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- Review -
Androgenic-anabolic steroids and the Olympic Games
Kenneth D. Fitch#
School of Human Movement and Exercise Science, Faculty of Life and Health Sciences, University of Western Australia,
Nedlands 6009, Australia
Abstract
Androgenic-anabolic steroids (AAS) have been misused by athletes at the Olympic Games, both before and after
they were prohibited in sport in 1974. Systematic doping with AAS occurred in the German Democratic Republic
(GDR) from 1965 to 1989 which assisted that country to win many medals at Olympic Games, especially in female
events. Currently, AAS are the most frequent category of prohibited substances detected in the urine of athletes both
globally and at the last two Summer Olympic Games. Scientific confirmation that AAS are effective in enhancing
sports performance was difficult because ethical approval was difficult for research involving male subjects taking
massive doses of androgens as some athletes and bodybuilders did. Methods to detect AAS have evolved gradually
over the past three decades and currently, despite an impressive array of sophisticated analytical equipment and
methods, anti-doping authorities and analytical scientists continue to face challenges as have occurred from the use by
athletes of designer AAS during the past few years. The future development and use of selective androgen receptor
modulators (SARMs) can be anticipated to pose problems in the years ahead. Endocrinologists should be aware that
on occasions, replacement testosterone (T) therapy may be authorized in sport as a therapeutic use exemption (TUE)
and these circumstances are discussed. (Asian J Androl, 2008 May; 10:
384_390)
Keywords: doping; androgenic-anabolic steroids; history; Olympic Games; detection; designer steroids; therapeutic use exemption
Correspondence to: Prof. Kenneth D. Fitch, School of Human Movement and Exercise Science, Faculty of Life and Health Sciences,
University of Western Australia, Nedlands 6009, Australia.
Tel: +61-8-9386-3220 Fax: +61-8-6488-1039
E-mail: kfitch@cyllene.uwa.edu.au
Received 2007-11-09 Accepted 2007-11-15
#Member of Medical Commission of the International Olympic Committee (IOC) since 1985; previously physician to Australian Olympic
teams 1972_1984; Chair of IOC's Therapeutic Use Exemption Committee since 1992.
DOI: 10.1111/j.1745-7262.2008.00377.x
1 Introduction
Since the ancient Olympic Games in Greece, athletes have endeavoured to enhance their performance through
artificial means. During the last five decades, androgenic-anabolic steroids (AAS) have been one of the most
commonly used and effective groups of drugs that have assisted athletes to achieve improved sports performance. Yet
AAS were not prohibited in sport until 1974. Unlike some other ergogenic aids, AAS provide greater benefit if
administered during training than immediately prior to competition. Anti-doping authorities
have continually attempted to reduce and if possible eradicate cheating by AAS misuse. This review will examine the history of doping by athletes
with AAS, especially testosterone (T), with an emphasis on the Olympic Games. It will discuss the methods used to
detect such misuse but observe that throughout, this has been a constant attempt to catch up to scientists, coaches and
others who unethically aid athletes to cheat. Finally, the permitted use of AAS, predominately T, to treat genuine medical
conditions experienced by athletes will be discussed.
2 Early history of T use by athletes at the Olympic Games
In 1935, T was isolated, synthesized, its anabolic properties identified by several groups of researchers and a
commercial preparation became available for androgen deficient males. Quoted in most accounts of the history of
doping in sports is that a US physician Dr John Ziegler travelled to Vienna with the US team for the 1954 World
Weightlifting Championship and is alleged to have been
informed by a Russian official that the Soviet weightlifters
were taking T. On his return, Dr Ziegler began to
administer T to weightlifters at his gymnasium in
Pennsy-lvania. In 1958, when Ciba released methandrostenolone
(methandienone, Dianabol®), Dr Ziegler switched to this
preparation. Following publication in the non scientific
press of his experiments and the success of power
athletes after taking methandienone, the use of AAS
commenced to be used in a wide range of sports [1].
Although the use of AAS may have occurred as early as
Olympic Games in the 1950s, it seems clear that some
athletes did administer AAS at the Games during the 1960s (Rome
1960, Tokyo 1964 and Mexico City 1968) and such use was
more prevalent at the 1972 Munich Olympics [2, 3].
