Red flags for performance-enhancing drug use
- Rapid increase in muscle bulk and loss of body fat
- Unexplained high blood pressure, cardiomyopathy, or arrhythmia in a previously healthy adolescent or young adult
- Signs and symptoms of feminization in males or virilization in females
- Increased aggression, violent behavior, or insomnia
- Abnormal lab work, including increases in liver enzymes or hematocrit
- Polypharmacy or increased use of medications and dietary supplements.
Dehydroepiandrosterone: Marketed as a “wonder drug”
Dehydroepiandrosterone (DHEA), marketed under the names Prastera, Fidelin, and Fluasterone, is another precursor of testosterone. It is produced in the adrenal cortex and has weak androgenic properties.2 DHEA is a dietary supplement marketed as a “wonder drug” and, like androstenedione, is advertised to promote muscle-building and fat-burning. It is also said to have anti-aging properties.11,14 DHEA has been used by athletes in the belief that it will increase testosterone levels and muscle bulk.30
In studies done in healthy men, however, even large doses of DHEA (1600 mg/d) did not result in an increase in testosterone levels. An increase in estradiol levels was noted in elderly men. Women who supplement with DHEA were found to have increased levels of testosterone and virilization effects, even at small doses (25-50 mg/d).31 Because of the risk of these side effects and the lack of long-term studies, DHEA supplementation is not recommended for use by adolescents or women.30 There is no convincing evidence to support claims of the anabolic and anti-aging effects of DHEA.
Human growth hormone: Side effects include hypertension
Human growth hormone (HGH) is an endogenous pituitary hormone with anabolic functions that increases muscle mass without the androgenic side effects. It is used medically for patients with decreased endogenous levels of GH or dwarfism. As an ergogenic aid, it has been found to increase levels of insulin-like growth factors, and the combination leads to increased protein synthesis and muscle mass.32
Side effects of HGH include insulin resistance, GH-induced myopathy, and acromegaly-like effects.11 There have been reports of hypertension, cardiomegaly, ventricular hypertrophy, and abnormal lipids with excessive use.19,33 Premature physeal closure may occur in the adolescent HGH user.8 It’s unclear whether HGH actually enhances sports performance, because the evidence is insufficient.34
Ephedrine: Used by hockey players
Ephedrine is a stimulant derived from the herb ma huang. It goes by many names, among them Ma Huang, Bolt-ephedrine, Asia Black 25, Hot Body Ephedra, and Thin Quick. Its chemical structure is related to amphetamine. Among college athletes, ephedrine and amphetamine use is more common in power sports, those requiring increased concentration (eg, rifle shooting, fencing), ice hockey, and field sports.35 Users feel less fatigue, experience bursts of energy, and lose weight.8,36
Users may experience irritability, anxiety, insomnia, and tremors, especially if stimulants are used in conjunction with high doses of caffeine.35,37 Ephedrine stimulates the release of norepinephrine, which produces increases in blood pressure, peripheral vascular resistance, and heart rate. These norepinephrine effects are the proposed mechanism for reported cases of myocardial infarction, cerebral artery vasoconstriction, and stroke associated with ephedrine use.13
Marketing of dietary supplements that contain ephedrine has been banned by the FDA because of the stimulant’s potential for increasing cardiovascular and stroke risks.38
Caffeine: May give sprinters a leg up
Caffeine—which is found in everything from coffee to energy tablets and energy drinks—increases a person’s energy level. In endurance sports, it also increases time to exhaustion.32 Studies in endurance-trained cyclists have shown that caffeine intake reduced leg pain, increased maximal leg force, and lengthened time to fatigue.39,40 A recent study in Australia also showed that caffeine may improve intermittent-sprint performance in competitive male athletes.41
Serious cardiovascular risks and even death have been documented when caffeine has been used with other stimulants, such as ephedrine or amphetamines. The combination of high doses of caffeine and ephedrine has a potential for life-threatening arrhythmia, hypertension, and stroke.42 Other psychomotor side effects include anxiety, irritability, tremor, and the potential for withdrawal symptoms.42,43 Because of caffeine’s stimulant nature, the International Olympic Committee and the National Collegiate Athletic Association have set urinary thresholds for its use in competition.
Erythropoietin: Promotes endurance
Erythropoietin (EPO) is a hormone produced in the kidneys that stimulates production of red blood cells (erythropoiesis). Marketed under the brand names Epogen and Procrit, EPO has legitimate medical uses. As an ergogenic substance, EPO is used to promote endurance by increasing the oxygen-carrying capacity of the blood with the increased red blood cell mass. In endurance athletes, the benefits of recombinant erythropoietin (rEpo) may last several weeks.23 There is also a practice called “blood doping,” which is a transfusion prior to competition, to produce the same effect.