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Do anabolic-androgenic steroids enhance sporting performance?
A recent study has provided evidence that testosterone increases muscle strength, but does this translate to enhanced performance?
For almost half a century, athletes have believed that use of anabolic-androgenic steroids can improve sporting performance. The United States physician John Zeigler was so convinced of their positive effects that on his return from the World Powerlifting Championships in Vienna in 1954 he worked on the development of methandrostenolone as a means of enhancing sporting performance.
1 This belief has persisted, leading to the widespread and much-publicised use of these drugs at all levels of sport (professional and amateur). It has been promoted by the banning of these drugs by sporting bodies to ensure fair competition.
2 Media reports and "underground" guides to anabolic steroids have also propagated the use of anabolic-androgenic steroids, which has spread from elite athletes to recreational bodybuilders, amateur athletes and adolescents.
3 Are the athletes and their coaches mistaken in their belief?
Theoretically, anabolic-androgenic steroids should improve athletic performance by increasing muscle mass (via increased protein synthesis, nitrogen retention and antiglucocorticoid actions), as well as by increasing aggression and motivation.
Moreover, recent isotope uptake studies in humans indicate that androgens may increase muscle protein synthesis, possibly through stimulation of intramuscular insulin-like growth factor-I (IGF-I) gene expression.
4 However, clinical studies have, in general, been inconclusive, partly because of the many unique methodological problems in studying the effects of anabolic-androgenic steroids (see below).
In 1991, 16 randomised, placebo-controlled studies that used objective measures of performance were analysed by Elashoff et al.
5 They concluded that, while the possibility of anabolic-androgenic steroids improving sporting performance could not be excluded, "the data are insufficient to allow any firm conclusion about the efficacy of anabolic steroids in enhancing overall athletic performance".
Since then, apart from a non-placebo-controlled study that showed an increase in lean body mass in healthy male volunteers receiving weekly injections of testosterone enanthate,
6 there were few real developments in the area until Bhasin et al.
7 published their study in July 1996.
This study will probably become, in time, one of the most-cited articles on drugs and sport. Funded by the National Institutes of Health (US), the study examined the effect of high doses of testosterone enanthate in sesame oil (600 mg/week intramuscularly for 10 weeks); the authors made every attempt to remove confounding variables (such as diet, training, and weightlifting experience), and used standardised measures.
Forty-three experienced weightlifters were randomly assigned to one of four groups (placebo with or without exercise, or testosterone with or without exercise). Strength was measured by two single weightlifts -- upper-body strength by benchpress, and lower-body strength by squatting. Fat-free body mass was measured by underwater weighing, and muscle size by magnetic resonance imaging. Forty subjects completed the study.
Body weight increased only in the two testosterone-treated groups, and fat-free body mass only in the exercise groups, with the greatest change in fat-free mass in the testosterone plus exercise group (increase, 6.1 kg).
Percentage body fat did not change in any group. Muscle size increased more in the testosterone groups than in either placebo group.
Strength increased in both testosterone groups, as well as in the exercise group receiving placebo, but was greater in the exercise group with testosterone than in the exercise group with placebo.
No significant adverse drug reactions were reported. Hence, for the first time, in a well designed study, supraphysiological testosterone did appear to increase muscle strength.
One other placebo-controlled study has used higher doses of anabolic steroids (methandrostenolone, 100 mg/day for six weeks).
8 Reported 20 years ago, it used a crossover design, with attempts to control for most variables. The active drug was found to be no better than placebo in increasing strength.
However, some caveats should be considered in assessing Bhasin et al.'s data. A placebo response has not been completely eliminated. It was not stated that the placebo was identical to the active drug in terms of pH, viscosity and other factors that may have allowed the code to be broken by either the administrator or recipient of the drug. Indeed, in a controlled study of oral anabolic steroids, all subjects correctly identified the active drug when directly asked.
9 The importance of the placebo response was shown by Ariel and Saville, who found that strength increased considerably in subjects who received placebo, but who were told they were receiving anabolic steroids.