3 Systematic doping with AAS at the Olympic Games
Because the results of doping with AAS have included
enhanced sporting success, a number of countries have
failed to act when their athletes have tested positive to
prohibited drugs while others have turned a blind eye to
organized doping that was occurring amongst some of
their athletes. However, no country has ever embraced
a national system of scientific doping perpetrated by
doctors, sports scientists and coaches and masterminded
by the state as did East Germany (the misnamed German
Democratic Republic, GDR) between 1965 and 1989. The unification of the two Germanys that commenced
in late 1989 has unearthed some documents that had not
been shredded and these have detailed the extent of these
doping practices. Evidence given by former athletes
during trials in Germany of doctors and officials who
oversaw and implemented this program revealed the extent
of the acute and permanent side-effects of the
administration of AAS on them and even of the late consequences
on their children [4, 5].
GDR was a relatively obscure Soviet satellite of with
a population of 17 million
that resolved to achieve international recognition and respect through success in sport.
Backed by a talent identification program that was well
ahead of its time, sports schools and clubs staffed by
sports medicine specialists, sport scientists and well
qualified coaches, all financially supported by the state and
offering significant rewards in money and kind to its
successful athletes and their families, GDR was likely to
have become a major force in international sport even
without resorting to systematic doping.
After the development of chlor-substituted derivative
of methandrostenolone
(Oral-Turbinabol®) by a state-owned pharmaceutical company in 1965, GDR
commenced to administer it predominately to female athletes
in preparation for the 1968 Olympic Games. Known as
Unterstützende Mittel (UM or supporting means), oral
Turbinabol® was supplemented by mestanolone (STS
646), briefly by injected nandrolone esters (ceased
because a female shot putter tested positive) and finally T by
injection [6]. UM was provided mostly to female
athletes with impressive improvements in performance.
Additional evidence to confirm the success of this national
doping with AAS can be obtained by comparing the
results of East Germany (EG) and West Germany (WG).
Prior to the commencement of the UM program, in the
three Olympic Games 1956_1964, EG won 45 Olympic medals compared to 81 by WG. In 1968, soon after the
UM program commenced, EG with 25 medals closed on WG's 26.
In the next three Games in which both competed (boycotts eliminating WG from 1980 Moscow and
EG from 1984 Los Angeles Olympics), 1972, 1976 and
1988, EG won 258 medals compared with 119 by WG [7].
4 Why athletes dope with AAS
The scientific literature was years behind the
"underground press" in acknowledging that AAS improved
sports performance. The underground press was begun
by Dan Duchaine from Los Angeles who for many years
published the Underground Steroid Handbook, a
combination of knowledge acquired from reading scientific
sources but principally from personal knowledge and
experience with bodybuilders and athletes who followed
his AAS regimes [8, 9]. Two scientists, Hatfield [10]
and Di Pasquale [11] quickly followed in the promotion
of AAS, especially for bodybuilders. Primarily because
uncontrolled studies had administered only physiological
doses of T [12], it was not until 1996 in a double blind
controlled study, that Bhasin and colleagues [13] in Los
Angeles administered supraphysiological doses of T (600
mg of T enanthate per week for 10 weeks) and demonstrated
increased muscle size and strength, even without exercise.
Greater gains in arm and leg strength were achieved by
subjects who were administered T and exercised. The
same researchers [14] reported that the administration
of T to young and older eugonadal males increased lean
body mass and reduced fat mass, changes being dose
but not age dependent.
Although unconfirmed by scientific evidence, users
of AAS have repeatedly acknowledged that AAS result in
an ability to train and compete harder and more
aggressively and to recover more quickly from hard training
sessions and competitions. The scientists and coaches
of the GDR were aware 30 years before Bhasin as has
been disclosed from information obtained after the
unification of Germany. It was documented that treatment
with AAS for four years, coupled with scientific training
methods could improve shot put distance in men by
2.5_4 m and in women by 4.5_5 m; women were 4_5 s faster
over 400 m and 7_10 s faster over 800 m [6]. Evidence
of this exists today because no female athlete has come
within half a second of the longest standing track and
field record 400 m set in 1985 by a GDR female athlete
treated with UM [15]. One crucial aspect that impaired
the scientific examination of the effects of AAS was that
athletes used massive doses of not one but several
different AAS, taken concurrently. Often the consequences
were huge gains in strength and power and many
side-effects. Scientists could never obtain ethical approval to
conduct research involving such polypharmacy and supratherapeutic doses. "Stacking" (taking two or more
AAS concurrently) and "cycling" (commonly a
6_10-week cycle followed by a drug-free period of a similar
length to reduce side-effects and tolerance) have been
practiced for many years by bodybuilders not subjected
to drug testing and having little respect for either their
bodies or the side-effects [8, 9]. In a review of 500
anonymous AAS users, 78% of whom were non competitive bodybuilders or non athletes, almost 60% reported
administering at least 1 000 mg of T or its equivalent a
week, with 25% admitting the concomitant use of human growth hormone (hGH) and insulin for their
anabolic effects. Not surprisingly, 99% reported
side-effects from AAS use [16].
