Androgen abuse in athletes: detection and consequences

Illegal and falsified medicines self-administrated in not approved post-cycle therapy after the cessation of anabolic-androgenic steroids - qualitative analysis

Background

The term post-cycle therapy (PCT) often appears in bodybuilding forums in the context of anabolic-androgenic steroids (AAS) cessation. To reduce the negative impact of AAS on the hormonal system, unapproved PCT is used, which consist of medications that help restore hormonal balance. The most used medicinal products are selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), and preparations containing human chorionic gonadotropin (hCG). These substances are prohibited in sports by the World Anti-Doping Agency.

Methods

Between January 2020 and the end of August 2024, 601 samples seized by the police and prosecutor's office from the illegal market, intended for use as performance-enhancing drugs (PEDs), were tested at the Polish Official Medicines Control Laboratory. Samples were analyzed using accredited methods, including liquid chromatography coupled with high-resolution hybrid mass spectrometry and X-ray powder diffraction, to estimate PCT drug prevalence among other PED samples. In total, 411 (68.4%) samples declaring to contain AAS, 63 (10.5%) declaring to contain substances used in PCT, and 127 (21.1%) other PEDs were tested.

Results

Among the PCT drug samples, 33.3%, 25.4%, and 41.3% indicated the presence of SERMs (tamoxifen and clomiphene), AIs (anastrozole, letrozole, and exemestane), and other substances (hCG, cabergoline, and mesterolone), respectively according to the label. However, not all samples were consistent with the declarations. In 65.1% of the samples, the declared active pharmaceutical ingredients (APIs) were present, whereas in 34.9%, they were not. Furthermore, among the samples in which the declared API was found, 58.7% contained only the declared API, while 6.4% included an additional undeclared API. Conversely, among the samples without the declared API, 20.6% contained neither a declared API nor any API, while 14.3% had other undeclared APIs.

Conclusion

We have shown that illicit drugs used in PCT may be substituted, adulterated, or contain no active ingredients. Our results indicate that in view of the high prevalence of illicit AAS use, the self-administration of unapproved PCT using illegal and falsified medicines is dangerous and can be considered a potential threat to consumer health.

Inequalities in Survival of US Olympians

OBJECTIVE

To determine the disparities in length of live and age-specific probabilities of death of US Olympians by sex, performance level, and age at debut at the Olympics.

METHODS

We apply parametric models of mortality to estimate probabilities of death by age. The best performing model (Gompertz model) is then used to calculate life tables for subpopulations of Olympians. The life table functions are then used to decompose the differences in life expectancies by age.

RESULTS

Olympians live longer than the general population but are a diverse population in terms of survival. Gender gap in survival is substantially smaller in Olympians than in general population. Medalists have a shorter lifespan than nonmedalists. Olympians debuting at extremely young ages (<22) have a survival disadvantage compared with Olympians debuting at older ages. The differences between general population and Olympians are widening in younger cohorts.

CONCLUSION

US Olympians outlive the general population, but they constitute diverse group in terms of survival by sex, age at debut, and performance level. Studying and monitoring health disparities within the Olympic population is crucial for informing policies and regulations in sports organizations.

Review on activity-based detection of doping substances and growth promotors in biological matrices: do bioassays deserve a place in control programs?

BACKGROUND

Control programs such as anti-doping control and growth promotor residue surveillance programs are challenged by the emergence of designer drugs and the use of low-level drug cocktails. In order to cope with these challenges, the use of bioassays, measuring biological activity in a matrix, has been explored over the past two decades as a universal means to detect (combinations of) unknown drugs, regardless of their chemical structure.

RESULTS

This review compiles the experience on the use of activity-based assays to detect doping substances and growth promotors in biological matrices of humans (athletes) or live animals (race and/or food-producing animals). The aim is to learn from the scientific progress, going from initial research to the recent revival of this topic. Bioassay improvements and remaining limitations are discussed, along with a rational evaluation of possible applications of bioassays in control programs at their current functionality. Limitations include the possible interference by endogenous compounds and the challenge to detect metabolically activated (pro-)drugs. Nevertheless, successful validation of bioassays has been achieved, ensuring robust, reliable and valid results.

SIGNIFICANCE

We conclude by proposing three applications of bioassays that provide added-value to the current testing procedures: (i) characterization of compounds to provide indisputable proof of biological effects and to prioritize legislative (cf. expansion of bans) and research endeavors (cf. method development), (ii) bioassay-based screening of biological samples to direct intelligent sample storage, sample retesting and targeted athlete testing, (iii) bioassay-guided identification of drugs to overcome the challenges of suspicious peak selection, related to high-resolution techniques.

