Safety of Performance-Enhancing Drugs by 2050
Based on current medical evidence, certain performance-enhancing drugs—specifically testosterone replacement for documented deficiency and recombinant human growth hormone for specific wasting conditions—are already safe when used under strict medical supervision for legitimate therapeutic indications, but none can be recommended for enhancement purposes in healthy individuals due to significant adverse effects that outweigh any potential benefits.
Current Evidence on Safety Profile
Testosterone and Anabolic Steroids
Testosterone replacement is safe and effective only for documented hypogonadism, not for enhancement in healthy individuals. 1
- In men with COPD and documented low testosterone levels, testosterone enanthate (100 mg weekly) increased lean body mass and leg muscle strength without adverse effects in short-term (10-week) studies 1
- However, side effects increase in a dose-dependent fashion, including increased hemoglobin, decreased HDL cholesterol, and most concerning, potential acceleration of prostate cancer growth 1
- Raising testosterone levels above physiologic ranges seen in healthy young men is medically inadvisable 1
- In women, achieving muscle hypertrophy without virilization (masculinization) has proven extremely difficult, making anabolic steroids particularly problematic for female use 1
Oral anabolic steroids carry unacceptable hepatotoxicity risks. 1
- Oxymetholone (100 mg/day) caused dose-dependent liver toxicity in 30% of patients 1
- Oral preparations are associated with liver dysfunction, including carcinoma and peliosis hepatis 2
- Long-term use may increase cancer risk, though effects may not appear for 20+ years 3, 2
Human Growth Hormone (HGH)
Recombinant human growth hormone increases lean body mass but fails to consistently improve functional outcomes and carries significant metabolic risks. 1
- In underweight COPD patients, 3 weeks of daily growth hormone injections increased lean body mass by 2.3 kg versus 1.1 kg in placebo, but showed no improvements in muscle strength, inspiratory pressure, or exercise capacity 1
- The 6-minute walk distance actually decreased significantly in the growth hormone group 1
- Side effects include salt and water retention, impaired glucose metabolism, and high cost 1
- Studies in healthy subjects show muscle mass increases but seldom demonstrate actual strength improvements 1
Selective Androgen Receptor Modulators (SARMs)
SARMs represent a theoretical future option but lack sufficient clinical data for any recommendation. 1
- These non-steroidal molecules are designed to selectively activate skeletal muscle androgen receptors while avoiding prostate stimulation in men and virilization in women 1
- Early phase 2 trials with enobosarm showed increased lean body mass and improved stair climbing performance in cancer patients 1
- However, large-scale trials have not been reported, and no SARM has received approval for clinical use 1
- Insufficient data exists to recommend SARMs for routine use 1
Critical Safety Concerns Across All PEDs
Cancer Risk
Long-term PED use carries documented cancer risks that may not manifest for decades. 3, 2
- Anabolic steroids provoke liver tumors 3
- Growth hormone and elevated IGF-1 levels are associated with colon, breast, and prostate cancers 3
- IGF-1 promotes cell cycle progression, inhibits apoptosis, and interacts with carcinogenic pathways 3
- Athletes using supraphysiologic doses face higher cancer risk than patients on replacement therapy 3
Cardiovascular and Metabolic Effects
Dose-dependent adverse effects make enhancement doses particularly dangerous. 1, 2
- Testosterone causes lipid abnormalities and polycythemia 1
- In older men with potential subclinical prostate cancer, testosterone may enhance tumor growth 1
- Supraphysiologic doses should be avoided entirely 1
Endocrine Disruption
PED use causes profound hormonal disruption with lasting consequences. 2
- In adult males: testicular atrophy, reduced gonadotropins, and suppressed endogenous testosterone 2
- In children: interrupted growth and virilization 2
- In women: severe virilization that is difficult to reverse 2
- Birth defects in the unborn 2
Clinical Context: When PEDs Are Medically Appropriate
Documented Deficiency States
The only safe use of these agents is for documented medical conditions under physician supervision. 1
- HIV-positive patients with documented testosterone deficiency should receive testosterone replacement to restore muscle mass 1
- Meta-analysis of 417 HIV patients showed testosterone increased lean body mass by 0.63-1.04 kg with similar adverse effect rates to placebo 1
- However, concerns exist about long-term metabolic effects requiring extended follow-up 1
Wasting Syndromes
Growth hormone may be considered for severe wasting conditions when other options are exhausted. 1
- In HIV patients on HAART who lost >10% body weight, rhGH produced 1.5-2.2 kg weight gain consisting mainly of lean body mass 1
- Quality of life indices improved 1
- However, rhGH is extremely expensive and should only be used after exhausting other treatment options 1
Projection to 2050
Why Enhancement Use Remains Unsafe
No evidence suggests that fundamental safety concerns will be resolved by 2050. 1, 3
- The dose-dependent nature of adverse effects means enhancement doses will always carry greater risks than replacement doses 1
- Cancer risks associated with hormonal manipulation are inherent to the mechanisms of action 3
- Even with SARMs, large-scale long-term safety data will be required before any enhancement recommendation could be made 1
The Only Safe Path Forward
The distinction between therapeutic use for deficiency and enhancement in healthy individuals must remain absolute. 1
- Testosterone replacement for documented hypogonadism (levels below normal range) is safe and effective 1
- Any use in individuals with normal hormone levels carries unacceptable risk-benefit ratios 1
- No anabolic supplement has received sufficient study to be considered for routine inclusion even in supervised rehabilitation programs 1
Common Pitfalls to Avoid
Do not confuse therapeutic efficacy in disease states with safety for enhancement purposes. 1, 3
- Studies showing benefits in COPD, HIV wasting, or cancer cachexia do not translate to healthy individuals seeking performance enhancement 1
- The risk-benefit calculation is fundamentally different when treating disease versus enhancing normal function 3