5 Detection of T misuse by athletes
In 1967, the International Olympic Committee (IOC)
established a Medical Commission (IOC-MC) whose
primary role was to fight the misuse of drugs by Olympic
athletes. Between 1967 and 2003, the IOC-MC compiled
a List of Prohibited Substances and Prohibited
Methods for the Olympic Games. A majority of International Sport
Federations (IFs) adhered to this list although some IFs
had their own lists. The accreditation of Sports
Anti-Doping Laboratories was commenced by the
International Association of Athletics Federations (IAAF) in the
mid 1970s with the responsibility ceded to the IOC-MC
in 1983 by mutual agreement. The World Anti-Doping
Agency (WADA) assumed both these roles in 2004.
Token testing was undertaken at the 1968 Games but it was not until the Munich Olympic Games in 1972
that a major drug testing program was introduced with
more than 2 000 tests undertaken, albeit only for
stimulants and narcotics. The absence of any analytical test
to identify AAS is the presumed reason why the IOC
delayed in prohibiting them in sport. With hindsight and
subsequently, the IOC did prohibit other doping agents
without any possibility of detecting their administration,
e.g. blood doping in 1985, hGH in 1989, erythropoietin
in 1990, this was an error.
For many years, accredited laboratories have identified
more adverse analytical findings in the category of anabolic
agents than in any other prohibited class. In 2006, the 33
WADA accredited laboratories in 29 countries reported
1 966 (45.4%) of the 4 332 adverse analytical findings were
anabolic agents. Of these, 57.2% were T, 12.1% nandrolone,
11.3% stanozolol and 6.4% methandienone [18]. However, it must be stressed that these numbers do
not represent sanctioned anti-doping rule violations as some
may have been athletes who had a therapeutic use
exemption for T and others could have been a consequence
of additional investigations conducted after an elevated
testosterone/epitestosterone (T/E) ratio was identified.
6 AAS detection by radio-immunossays
In 1974, after Brooks and colleagues in London [19]
had developed radio-immunoassays (RIA) that could
detect some AAS, the IOC prohibited AAS with the first
positives at the 1976 Montreal Games. A total of eight
athletes were disqualified for use of methandienone, seven
weightlifters and one athlete in a field event. No positive
tests were announced at the boycotted 1980 Games in
Moscow. Having closely observed the physique of the
Eastern Block athletes, especially females in power events,
the author was sceptical especially when it was stated
that the absence of positives tests was alleged because the
RIA test was performed. Post Games, the unused B samples were transported to be analysed anonymously by
gas chromatography and mass spectrometry (GC/MS) at
the IAAF accredited Laboratory in Cologne, Germany.
Although no information on how many of these samples
contained doping agents was ever published, a
subsequent PhD thesis reported 7.1% of all females urines at
the Moscow Games had a T/E ratio > 6 [20].
7 AAS detection by GS/MS, HRMS and the T/E ratio
In 1982, having analysed 2 700 urines including the
B samples from Moscow 1980, Donike et al. [21]
identified that the ratio of the concentration of urinary T to
its 17α epimer E (the T/E ratio) was around unity. He
proposed that if the T/E ratio exceeded 3, this was
indicative of misuse of T but was persuaded to increase
this to 6 and this became valid in 1983.
Unknown until after the demise of the GDR in 1989,
the head of the GDR Doping Laboratory in Kreischa,
Germany, Clausnitzer possessed greater knowledge of
the T/E ratio than anybody including his ethical West
German counterpart Donike in Cologne, Germany. Within
one year of the introduction of the T/E ratio to detect doping with T, Clausnitzer had researched the
subject in his large pool of elite athletes being
systematically doped and undertook pre-testing of his athletes
before they competed internationally. E was available in
GDR in 1983 and was administered to athletes to reduce
their T/E ratios to less than 6 [6]. The most ironic and
frustrating aspect for the author was that Clausnitzer was
a member of the IOC-MC from 1981 to 1989.