Biochemical liver damage during gender affirming therapy in trans adults assigned female at birth: a meta-analysis

PURPOSE

To assess the effects of testosterone (T)-based gender affirming hormone therapy (GAHT) on liver blood tests (LBTs) in assigned female at birth adults, using a meta-analytic approach.

METHODS

Prospective and retrospective studies were selected that reported the prevalence of biochemical liver damage (BLD) and LBTs changes during T therapy. Data collected included pre-and-during therapy alanine-aminotransferase (ALT), aspartate-aminotransferase (AST), gamma-glutamyl-transferase (GGT), and alkaline phosphatase (ALP) mean concentration values.

RESULTS

The prevalence of BLD in 14 studies on 1698 subjects was 1% (95% CI 0.00-3.00; I2 = 14.1%; p = 0.82). In 17 studies on 2758 subjects, GAHT was associated with a statistically (but not clinically) significant increase in AST, GGT and ALP at 12 months and ALT at 3-7 (MD: 1.19 IU/l; 95% CI 0.31, 2.08; I2: 0%), at 12 (MD: 2.31 IU/l; 95% CI 1.41, 3.21; I2: 29%), but with no more significant increase at 24 months (MD: 1.71 IU/l; 95% CI -0.02, 3.44; I2: 0%).

CONCLUSIONS

Analysis of aggregate estimates confirms a low risk of BLD and abnormalities in LBTs, transient in most cases, during T-based GAHT, thus suggesting a limited need for careful liver monitoring in AFAB people.

Fatal anabolic androgenic steroid overdose in an amateur bodybuilder: a clinical and autopsy report

Stanozolol is a synthetic anabolic-androgenic steroid commonly used by bodybuilders to increase muscle mass. However, its use can lead to serious adverse effects on the liver, including cholestasis, hepatic necrosis, and even death. In this case report, we describe a fatal case of stanozolol overdose in an otherwise healthy 35-year-old amateur bodybuilder. The patient presented with general malaise, jaundice, and a history of hematemesis after taking stanozolol tablets orally for 3 months. Upon admission, his liver function tests were significantly abnormal, and he succumbed within 48 h despite symptomatic treatment. The autopsy revealed sub-massive hepatic necrosis, focal macro-vesicular steatosis, and a cholestatic pattern of acute liver injury, with the chemical examination confirming the presence of stanozolol in the blood, liver, and kidneys. The cause of death was determined to be hepatic necrosis as a complication of stanozolol overdose. The overuse of anabolic steroids like stanozolol can cause hepatotoxicity, resulting in reversible cholestatic hepatitis or, in rare cases, fatal liver injury. The mechanism of anabolic androgenic steroid (AAS) drug-induced liver injury is obscure, but proposed mechanisms include oxidative stress and cholestasis. In this case, the recent overuse of stanozolol, a 17 alpha-alkylated (oral) AAS led to sub-massive hepatic necrosis and subsequent liver failure, proving fatal. It is imperative that healthcare providers and the public are informed about the dangers of AAS use, especially since AAS usage has increased recently due to easy online access, to prevent potentially life-threatening consequences.

Sexual hormones monitoring in surface waters and wastewaters from Northern Italy by thin film microextraction coupled with HPLC-MS/MS

The occurrence of sex steroid hormones, viz. oestrogens and progestins, in aquatic ecosystems is of global concern due to their role as endocrine disrupting chemicals, even at low concentration (μg L-1 or less). Thus, it is essential to monitor these organic pollutants to get a realistic picture of their presence and to control their contamination levels in environmental water bodies. In this respect, we have explored the use of self-prepared polymeric films as novel sorptive phase for the microextraction of 17β-estradiol, 17α-ethinylestradiol, estrone, progesterone, medroxyprogesterone acetate and hydroxyprogesterone. The thin film microextraction procedure has been developed, evaluating different film compositions, sample volumes and elution conditions to recover the sorbed analytes. The overall method provides good reproducibility (RSD < 12%) and recoveries higher than 60%. The final method has been applied to environmental monitoring in surface waters (river and lake samples) and urban wastewater treatment plant effluents and influents from Northern Italy, to get a contamination snapshot of this highly urbanized area.

