VOLUME 41 : NUMBER 1 : FEBRUARY 2018

ARTICLE

Adverse effects of sports supplements

in men
Sarah J Martin
Sexual health physician1 SUMMARY
Senior lecturer2
Sports supplements are widely available over-the-counter and online. They may contain
Miranda Sherley
Sexual health registrar1 undeclared substances including androgenic steroids.
Lecturer2 According to the Australian Sports Anti-Doping Authority almost one in five sports supplements
General practitioner3 contain banned substances including stimulants and anabolic drugs. It warned that any
Malcolm McLeod supplement may not be safe to use.
Associate professor
College of Physical and Some supplements contain large amounts of protein or creatine. Their use may cause a raised
Mathematical Sciences4 blood urea or creatinine in an otherwise healthy individual.
1
Canberra Sexual Health Androgen deficiency with symptoms of hypogonadism may be due to use of androgenic
Centre steroids. This may be inadvertent as the labels on the sports supplements may not list steroids
Canberra Hospital in the ingredients.
2
Australian National
University Medical School If a person admits to using sports supplements it is an opportunity to discuss their health and fitness.
Canberra The Australian Sports Commission has advice on building muscle and the use of supplements.
3
Bungendore Medical
Centre
Bungendore
Introduction Energy drinks
New South Wales Legally obtained supplements marketed for Unlike sports drinks, which are generally used as
4
Australian National performance enhancement are commonplace and hydration fluids, energy beverages are used for their
University include sports drinks, energy beverages, and a wide supposed performance-enhancing properties.9,10
Canberra
range of pills and powders for oral consumption. Common energy beverages contain caffeine, taurine
Multi-ingredient sports supplements containing (an amino acid found naturally in meat and fish),
Keywords taurine, creatine or other amino acids are readily B vitamins and sugars.9
anabolic steroids, androgen
available and appear to be increasingly popular. Caffeine has stimulant effects on blood pressure and
deficiency, hypogonadism,
sport In a 2011–12 survey, 2.9% of Australian adults of all heart rate. It can cause nervousness, irritability and
ages reported using a special dietary product on the sleep disturbance.
day before interview. Approximately 70% of these Taurine is promoted for its ability to improve
Aust Presr 2018;41:10-13
supplements were sport and protein beverages or exercise capacity and performance, but most energy
https://doi.org/10.18773/
powder. The rate of use was 7.8% in men aged 19–30.1 beverages do not contain enough of it for therapeutic
austprescr.2018.003
People take supplements to gain muscle mass, lose or adverse effects.9 Little is known about the effects
weight and improve their performance or general of heavy or long-term taurine use.
health. They may be unaware that long-term use of
supplements can have adverse effects. Supplements Creatine
could potentially worsen some health conditions or Creatine is derived from amino acids and produced by
interact with drugs. the liver and kidneys. It is primarily stored in skeletal
Some products are contaminated with substances muscle cells, where it serves as an energy source.
that are prohibited in sport.2-4 They may contain Sports supplements may contain creatine alone or in
steroids that are not listed on the product label.5,6 combination. Creatine monohydrate has been popular
Australian research has found anabolic drugs or for over a decade despite a lack of evidence of safety
stimulants in 13 out of 67 supplements.2 It was with long-term use. Supplementation may improve
recognised over a decade ago that some 20% of exercise performance in adults performing high-
nutritional supplements sold in Europe and the USA intensity short-duration exercises, although the extent
contained anabolic steroids.7 Even products supplied of benefit is variable.11 There is little evidence for the
by overseas pharmacies may contain prohibited efficacy for creatine in combination products or of the
substances.8 The importation of prohibited substances safety of some of the newer forms of creatine such as
may also breach customs regulations. creatine ethyl ester.12

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Steroids hypothalamic-pituitary axis (see Fig.). Symptoms can

Some sports supplements also contain endocrine be non-specific, such as lethargy, fatigue, low mood,
disruptors including anabolic drugs, or androgenic irritability and poor concentration. More specific
problems include male pattern hair loss, acne, liver
steroids.5,6,13 When these synthetic drugs have
injury, increased cardiovascular risk, osteopenia or
been developed to evade regulatory control, they
osteoporosis, reduced muscle mass and strength,
are referred to as ‘designer steroids’.6 In many
increased fat mass and gynaecomastia.17 There may
cases these synthetic steroids have never been
be reduced sexual and reproductive function, with low
evaluated by regulatory bodies for purity, clinical
libido and erectile dysfunction.14,18 Infertility may also
efficacy or toxicity, so there are additional risks.6
occur.19 Other causes of hypogonadism must also be
Designer steroids are often heavily marketed as
considered when making the diagnosis.
prohormones, natural steroids and testosterone
boosters on websites that promote supplement use Some patients may present requesting prescriptions
for muscle bulk and strength.6 The use of sports for drugs such as selective oestrogen receptor
supplements containing steroids is a growing modulators and aromatase inhibitors.16 Consider
public health concern with evidence of increasing whether this may be for the mitigation of
use among young gym attendees and men over adverse effects of androgen or anabolic steroid-
40 years old.14,15 induced hypogonadism.
Many users of high-protein sports supplements will
Androgen deficiency and
be asymptomatic. However, renal function tests, done
supplement cycling
as part of an assessment for other clinical conditions,
Sports supplement users may engage in supplement may find an incidental raised blood urea or creatinine.
cycles, with periods of intensive use followed by This should trigger an enquiry about supplement
washout periods. If one or more products contain use. Supplements containing high quantities
anabolic drugs, the exogenous androgens may of protein may cause increased blood urea.20
promote muscle bulk, but will also suppress Those containing creatine may lead to increased
testicular testosterone production and exert negative creatinine concentrations.
feedback on the release of gonadotropins from the
pituitary gland.14,16 Excess circulating testosterone is
converted into oestradiol, providing further negative
feedback to the pituitary. High concentrations of Fig. Androgenic adverse effects in men
oestrogen may lead to oestrogenic adverse effects
including gynaecomastia.14 Hair loss Irritability
At the end of a supplement cycle, the body’s own
testosterone concentrations may be very low.
Symptomatic individuals may then use post-cycle
drugs such as aromatase inhibitors, to slow the Mood swings Acne
conversion of endogenous androgens to oestrogen,
or selective oestrogen receptor modulators such as
clomiphene and tamoxifen, to reduce the effects of
circulating oestrogen.16 While these are prescription Gynaecomastia Increased
cardiovascular risk
drugs in Australia, they are readily purchased online
and may also be found in some supplements. There
is little evidence that these approaches increase
Liver damage Impotence
endogenous testosterone after supplement use.16