The 1984 Olympic Games were the first where GS/MS was used to detect and identify AAS. A cross
country skier at the Winter Olympic Games in Sarajevo was
positive for methandienone and nine athletes were
disqualified for AAS use at the Summer Games in Los
Angeles, five for nandrolone and two for both
metheno-lone and T [22]. The most bizarre was the middle
distance runner, who had also blood doped with autologous
blood (blood doping was not prohibited until 1985) and
had been taking methenolone when his blood was withdrawn. After being stored for several weeks, his
blood was re-infused pre race and the methenolone was
administered. Two athletes were noted to have a T/E
ratio in excess of 6 and were disqualified. One, a
hammer thrower was stated to have a very high urinary T
concentration. The other, a Japanese volleyball player,
had a urinary T concentration of 70, a T/E of 10 and
thus low levels of E. As anabolic steroids would be
unlikely to be misused by a volleyball player, it was
questioned if this athlete had a naturally occurring elevation
of his T/E ratio. Further investigations were performed
in Japan and revealed that this athlete did have a
naturally elevated T/E ratio [23]. Despite this result and the
methods the GDR scientists employed to ensure athletes
did not compete with a T/E ratio greater than 6, the
concept of the T/E ratio did present a threat to the
unrestrained misuse of T by athletes.
At the 1988 Winter Olympics in Calgary, an ice hockey player with a T/E > 8.0 was disqualified for T
misuse [24]. In contrast, at the Seoul Olympics in 1988,
a US basketball player had a T/E ratio of 7.1 but was
exonerated because three previous tests performed in USA
during 1988 had all demonstrated a T/E ratio of between
5.4 and 5.8. The co-efficient of variation was deemed
to be low (10%) and the sample was declared negative.
Seoul 1988 was notable for the disqualification of the
winner of the 100 m final because he tested positive for
the AAS, stanozolol as did two other athletes. Barcelona
1992 resulted in two power athletes being sanctioned
after they tested positive to clenbuterol, a beta 2 agonist
with anabolic properties and highly recommended for
bodybuilders [9]. It was not until 1992 that the IOC
decided that all urine samples with a T/E between 6 and
10 must be investigated, either by reviewing previous
tests or by undertaking three unannounced tests over a
three-month period before declaring the athlete positive
for doping with T. Any sample with a T/E ratio > 10 was
automatically declared positive. Two years later, the IOC
reviewed this clause and decided that all urines with a T/E
greater than 6 should be investigated before being
declared positive. High resolution mass spectrometry
(HRMS) was introduced for the 1996 Atlanta Olympic
Games but no AAS were detected in any athlete's urine.
Although there has been no general direction made
for Laboratories to correct concentrations of Prohibited
Substances for specific gravity (SG), since 2004 WADA
has advised laboratories to correct urinary
concentrations of endogenous steroids to a SG of 1020 [25].
Corrected concentrations of T > 200 ng/mL are suggestive
of the administration of T. The administration of E
occurred initially in GDR to normalise T/E ratios and in
2004, WADA stated that corrected urinary concentrations of E > 200 ng/mL are suspicious of the
administration of E [26]. Complicating this issue is that E
production is often reduced by the administration of AAS
including T. Thus, consistently stable concentrations of E
are not suggestive of the use of exogenous T.
In 2005, WADA lowered the T/E cut-off from 6 to 4
for two main reasons. Firstly, some authorities
considered that athletes were doping with low dose T, especially
patches and gels and remaining below the T/E cut-off of
6 [27]. Secondly, many East Asian athletes have a
normal T/E ratio significantly below 1 and a 6_10-fold
increase in the ratio may not exceed 6 [28, 29]. However,
this has not produced any increase in athletes being
identified as doping with T. Rather, it has resulted in large
increases in work and costs for anti-doping agencies as
more and more athletes require unannounced follow-up
tests. Currently WADA employs a co-efficient of
variation of 30% for males and 60% for females when
assessing whether past or subsequent tests confirm that the
athlete has a normally elevated T/E ratio. The co-efficient of
variation is not a strictly enforced and laboratories can use
discretion when reviewing the overall steroid profiles. The
commonest reason for a naturally elevated T/E ratio is
low excretion of E, the inactive epimer of T. Other less
common causes are androgen secreting tumours,
predominately in females and enzyme deficiencies.
