AAS Use in Sports, Health, and Society

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madman

Super Moderator
ABSTRACT

This consensus statement is an update of the 1987 American College of Sports Medicine (ACSM) position stand on the use of anabolic-androgenic steroids (AAS). Substantial data have been collected since the previous position stand, and AAS use patterns have changed significantly. The ACSM acknowledges that lawful and ethical therapeutic use of AAS is now an accepted mainstream treatment for several clinical disorders; however, there is increased recognition that AAS is commonly used illicitly to enhance performance and appearance in several segments of the population, including competitive athletes. The illicit use of AAS by competitive athletes is contrary to the rules and ethics of many sport governing bodies. Thus, the ACSM deplores the illicit use of AAS for athletic and recreational purposes. This consensus statement provides a brief history of AAS use, an update on the science of how we now understand AAS to be working metabolically/biochemically, potential side effects, the prevalence of use among athletes, and the use of AAS in clinical scenarios.




SYNOPSIS

This consensus statement is an update of the previous position stand from the American College of Sports Medicine (ACSM), published in 1987 (1). Since then, a substantial amount of scientific data on anabolic-androgenic steroids (AAS) has emerged and the circumstances of AAS use have evolved in the athletic, recreational, and clinical communities. The objective of this consensus statement is to provide readers with a brief summary of the current evidence and extend the recommendations provided in the 1987 document (1). Key topics discussed are the brief history of AAS, epidemiology, methods, and patterns of AAS use, androgen physiology and ergogenic effects, side effects of AAS, and clinical uses of AAS (see Box 1). The writing group used the rating system of the National Heart Lung and Blood Institute (Table 1) and a consensus approach to synthesize the available evidence from clinical trials and case reports, narrative and systematic reviews, and meta-analyses (3). The recommendations represent the consensus of the writing panel, the ACSM, and incorporate guidance from other professional organizations with expertise in the area.





INTRODUCTION

Anabolic-androgenic steroids are drugs chemically and pharmacologically related to testosterone (T) that promote muscle growth and are not estrogens, progestins, or corticosteroids. An androgen is any natural or synthetic steroid hormone capable of promoting the development of male primary and secondary sexual characteristics via binding to androgen receptors at the tissue level. The term anabolic describes a hormone or other substance capable of enhancing the growth of somatic tissue, such as skeletal muscle and bone. In a sport-related setting, this is typically used to describe the enhancement of skeletal muscle. Table 2 presents nomenclature associated with AAS. In the United States, AAS are classified as Schedule III controlled substances (5). Although AAS has a legitimate medicinal use, nontherapeutic use among athletes and recreationally active young men and women is performed to improve strength, power, increase muscle mass, and improve appearance. Athletic and recreational (i.e., non-competitive) use of AAS has been widespread over the last 50 yr, creating considerable interest by the scientific and medical communities, as well as sport governing bodies, in examining the potential medical, legal, and ethical issues surrounding the use of these substances. All major national and international sports organizations have banned the illicit use of AAS by athletes.




*HISTORICAL PERSPECTIVES

*EPIDEMIOLOGY OF AAS USE

*METHODS/PATTERNS OF AAS USE

*ANDROGEN PHYSIOLOGY

Testosterone is the principal androgen and has both androgenic (masculinizing) and anabolic (tissue building) effects. Testosterone is synthesized from cholesterol via the Δ-4 or Δ-5 pathways through the sequential action of several enzymes (Fig. 2). In men, >95% of T is synthesized in the Leydig cells of the testes (with smaller adrenal contributions) under control of the hypothalamic-anterior pituitary-gonadal axis where gonadotropin-releasing hormone stimulates the release of luteinizing hormone (LH). Healthy men produce ~4 to 9 mg of T per day (10–35 nmol·L−1 ) whereas women have approximately 0.5 to 2.3 nmol·L−1 of circulating T in the blood (5). Gonadotropin-releasing hormone function is under the control of hypothalamic neuropeptides, such as kisspeptins, neurokinin-B, dynorphin-A, and phoenixins (51). In women, androgens are produced primarily by the ovaries and adrenal glands (52). Skeletal muscle produces small amounts of androgens (53). Testosterone circulates in the blood bound to sex hormone-binding globulin (44%–60%), albumin, orosomucoid, and cortisol-binding globulin. Testosterone and other 19-carbon androgens can be converted to 5α-dihydrotestosterone (DHT) by the action of steroid 5α-reductase or converted to estradiol or estrone by the aromatase enzyme. The liver inactivates T, and the resultant metabolites are excreted in the urine.

*Androgens perform many ergogenic, anabolic, and anticatabolic functions in skeletal muscle and neuronal tissue, leading to increased muscle strength, power, endurance, and hypertrophy in a dose-dependent manner (54).


