Androgens are commonly used in high-dosage combinations by competitive athletes who hope that these steroids will improve muscle strength, endurance, and athletic performance.138,139 Their use has been prohibited by local, national, and international athletic organizations (e.g., the International Olympic Committee), but the covert use (i.e., abuse) of very high dosages of androgens has become widespread, despite a lack of objective evidence for the long-term risks and benefits of their use. In the late 1950s, androgens were used almost exclusively by weight lifters, bodybuilders, and heavy throwers. Today, their use has spread to football players, swimmers, and track and field participants at all levels of athletic competition. Surveys also reveal a relatively high prevalence of androgenic anabolic steroid abuse in peripubertal boys, not only to enhance athletic performance but also to improve their appearance.140

Whether androgen administration improves athletic performance is controversial. One review of 25 well-documented studies of the effects of anabolic steroids on athletic performance concluded that androgen use alone did not increase muscle strength or improve athletic performance.141 Anabolic steroids did significantly increase strength in athletes who had intensive weight training before and during steroid treatment and who maintained a high-protein diet.141 Many of these studies were not blinded or placebo-controlled, however, and most did not control for energy and protein intake or training.121 A randomized, double-blind, placebo-controlled study demonstrated that short-term administration (10 weeks) of a supraphysiologic dosage of testosterone enanthate (600 mg weekly) with or without resistance exercise increased fat-free mass, muscle size, and muscle strength in normal men.120 When high-dosage testosterone was combined with exercise, the increases in strength were greater than those found with either testosterone or exercise alone. This study clearly demonstrated the short-term anabolic effects of supraphysiologic testosterone administration in normal men in whom diet and exercise were carefully controlled. However, the longer-term effects on muscle strength and risks of high-dosage androgen use are not known.Moreover, the effects of androgens on muscle and athletic performance remain to be demonstrated in carefully controlled studies. Uncontrolled studies investigating the effect of androgens on strength and athletic performance may be confounded by the covert use of other androgenic steroids and/or anabolic agents, such as GH.

Athletes often take multiple androgenic anabolic agents in combination, including 17α-alkylated androgens, in extremely high dosages (10–100 times the therapeutic dosages) with little regard for potentially serious side effects. Abnormalities in liver function as well as more life-threatening hepatotoxicity (e.g., peliosis hepatis and hepatocellular carcinoma), impaired spermatogenesis causing infertility, gynecomastia, cardiomyopathy, thrombotic events, severe mood and behavioral disturbances, and, in women, hirsutism and virilization have been observed in athletes taking anabolic steroids, especially 17α-alkylated androgens.138,139,142,143 and 144 Moreover, the long-term sequelae of huge dosages of the safer testosterone esters is unknown. For example, self-administration of high dosages of androgenic steroids by weight lifters and bodybuilders sharply reduces HDL cholesterol and elevates low-density lipoprotein cholesterol, producing an atherogenic lipoprotein profile, despite high-level exercise training.145 Effects on lipoproteins occur to a greater extent with oral 17α-alkylated androgens than with parenteral 17β-hydroxyl testosterone esters, but supraphysiologic doses of the latter significantly suppress HDL cholesterol.1,20,146,147 Whether the continued, long-term use of androgenic steroids will cause premature atherosclerotic cardiovascular disease is unknown.