Although the rationale for reducing the T/E cut-off
from 6 to 4 appeared sound, history had already
demonstrated that it was a questionable decision. As early as
the 1988 Winter Olympic Games in Calgary, the
laboratory reported 17 athletes (15 males and two females) had
T/E ratios between 4 and 6 [24]. In 1996, the accredited
Laboratory in Stockholm investigated 28 of 8 946 urines
that had a T/E > 6 and conclude that only one with a T/E
of 10.5 and a CV of 126% could be confirmed as doping
with T [30]. It is possible that some of these athletes in
Calgary and in Sweden may have been low dosing with T
because GC-combustion-isotope ratio mass spectrometry
(IRMS) [31] was not yet available.
Since January 2005 when WADA reduced the T/E cut-off to 4, in a review of Australian athletes who have
had to be further examined because of their T/E ratio
was between 4 and 6, the author has identified that the
annual numbers of cases necessitating further
investigation have increased more than three-fold and not one
athlete whose T/E ratio was between 4 and 6 has been
identified as having used exogenous T, with IRMS
performed in every instance.
8 Detection of AAS by other methods
Because the administration of T inhibits LH
produc-tion, in 1979, Brooks and colleagues [32] recommended
the ratio of urinary T to LH as a valuable index to identify
doping with T and re-examined this premise a decade
later [33]. Another group demonstrated that after an
injection of T, the T/LH ratio remains significantly elevated
longer than the T/E ratio [34]. The negative aspect is
that after more than 25 years, there is no standardized
urinary immunoassay or methodology to measure urinary LH and this has contributed to the T/LH ratio not
becoming globally accepted as the gold standard index
although it does remain an ancillary indicator suggestive
of exogenous T administration [27].
9 Detection of AAS by GC-combustion-IRMS
Synthetic androgens, derived by semisynthesis from
plant origin, have less 13C than their endogenously
produced counterparts and thus allow a potential
differentiation of the 13C content between endogenous steroid
metabolites and their synthetically derived analogues. The
method is by GC with combustion to CO2 and mass
spectrometric analysis of the gas in a mass spectrometer (gas
chromatography-combustion-isotope ratio mass spectrometry [IRMS]). The aim is to compare the urinary
13C/12C ratio with reference steroids in the sample
unaffected by exogenous administration. Where any
para-meter in the steroid profile indicates the need for further
investigation, most commonly T because of a T/E ratio
> 4, the 13C /12C value expressed in
δ units per mL (d0/100) of that steroid or its metabolites is measured [35]. If the
13C/12C value differs by 3 δ units or more from the
urinary reference steroid chosen, this is considered
consistent with the exogenous administration of that AAS [26].
IRMS can detect the administration of E [36].
IRMS was accepted by the IOC in 1999 as an approved analytical method and used by the Laboratory at
the Olympic Games in Sydney 2000. However, IRMS was not required to identify any of the six AAS positive
at these Games; four nandrolone, three of which were
low level (< 7 ng/mL) and likely to have been ingested
inadvertently in supplements and two stanozolol. All
six athletes were disqualified. In Salt Lake City 2002,
two athletes were positive for nandrolone. The first
Olympic competitor disqualified as a result of IRMS
for misuse of T was a Greek wrestler at the Athens
Olympic Games 2004. At the 2004 Games, five other
athletes tested positive for AAS; stanozolol three,
oxandrolone one and metabolites of methyltestosterone
one. Two other athletes were disqualified for using
clenbuterol.
10 Designer AAS
In recent years, three designer anabolic agents that
have never been marketed have been identified. The first
was discovered in 2002 by Catlin, head of the UCLA
Analytical Laboratory [37], who detected a potent
19-nor anabolic steroid norbolethone the urine of a female
cyclist. In 2003, Catlin received a used syringe
containing a residual substance tetrahydrogestrinone (THG),
which he identified, synthesized by hydrogenation of
gestrinone and a developed specific method of detection
[38]. THG has been demonstrated to be a highly potent
androgen and progestin [39] and several athletes have
been sanctioned for its use. As some of these athletes
participated at the Sydney Olympic Games, the obvious
question was whether THG was used by athletes at the
2000 Games? In 2007, the most successful female track
athlete who won five medals including three gold at the
Sydney Olympic Games, admitted that she had taken designer steroids since 1999 and returned her medals.