*ANDROGEN SIGNALING

*SIDE EFFECTS ASSOCIATED WITH ANDROGEN USE AND ABUSE

*CLINICAL USES OF ANDROGEN THERAPY




CONCLUSIONS


Anabolic-androgenic steroids include a wide spectrum of compounds that exert their effects through various mechanisms. Anabolic-androgenic steroid use is advantageous in athletic performance predominantly through enhancements in strength, power, increases in muscle mass, reduced recovery time, and other factors. Major competitive sporting bodies ban the use of AAS; however, the predominant area of AAS usage has now expanded into clinical scenarios, persons undergoing sexual reassignment, and those interested in AAS for purely aesthetic enhancement. Thus, it is not only athletes who are using AAS to gain performance advantages but also other individuals for various reasons. The use of AAS to enhance athletic performance is banned, and coaches, trainers, and medical staff should monitor for signs of use. The use/abuse of AAS has several notable side effects with various consequences that are, in some cases, reversible. Coaches, parents, trainers, and medical staff need to understand why athletes might use AAS and provide educational programming in a preventive capacity. The position of the ACSM is that the illicit use of AAS for athletic and recreational purposes is, in many cases, illegal, unethical, and also poses a substantial health risk. Nonetheless, TRT is used in treating various conditions, and clinicians may elect to use this therapy when medically necessary. The ACSM acknowledges the lawful and ethical use of AAS for clinical purposes and supports the physicians’ ability to provide androgen therapy to patients when deemed medically necessary.
 

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madman

Super Moderator
Consensus Statements and Recommendations

1. The administration of AAS in a dose-dependent manner significantly increases muscle strength, lean body mass, endurance, and power. The effects are primarily seen when AAS use is accompanied by a progressive training program. Evidence Category A.

2. Historically, AAS use was primarily seen in competitive athletes and aspiring bodybuilders, and powerlifters. Recreational AAS use appears to have surpassed athletic AAS use indicated by survey prevalence estimates demonstrating that recreational trainees are the leading consumers of AAS. The ACSM deplores the illicit use of AAS for recreational purposes. Evidence Category C.

3. AAS are classified as schedule III drugs, banned by several sport governing bodies, and are illegal to use for athletic purposes. The ACSM deplores the illicit use of AAS for recreational use and performance enhancement in athletes. Evidence Category D.

4. Coaches, trainers, and medical staff should monitor and be cognizant of visible signs of AAS use and abuse. These include (but are not limited to): a substantial increase in muscle mass, strength, and power in a relatively short period of time (or the reverse which could denote AAS withdrawal); acne that is resistant to medical treatment; development of unexplainable rash, gynecomastia, increased body hair, and prominent increases in surface vascularity; changes in temperament, mood, and aggressive behavior (severe depression or suicidality could indicate AAS withdrawal); facial masculinization and fluid retention; and muscle mass that appears disproportionate to body structure or pubertal status in young athletes. In addition, the presence of AAS-related materials (books, articles, websites, dealer information, needles, vials) on the individual could reflect the intent and may warrant further dialogue from the coaching, trainer, and medical staff. Medical staff should be aware of regulations and documentation requirements regarding the use of AAS for athletes with medical indications for their use. Evidence Category C.

5. Use and abuse of AAS is associated with several notable adverse effects in men and women including (but not limited to) suppression of the hypothalamic-pituitary-gonadal axis, psychological changes, immunosuppression, and unhealthy cardiovascular, hematological, reproductive, hepatic, renal, integumentary, musculoskeletal, and metabolic effects. Several adverse effects may be reversible upon discontinuation but some could pose health risks beyond the duration of AAS use. Evidence Category B.

6. Use of AAS in prepubertal and peripubertal children may lead to early virilization, premature growth plate closure, and reduced stature. Evidence Category C.

7. Coaches, trainers, and medical staff should be cognizant of the reasons for AAS use and abuse and deter use when possible. Prevention programs based on education may assist, and providing the individual with scientific nutrition and training advice is a recommended strategy to mitigate the temptation of AAS use. Evidence Category D. 8. Androgen replacement therapy is approved for the medical treatment of several clinical diseases and abnormalities. The ACSM acknowledges the lawful and ethical use of AAS for clinical purposes and supports the physicians’ ability to provide androgen therapy to patients when deemed medically necessary. The reader is referred to guidelines established by the Endocrine Society (4). Evidence Category C
 

madman

Super Moderator
TABLE 1. Evidence categories.
Screenshot (6205).png
 

madman

Super Moderator
TABLE 5. Lifetime prevalence data from the 2018 MTF survey based on answers to the following query: “Anabolic steroids are prescription drugs sometimes prescribed by doctors to treat certain conditions. Some athletes, and others, have used them to try to increase muscle development.” The question then asks, “on how many occasions have you taken steroids on your own—that is, without a doctor telling you to take them?”
Screenshot (6210).png
 

madman

Super Moderator
TABLE 6. Lifetime prevalence data from the 2017 YRBS survey based on answers to the following query: “During your life, how many times have you taken steroid pills or shots without a doctor’s prescription?”
Screenshot (6211).png
 

madman

Super Moderator
FIGURE 3—Physiological and molecular-level consequences of AAS usage that may affect physical performance. NT, neurotransmitter; CSA, cross-sectional area; AR, androgen receptor; GC, glucocorticoid; GH, growth hormone; Acvr2b, activin receptor type-2B; TG, triglyceride; RBC, red blood cell; Hgb, hemoglobin; S6K1, ribosomal protein S6 kinase beta-1; ERK1/2, extracellular signal-regulated kinase 1 and 2; PI3, phosphoinositide 3-kinase; AKT, protein kinase B; Ankrd1, ankyrin repeat domain 1; MuRF1, muscle RING-finger protein-1; MGF, mechanogrowth factor; MCT1/4, monocarboxylate transporter 1 and 4; RFD, rate of force development.
Screenshot (6219).png
 

madman

Super Moderator
FIGURE 4—Potential adverse physiological and psychological effects associated with AAS use. TC, total cholesterol; ApoA1, apolipoprotein A1; LV, left ventricle; ECG, electrocardiogram; T, testosterone.
Screenshot (6221).png
 
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