Screening anabolic androgenic steroids in human urine: an application of the state-of-the-art gas chromatography-Orbitrap high-resolution mass spectrometry

Over the past few decades, anabolic androgenic steroids (AASs) have been abused in and out of competition for their performance-enhancing and muscle-building properties. Traditionally, AASs were commonly detected using gas chromatography-mass spectrometry in the initial testing procedure for doping control purposes. Gas chromatography-Orbitrap high-resolution mass spectrometry (GC-Orbitrap-HRMS) is a new technology that has many advantages in comparison with GC-MS (e.g., a maximum resolving power of 240,000 (FWHM at m/z 200), excellent sub-ppm mass accuracy, and retrospective data analysis after data acquisition). Anti-doping practitioners are encouraged to take full advantage of the updated techniques of chromatography-mass spectrometry to develop sensitive, specific, and rapid screening methods for AASs. A new method for screening a wide range of AASs in human urine using GC-Orbitrap-HRMS was developed and validated. The method can qualitatively determine 70 anabolic androgenic steroids according to the minimum required performance limit of the World Anti-Doping Agency. Moreover, the validated method was successfully applied to detect six metabolites in urine after the oral administration of metandienone, and their excretion curves in vivo were studied. Metandienone M6 (17β-hydroxymethyl-17α-methyl-18-nor-androst-1,4,13-trien-3-one) has been identified as a long-term urinary metabolite which can be detected up to 7 weeks, thus providing a longer detection window compared with previous studies. This study provides a rationale for GC-Orbitrap-HRMS in drug metabolism and non-targeted screening.

Effects of Nandrolone Decanoate on Skeletal Muscle and Neuromuscular Junction of Sedentary and Exercised Rats

Background and Objectives: Nandrolone decanoate (ND) is the most widely used among the anabolic androgenic steroids (AAS), synthetic substances derived from testosterone, to improve muscular and health gains associated with exercises. The AAS leads to physical performance enhancement and presents anti-aging properties, but its abuse is associated with several adverse effects. Supraphysiological doses of AAS with or without physical exercise can cause morphological and functional alterations in neuromuscular interactions. This study aims to investigate the effects of ND supraphysiological doses in neuromuscular interactions, focusing on the soleus muscle and its neuromuscular junctions (NMJs) in rats, associated or not with physical exercise. Materials and Methods: Forty male Sprague Dawley rats were divided into four groups: sedentary and exercised groups, with or without ND at the dose of 10 mg/kg/week. The animals were treated for eight weeks, with intramuscular injections, and the soleus muscle was collected for morphological analyses. Results: The supraphysiological doses of ND in the sedentary group caused muscle degeneration, evidenced by splitting fibers, clusters of small fibers, irregular myofibrils, altered sarcomeres, an increase in collagen deposition and in the number of type I muscle fibers (slow-twitch) and central nuclei, as well as a decrease in fibers with peripheral nuclei. On the other hand, in the ND exercise group, there was an increase in the NMJs diameter with scattering of its acetylcholine receptors, although no major morphological changes were found in the skeletal muscle. Thus, the alterations caused by ND in sedentary rats were partially reversed by physical exercise. Conclusions: The supraphysiological ND exposure in the sedentary rats promoted an increase in muscle oxidative pattern and adverse morphological alterations in skeletal muscle, resulting from damage or post-injury regeneration. In the ND-exercised rats, no major morphological changes were found. Thus, the physical exercise partially reversed the alterations caused by ND in sedentary rats.

New perspectives in functional hypogonadotropic hypogonadism: beyond late onset hypogonadism

Functional hypogonadotropic hypogonadism (FHH) is an increasingly frequent condition, whose pathological mechanisms are not yet fully clarified. The concept of FHH has now completely replaced that of late onset hypogonadism, that only concerned the ageing man. FHH is the result of an impairment of the hypothalamic-pituitary gonadal axis (HPG-A) function, resulting in decreased testosterone concentrations associated with low or inappropriately normal gonadotropin levels and infertility; it can be diagnosed once organic causes of hypogonadism are excluded. The growing occurrence of FHH derives from its association with widespread conditions, such as obesity and diabetes mellitus, but also to the increasing ease and frequency of use of several drugs, such as opioids, glucocorticoids, and sex steroids. Moreover, given the tendency of many subjects to excessive physical activity and drastic reduction in caloric intake, FHH may also be secondary to low energy availability. Finally, the association with HIV infection should not be overlooked. Therefore, there is an important variability in the diseases that can lead to FHH. Despite the heterogeneity of the underlying pathologies, the mechanisms leading to FHH would seem quite similar, with the initial event represented by the impairment at the HPG-A level. Nevertheless, many different biological pathways are involved in the pathogenesis of FHH, therefore the aim of the current paper is to provide an overview of the main relevant mechanisms, through a detailed analysis of the literature, focusing specifically on pathogenesis and clinical, diagnostic and therapeutic aspects.