Also in 2003, Canadian custom authorities at the
US-Canadian border seized a quantity of steroids which were
identified as desoxy-methyl-testosterone (DMT).
Further investigation by Catlin and colleagues [40] and in
Germany [41] both of whom termed the substance "madol", demonstrated DMT to be a potent androgen
receptor agonist with anabolic activity and could be
detected in urine.
11 The future selective androgen receptor
modulators (SARMs)
The concept of SARMs, first introduced in 1999 [42]
has progressed to early phase clinical trials in the
deve-lopment of non-steroidal selective androgen receptor
agonists. These appear to have the likelihood of
inducing anabolic effects on muscle and bone with minor
androgenic effects. It is these androgenic side-effects that
constitute a major disadvantage of AAS misuse [43].
Thus SARMs have the potential to be highly effective
doping agents in the future and not surprisingly, WADA
has prohibited SARMs in sport from 1 January 2008 [44].
12 Beijing 2008
The Beijing Doping Laboratory for the 2008
Olympic Games will have the most sophisticated state of the art
analytical equipment which will be at the disposal of the
most experienced team of chemists ever assembled at an
Olympic Games. Three thousand five hundred blood and urine samples will be collected and analysed in the
month from the opening of the Olympic Village on 27
July 2008. This is an increase of 22% of tests from
Athens 2004. The IOC and the Beijing Organising
Committee are making strenuous efforts to limit doping with
AAS and other substances at the 2008 Olympic Games.
13 Permitted administration of AAS to athletes
After glucocorticosteroids, diuretics and beta blockers
were prohibited in sport by the IOC in 1985, some
athletes with medical conditions became significantly
disadvantaged. In the late 1980s, two athletes were given
permission to administer T and participate in national
competitions only. One in Sweden had had both testes
removed for malignancies and the other an Australian had
neonatal torsions of both testes. It was not until 1992
that the IOC agreed to a policy that allowed the
permitted use of prohibited substances for genuine medical
conditions. Subsequently known as Therapeutic Use
Exemption (TUE), a number of conditions needed to be
fulfilled before a TUE could be granted. These were:
· the athlete would experience significant impairment
of health if the prohibited medication was withheld;
· no enhancement of performance would result from
the administration of the prohibited substance as
medically prescribed;
· no permitted and practical alternative medication
could be substituted for the prohibited substance.
The TUE concept, based on these criteria, was
approved by the IOC in 1992 and TUEs for oral
glucocor-ticosteroids for inflammatory bowel disease were first
granted at the 1992 Barcelona Olympic Games. When
the World Anti-Doping Code was approved in March 2003, concept of TUE was included and subsequently
an International Standard for TUE was approved later in
2003 [45].
There are only two anabolic agents for which TUEs
may be approved: T and danazol. There are two medical
conditions that may warrant a TUE for danazol. One
athlete competed at the 1996 Olympic Games having been
granted a TUE for danazol with documented genetic
deficiency of C-1 esterase inhibitor causing life threatening
hereditary angioneurotic edema. The other condition is
more common and is disabling endometriosis which has
not responded to all permitted methods of treatment
including surgery and must be on the recommendation of
a gynaecologist. Because danazol is anabolic and has
potential to enhance performance in females, the
duration of all approvals for endometriosis should be for a
maximum of 3_6 months. In 2004, a yachtsman
participated at the Olympic Games, having been granted a TUE
for T initially in 1995 for bilateral orchidectomies due to
carcinomas but he had failed to qualify for the 1996 and
the 2000 Olympic Games.
14 Conclusion
The misuse of AAS by athletes at the Olympic Games
commenced some years before these substances were prohibited in sport in 1974. When subject to doping
controls, AAS remain the commonest category of
pharmacological agent detected in athletes' urines and at
Summer Olympic Games of 2000 and 2004. The contest
between anti-doping agencies and doped athletes and their
pharmacological and medical supporters has continued
for several decades and shows no sign of diminishing.
Endocrinologists need to be mindful when confronted
by athletes who seek T replacement for low-normal or
age-reduced serum T levels. Occasionally,
athlete-patients will be encountered who have a completely valid
justification for T replacement therapy and the TUE
system is designed to serve their medical needs while
defending the fairness of elite sports.
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