ED; erectile dysfunction).
  • Ms.
  • Man and woman
    • Acne, severe
    • Striae distensae on chest and upper arms (due torapid muscle growth).
    • Hematocrit increase (Ht > 52%) → risk increase of thromboembolism, intracardiac thrombi and apoplexy.
    • LDL cholesterol elevation
    • Water retention (water retention) → increase in blood pressure.
    • Hepatotoxicity (liver toxicity ; especially 17α-alkylated substances) [bilirubin ↑↑; transaminases ↑]
    • Nephrotoxicity (kidney damaging effect) [creatinine ↑: cystatin C determination required]
    • Mental disorders: Anxiousness, depressive and obsessive-compulsive disorders; short-term aggressiveness and hyperactivity (esp. with high doses of testosterone (≥ 500 mg/week)).
    • In long-term abuse: atherosclerosis (arteriosclerosis, hardening of the arteries) with the consequences of peripheral arterial occlusive disease (pAVD), coronary heart disease (CHD; coronary artery disease), and left ventricular hypertrophy (LVH; left ventricular hypertrophy) with persistent diastolic relaxation disorder (i.e., part of the heart muscle does not relax normally)

It is important to provide medical education to athletes and to steer them in the right direction in a reasonable way. Here, the sports medicine supervising physician faces difficult tasks every day.