Clinical suspicions
Some clinical presentations should prompt
Infertility Low libido
questioning about the use of energy beverages
and sports supplements. Agitation, palpitations and
insomnia, possibly in conjunction with high blood
pressure, may be related to over-consumption of Shrinkage of Osteoporosis,
caffeine or energy beverages.9 the testicles osteopenia

Post-pubertal patients whose sports supplements

contain androgenic steroids may present with features
of androgen deficiency due to suppression of the

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 VOLUME 41 : NUMBER 1 : FEBRUARY 2018

ARTICLE Adverse effects of sports supplements in men

Obtaining a full history of supplement use can be Management

complex. Multiple products are available online and To the patient, problems resulting from sports
may no longer be available for retrospective review supplements can be counterintuitive if the motivation
of their contents. Even when details are available, for use is to ‘get fit’ and ‘bulk up’. Guidance may be
the anabolic steroid content is unlikely to be listed.5
sought online, from blogs, peers or personal trainers
Patients who are willing to provide a comprehensive
rather than consultation with a GP, sports physician or
history of their supplement use may deny taking
nutritionist. Additionally, sports supplements are costly
androgens, but this does not exclude inadvertent
so are often a significant personal financial investment
oral ingestion.
alongside gym equipment, gym membership and time
Examination spent working out.

The examination of a patient suspected of supplement Establish the patient’s aims in taking supplements before
use should include blood pressure, height, weight, reviewing and renegotiating use to reduce the risk of
body mass index and, if obese, waist circumference. harm. Discussion of sleep patterns and sleep hygiene
Assess facial, head and body hair distribution for measures may be helpful for patients reliant on energy
deviation from the normal male pattern. Check for drinks. For oral protein supplement users, take a dietary
gynaecomastia. Scrotal examination is essential and history and encourage adequate but not excessive
testicular volume should be assessed, preferably with protein intake through food rather than supplements.
an orchidometer (normal range 15–35 mL in men aged The Australian Sports Commission provides online advice
21–35 years).19 on building muscle, protein and sports supplements.22-24
Consider other explanations for any abnormal Consider referral to a specialist in sports medicine or a
findings. For example, if there is a history of headache nutritionist to optimise training and diet.
or changes in vision in the presence of hormonal For supplement users with androgen deficiency, care
changes, check the visual fields. Headache with a can be more complex, especially when a patient is
visual field defect should prompt further investigation reluctant to cease use for fear of losing muscle bulk,
for a pituitary mass. strength and endurance. Discuss the impact on fertility
as well as sexual function. Encourage them to stop
Investigation
the supplements and repeat hormone studies in three
When an androgen deficiency is suspected the months to demonstrate improvement in endogenous
initial hormonal assessment should include serum hormones. If the patient agrees to stop using
testosterone. If the result is low the test should be supplements, and hormone studies do not normalise
repeated at least once and gonadotropins should be over six to nine months, endocrinology referral is
measured.21 Serum testosterone is most accurately indicated.
measured between 8 am and 10 am as concentrations
may be lower later in the day (adjust timing for shift
Conclusion
workers to shortly after waking).
In addition to sex hormone assays, a full blood Sports supplements are ubiquitous. Their ingredients
count, liver and kidney function tests, and thyroid may be obscure and reasons for their use can be
stimulating hormone may be considered as part of complex. A history of use should be sought in patients
baseline assessment. presenting with concerns about agitation, sleep, libido
Secondary testicular failure (hypogonadotropic and sexual function, as well as infertility.
hypogonadism) due to sports supplement The advice of the Australian Sports Anti-Doping
use is a diagnosis of exclusion and referral to Authority to competitive athletes in relation to
an endocrinologist may be needed. Measure sports supplements generalises well to the broader
serum prolactin to help exclude prolactinoma or population. Think about whether supplements are safe,
macroadenoma with pituitary stalk compression. effective or necessary. Similar improvements in fitness
Iron studies may exclude thalassemia and may be gained through changes in nutrition, training or
hemochromatosis. Imaging of the pituitary is
sleep programs.
indicated when there is suspicion of pituitary or
hypothalamic disease. Conflict of interest: none declared

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