Ergogenic Drugs in Women
January 2000; Volume 2: 1-3
By Susan J. Piazza, MD and Jerrold B. Leikin, MD
With the increased popularity and visibility of women’s athletics, it follows that ergogenic (performance enhancing) drug use also would mushroom. Because most of the limited studies on this phenomena have focused on the effects of these agents on men, it would be incorrect to assume that these effects can be extrapolated to women.
Anabolic Steroids
Certainly the most dangerous ergogenic aid for women would be hormonal manipulation, or more specifically, use of anabolic steroids. Although several surveys indicate that steroid use by women is statistically less than use by male counterparts, this may be an underestimation: Women may be more secretive about use because of the substance’s virilization effects.1-5 Unlike the proud, almost "macho," utilization of anabolic steroids by men, the virilization effects of anabolic steroids on women athletes could be perceived negatively as opposed to these same effects on the male athlete. Outside of athletic drug testing, it may not be possible to obtain accurate anabolic steroid usage data in women by means of questionnaires or surveys. However, with what limited data are available, it appears that collegiate women’s track and field, basketball, tennis, and swimming are the sports most affected, with estimated past-year usage rates of 9.5%, 6.3%, 5.6%, and 5.4%, respectively.1 Women bodybuilders also appear to be utilizing anabolic steroids at about a 10% rate, as opposed to the estimated 50% usage rate in male bodybuilders.
Virilization effects and other changes (some of which may be permanent) induced in women by anabolic steroids include menstrual abnormalities, shrinkage of breasts, acne, and increases in sex drive, body hair, and clitoral size.1,3 Additionally, behavioral and mood changes similar to amphetamine use, along with cases of hypomania, psychotic behavior, and dependency, can occur.1,6-8 Cellulitis can occur when weight lifters reuse needles. An average weight gain of 2.2 kg can also occur although it is not clear whether this gain is due to an increase in muscle mass, other tissues, or intracellular fluid.
Creatine Monohydrate
Creatine monohydrate use has become a $220 million industry in the United States. It appears to be most useful in resistance-training programs by resupplying adenosine triphosphate (ATP) levels in high-intensity effort for up to about 30 seconds. Thus, short-duration, high-impact activity theoretically can be enhanced. Sports such as weight lifting, football, soccer, and rowing may be most benefited by use of creatine. While creatine ingestion may increase exercise performance by 5-7%, most of these studies focused on the trained male athlete.9 The few studies of women suggest that creatine may only work half as well. A weight gain of 1-2 kg can be expected, although, as with anabolic steroids, it is not known whether this weight gain is caused by water or muscle mass. There have been reports of kidney function abnormalities after administration of high doses of creatine.
Stimulants
Stimulants were among the first drugs used to alter performance in both men and women, with the first use documented in the early part of this century.3 Current popular stimulants include caffeine, phenylpropan-olamine, and ephedrine, which are readily available in drinks, food, and over-the-counter medications. In high doses these readily available compounds pharmacologically mimic the effects of amphetamine. Athletes experience euphoria, increased alertness, and decreased fatigue but data on performance enhancement are inconclusive. These stimulants are detectable by current drug screening methods. Even caffeine in urine concentrations greater than 12 µg/mL is banned by the International Olympic Committee.3 Hence, athletes have turned to other "natural" ergogenic aids such as human growth hormone (hGH) and erythropoietin (EPO).
Human Growth Hormone
Since the availability of recombinant DNA-derived hGH, its popularity with athletes has soared.3,11 Prior to 1985 only pituitary extracted hGH was available. During this time several cases of Creutzfeldt-Jakob disease were associated with contaminated pituitary extracts. The use of hGH, a recombinant polypeptide hormone, is appealing to athletes not only because it eliminates the potential infectious exposure but also because it cannot be directly detected by current drug testing procedures. With the advent of improved drug testing in the 1980s, which resulted in increased detection of anabolic steroids, athletes sought out other substances such as hGH. It is likely that the above events led the Olympic athletes to name the 1996 Atlanta Games, "The Growth Hormone Games."5
The mechanism of action of growth hormone has been shown to have an overall anabolic effect.10,11 More specifically it accelerates the transport and incorporation of amino acids into protein. Knowing this physiology, it is understandable why hGH-treated muscles have been shown to be larger in size when compared to muscles that were not treated with hGH. Athletes have reported lean body weight gains of up to 40 lbs. Female body builders and weight lifters would find hGH’s effects particularly useful because low body fat and good muscle definition are the athlete’s goal.