10 Bhasin et al.'s subjects were experienced weightlifters. Although they reported that they had not taken anabolic steroids, these medications are illicit, and thus self-reporting may not be reliable. As 38%-58% of bodybuilders and weightlifters have been reported to use anabolic steroids,
11,12 some of Bhasin et al.'s subjects may well have been able to identify the active drug.
Before generalising these results to athletes who use anabolic-androgenic steroids in the community, it should be remembered that they receive and use their supplies in very different ways to the controlled circumstances of Bhasin et al.'s study.
Street supplies are often veterinary or illegally manufactured preparations, often combined with other medications such as diuretics and stimulants.
Doses and duration are often well in excess of those used in this study. Although no major side effects were reported, the well documented long-term adverse effects of anabolic-androgenic steroids on cardiovascular risk, gynaecomastia, carcinogenesis, prostate and sexual function would not have been evident in a study of this duration.
13 On considering the available evidence, it appears that anabolic steroids definitely increase muscle size, and probably strength, but the mechanism is unknown.
Further studies, using a crossover design, including inexperienced as well as experienced weightlifters, and the same drug vehicle for both placebo and active drug, with confirmation of subject blinding, should probably be conducted to confirm these findings.
In addition, whether androgen-induced muscle hypertrophy translates into improved performance in sports that require skill as well as strength remains to be determined. But such studies should not overshadow the need for significant research into the prevention of anabolic-androgenic steroid abuse.
Michael C Kennedy
Department of Clinical Pharmacology and Toxicology,
St Vincent's Hospital; and Manly Hospital, Sydney, NSW.
Anthony J O'Sullivan
Departments of Medicine and Endocrinology, St George Hospital, Sydney, NSW.
Wade N. Anabolic steroids: Doctors denounce them, but athletes aren't listening. Science 1972; 176: 1399-1403.
Skolnick AA. Tougher drug tests for Centennial Olympic Games. JAMA 1996; 275: 348-349.
Buckley WE, Yesalis CE, Friedl KE, et al. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA 1988; 260: 3441-3445.
Urban RJ, Bodenburg YH, Gilkison C, et al. Testosterone administration to elderly men increases skeletal muscle strength and protein synthesis. Am J Physiol 1995; 269: E820-E826.
Elashoff JD, Jacknow AD, Shain SG, Braunstein GD. Effects of anabolic-androgenic steroids on muscular strength. Ann Int Med 1991; 115: 387-393.
Forbes GB, Porta CR, Herr BE, Griggs RC. Sequence of changes in body composition induced by testosterone and reversal of changes after drug is stopped. JAMA 1992; 267: 397-399.
Bhasin S, Storer TW, Berman N, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996; 335: 1-7.
Hervey GR, Hutchinson I, Knibbs AV, et al. "Anabolic" effects of methandienone in men undergoing athletic training. Lancet 1976; 2: 699-702.
Freed DLJ, Banks AJ, Longson D, Burley DM. Anabolic steroids in athletics: crossover double-blind trial on weightlifters. BMJ 1975; 2: 471-473.
Ariel G, Saville W. Anabolic steroids: the physiological effects of placebos. Med Sci Sports 1972; 4: 124-126.
Perry HM, Wright D, Littlepage BNC. Dying to be big: a review of anabolic steroid use. Br J Sports Med 1992; 26: 259-261.
Delbeke FT, Desmet N, Debackere M. The abuse of doping agents in competing body builders in Flanders (1988-1993). Int J Sports Med 1995; 16: 66-70.
Kennedy MC. Anabolic steroid abuse and toxicology. Aust N Z J Med 1992; 22: 374-381.
Reprints: Dr M C Kennedy, Manly Non-Invasive Cardiac Laboratory, Level 4, 22 Darley Road, Manly, NSW 2095.
Make a comment - Register to be notified of new articles by e-mail - Current contents list - To top of article - ©MJA 1996
<URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.