Human growth hormone also stimulates the breakdown of adipose tissue by mobilizing and then oxidating lipids for energy. Many athletes believe it boosts their energy, especially near the end of a fatiguing competition. It is this belief that encourages hGH use by track and field athletes, especially sprinters and short-distance swimmers.
It is important to stress that the performance enhancing effects of hGH are unproven. There are many claims, again by athletes, that performance improvement was lacking with use of hGH. There are also potential problems associated with the use of hGH. The early effects of acromegaly have been reported (coarsening of facial features and thickening of the hands and fingers). Women athletes have experienced menstrual irregularities, amenorrhea, and osteoporosis secondary to exogenous hGH use. Hypercholesterolemia and coronary artery disease are known adverse effects of excess hGH, which may potentially result in premature ischemic events in women. The potential benefits of exogenous hGH in athletes is at best inconsistent and at worse harmful.
Erythropoietin
EPO is a glycoprotein that also became available in recombinant form in the mid-1980s. Like hGH, EPO cannot be detected in the urine by current drug testing procedures. EPO has the ability to stimulate RBC productions in the bone marrow resulting in an elevated hemoglobin level. To the athlete seeking an advantage, it seems likely that the use of EPO would result in improved performance in endurance activities. In fact, EPO has been shown to increase hemoglobin levels in healthy individuals and it is likely that EPO improves endurance. As a result of published reports, EPO has begun to replace blood doping, which is the practice of transfusing autologous or homologous type-matched blood into an athlete approximately one week prior to a competition. The goal of transfusion is a hemoglobin level of approximately 17, but not higher, in order to avoid a hyperviscosity syndrome. This practice of blood doping, with resulting increases in baseline hemoglobin, is efficacious and studies have substantiated its use. Athletes view EPO as having the benefits of blood doping along with decreased risk for transmission of infectious diseases and transfusion reactions.
EPO, however, does have associated adverse effects. The expanded blood volume and increased viscosity can lead to thrombolytic events, such as cerebrovascular accident, myocardial ischemia, pulmonary embolus, and deep vein thrombosis. Seizures and hypertension are also potential adverse effects. Presently the dose-response relationship between EPO (use in healthy individuals) and hemoglobin levels is not well described. This makes the adverse effects significantly less predictable. It is important to educate athletes that the potential benefits associated with EPO use in anemic patients cannot be extrapolated to healthy athletes.
Conclusion
In a society that glorifies athletic achievement the pressure to use drugs that enhance performance is increasing. However, these drugs have not been systematically reviewed for efficacy and the adverse effects upon women are just being recognized. It is apparent that in today’s natural drug revolution, ergogenic drugs in sports provide increased risks with unknown (if any) benefit to women athletes.
Dr. Piazza is Medical Attending, Emergency Services, and Dr. Leikin is Associate Medical Director, Emergency Services, at Rush-Presbyterian St. Luke’s Medical Center in Chicago, IL.
References
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7. Rosenbloom D, Sutton JR. Drugs and exercise. Med Clin North Am 1985;69:177-187.
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9. Bosco C, et al. Effect of oral creatine supplementation on jumping and running performance. Int J Sports Med 1997;18:369-372.
10. Macintyre JG. Growth hormone and athletes. Sports Med 1987;4:129-142.
11. Haupt HA. Anabolic steroids and growth hormone. Am J Sports Med 1993;21:468-474.
January 2000; Volume 2: 1-3
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