We appreciate your comments.
A recent study has provided evidence that testosterone increases muscle strength, but does this translate to enhanced performance?
For almost half a century, athletes have believed that use of anabolic-androgenic steroids can improve sporting performance. The United States physician John Zeigler was so convinced of their positive effects that on his return from the World Powerlifting Championships in Vienna in 1954 he worked on the development of methandrostenolone as a means of enhancing sporting performance.
1 This belief has persisted, leading to the widespread and much-publicised use of these drugs at all levels of sport (professional and amateur). It has been promoted by the banning of these drugs by sporting bodies to ensure fair competition.
2 Media reports and "underground" guides to anabolic steroids have also propagated the use of anabolic-androgenic steroids, which has spread from elite athletes to recreational bodybuilders, amateur athletes and adolescents.
3 Are the athletes and their coaches mistaken in their belief?
Theoretically, anabolic-androgenic steroids should improve athletic performance by increasing muscle mass (via increased protein synthesis, nitrogen retention and antiglucocorticoid actions), as well as by increasing aggression and motivation.
Moreover, recent isotope uptake studies in humans indicate that androgens may increase muscle protein synthesis, possibly through stimulation of intramuscular insulin-like growth factor-I (IGF-I) gene expression.
4 However, clinical studies have, in general, been inconclusive, partly because of the many unique methodological problems in studying the effects of anabolic-androgenic steroids (see below).
In 1991, 16 randomised, placebo-controlled studies that used objective measures of performance were analysed by Elashoff et al.
5 They concluded that, while the possibility of anabolic-androgenic steroids improving sporting performance could not be excluded, "the data are insufficient to allow any firm conclusion about the efficacy of anabolic steroids in enhancing overall athletic performance".
Since then, apart from a non-placebo-controlled study that showed an increase in lean body mass in healthy male volunteers receiving weekly injections of testosterone enanthate,
6 there were few real developments in the area until Bhasin et al.
7 published their study in July 1996.
This study will probably become, in time, one of the most-cited articles on drugs and sport. Funded by the National Institutes of Health (US), the study examined the effect of high doses of testosterone enanthate in sesame oil (600 mg/week intramuscularly for 10 weeks); the authors made every attempt to remove confounding variables (such as diet, training, and weightlifting experience), and used standardised measures.
Forty-three experienced weightlifters were randomly assigned to one of four groups (placebo with or without exercise, or testosterone with or without exercise). Strength was measured by two single weightlifts -- upper-body strength by benchpress, and lower-body strength by squatting. Fat-free body mass was measured by underwater weighing, and muscle size by magnetic resonance imaging. Forty subjects completed the study.
Body weight increased only in the two testosterone-treated groups, and fat-free body mass only in the exercise groups, with the greatest change in fat-free mass in the testosterone plus exercise group (increase, 6.1 kg).
Percentage body fat did not change in any group. Muscle size increased more in the testosterone groups than in either placebo group.
Strength increased in both testosterone groups, as well as in the exercise group receiving placebo, but was greater in the exercise group with testosterone than in the exercise group with placebo.
No significant adverse drug reactions were reported. Hence, for the first time, in a well designed study, supraphysiological testosterone did appear to increase muscle strength.
One other placebo-controlled study has used higher doses of anabolic steroids (methandrostenolone, 100 mg/day for six weeks).
8 Reported 20 years ago, it used a crossover design, with attempts to control for most variables. The active drug was found to be no better than placebo in increasing strength.
However, some caveats should be considered in assessing Bhasin et al.'s data. A placebo response has not been completely eliminated. It was not stated that the placebo was identical to the active drug in terms of pH, viscosity and other factors that may have allowed the code to be broken by either the administrator or recipient of the drug. Indeed, in a controlled study of oral anabolic steroids, all subjects correctly identified the active drug when directly asked.
9 The importance of the placebo response was shown by Ariel and Saville, who found that strength increased considerably in subjects who received placebo, but who were told they were receiving anabolic steroids.
10 Bhasin et al.'s subjects were experienced weightlifters. Although they reported that they had not taken anabolic steroids, these medications are illicit, and thus self-reporting may not be reliable. As 38%-58% of bodybuilders and weightlifters have been reported to use anabolic steroids,
11,12 some of Bhasin et al.'s subjects may well have been able to identify the active drug.
Before generalising these results to athletes who use anabolic-androgenic steroids in the community, it should be remembered that they receive and use their supplies in very different ways to the controlled circumstances of Bhasin et al.'s study.
Street supplies are often veterinary or illegally manufactured preparations, often combined with other medications such as diuretics and stimulants.
Doses and duration are often well in excess of those used in this study. Although no major side effects were reported, the well documented long-term adverse effects of anabolic-androgenic steroids on cardiovascular risk, gynaecomastia, carcinogenesis, prostate and sexual function would not have been evident in a study of this duration.
13 On considering the available evidence, it appears that anabolic steroids definitely increase muscle size, and probably strength, but the mechanism is unknown.
Further studies, using a crossover design, including inexperienced as well as experienced weightlifters, and the same drug vehicle for both placebo and active drug, with confirmation of subject blinding, should probably be conducted to confirm these findings.
In addition, whether androgen-induced muscle hypertrophy translates into improved performance in sports that require skill as well as strength remains to be determined. But such studies should not overshadow the need for significant research into the prevention of anabolic-androgenic steroid abuse.
Michael C Kennedy
Department of Clinical Pharmacology and Toxicology,
St Vincent's Hospital; and Manly Hospital, Sydney, NSW.
Anthony J O'Sullivan
Departments of Medicine and Endocrinology, St George Hospital, Sydney, NSW.
Wade N. Anabolic steroids: Doctors denounce them, but athletes aren't listening. Science 1972; 176: 1399-1403.
Skolnick AA. Tougher drug tests for Centennial Olympic Games. JAMA 1996; 275: 348-349.
Buckley WE, Yesalis CE, Friedl KE, et al. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA 1988; 260: 3441-3445.
Urban RJ, Bodenburg YH, Gilkison C, et al. Testosterone administration to elderly men increases skeletal muscle strength and protein synthesis. Am J Physiol 1995; 269: E820-E826.
Elashoff JD, Jacknow AD, Shain SG, Braunstein GD. Effects of anabolic-androgenic steroids on muscular strength. Ann Int Med 1991; 115: 387-393.
Forbes GB, Porta CR, Herr BE, Griggs RC. Sequence of changes in body composition induced by testosterone and reversal of changes after drug is stopped. JAMA 1992; 267: 397-399.
Bhasin S, Storer TW, Berman N, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996; 335: 1-7.
Hervey GR, Hutchinson I, Knibbs AV, et al. "Anabolic" effects of methandienone in men undergoing athletic training. Lancet 1976; 2: 699-702.
Freed DLJ, Banks AJ, Longson D, Burley DM. Anabolic steroids in athletics: crossover double-blind trial on weightlifters. BMJ 1975; 2: 471-473.
Ariel G, Saville W. Anabolic steroids: the physiological effects of placebos. Med Sci Sports 1972; 4: 124-126.
Perry HM, Wright D, Littlepage BNC. Dying to be big: a review of anabolic steroid use. Br J Sports Med 1992; 26: 259-261.
Delbeke FT, Desmet N, Debackere M. The abuse of doping agents in competing body builders in Flanders (1988-1993). Int J Sports Med 1995; 16: 66-70.
Kennedy MC. Anabolic steroid abuse and toxicology. Aust N Z J Med 1992; 22: 374-381.
Reprints: Dr M C Kennedy, Manly Non-Invasive Cardiac Laboratory, Level 4, 22 Darley Road, Manly, NSW 2095.
Make a comment - Register to be notified of new articles by e-mail - Current contents list - To top of article - ©MJA 1996
<URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.
We appreciate your comments.