"What a man can do, a woman can do better": women farmers, livelihood and drug abuse in Adamawa State, northeastern Nigeria

Drug and substance abuse among female population is on the rise but yet to be given adequate scholarly attention. This study examines how women farmers in Adamawa State are engaging in drug and substance abuse to enhance their farming livelihood practices and the implications of their action for health and social cohesion around their communities. Using data collected from interviews and observations, the study discovered that rising female-breadwinning in the study area put a lot of pressure on women to engage in farming as owners, hired or eclectic farmers. To be able to withstand the stress of farming, some engage in the use of psychotropic stimulant substances to enhance their performance. The study also discovered that the most abused substances are cannabis and tramadol due to affordability and availability. On the other hand however, the study found out that increasing indulgence of women in substance abuse is already impacting on spousal relationship between the women indulging in substance abuse and their husbands. The study recommended that government of Adamawa State should enforce in full, the Adamawa State Unclassified (Local Substances) Abuse Law 2015 by establishing a rehabilitation center for correction and reformation of addicts in the state. Furthermore, it is also recommended that all stakeholders should give empowerment of women in the state serious attention.

Doping and sports endocrinology: anabolic-androgenic steroids

The use of anabolic steroids affects not only professional athletes but also the general population (bodybuilders, gym clients, and adolescents). In the first case, its use is prohibited and sanctioned by the World Anti-Doping Agency and Olympic committees. For the other users, it is difficult to establish its prevalence since many obtain the products via the internet. The reasons for its use are varied and different forms of use and other types of users have been described. Among the side effects of steroid use, hypogonadism is the most frequent cause for endocrinological consultation. After a general introduction to doping, this review describes the historical background of anabolic-androgenic steroids, their classification, forms of use, physiological effects, adverse effects on different organs and systems, treatment of hypogonadism, as well as detection methods.

Anabolic androgenic steroid-induced liver injury: An update

Anabolic androgenic steroids (AASs) are a group of molecules including endogenous testosterone and synthetic derivatives that have both androgenic and anabolic effects. These properties make them therapeutically beneficial in medical conditions such as hypogonadism. However, they are commonly bought illegally and misused for their anabolic, skeletal muscle building, and performance-enhancing effects. Supraphysiologic and long-term use of AASs affects all organs, leading to cardiovascular, neurological, endocrine, gastrointestinal, renal, and hematologic disorders. Hepatotoxicity is one of the major concerns regarding AASs treatment and abuse. Testosterone and its derivatives have been most often shown to induce a specific form of cholestasis, peliosis hepatis, and hepatic benign and malignant tumors. It is currently believed that mechanisms of pathogenesis of these disorders include disturbance of antioxidative factors, upregulation of bile acid synthesis, and induction of hepatocyte hyperplasia. Most toxicity cases are treated with supportive measures and liver function normalizes with discontinuation of AAS. However, some long-term consequences are irreversible. AAS-induced liver injury should be taken in consideration in patients with liver disorders, especially with the increasing unintentional ingestion of supplements containing AAS. In this paper, we review the most current knowledge about AAS-associated adverse effects on the liver, and their clinical presentations, prevalence, and pathophysiological mechanisms.

Testosterone Therapy is Associated With Depression, Suicidality, and Intentional Self-Harm: Analysis of a National Federated Database

BACKGROUND

Long-term use of testosterone can be associated with mood destabilizing effects. Most studies investigating psychiatric complications of anabolic steroids have used small samples, but a comprehensive assessment of the risk of developing mental health disorders after testosterone use has not been performed at the population level.

AIM

To determine whether testosterone therapy is associated with major depressive disorder or suicide attempts in men.

METHODS

We conducted a retrospective cohort study of 70.3 million electronic health records collected from 46 healthcare organizations encompassing flagship hospitals, satellite hospitals, and outpatient clinics since 2008 to determine whether testosterone use is associated with major depressive disorder and suicide attempts in a large population. We included men 18 or older who either used testosterone or did not, defined by reported use, insurance claim, or prescription use of testosterone documented in the electronic health record. We propensity-score matched by age, race, ethnicity, obesity, and alcohol-related disorder. Additionally, a sub-group analysis was performed in testosterone deficient (<300 ng/dL) men comparing those with TD on testosterone therapy to a control group of men with TD who are not using testosterone.

OUTCOMES

We determined measures of association with a new diagnosis of major depressive disorder and suicide attempt or intentional self-harm following testosterone use within 5 years.

RESULTS

A total of 263,579 men who used testosterone and 17,838,316 men who did not were included in the analysis. Testosterone use was independently associated with both Major Depressive Disorder (OR 1.99, 95% CI 1.94-2.04, P < .0001) and Suicide Attempt/Intentional Self-Harm (OR 1.52, 95% CI 1.40-1.65, P < .0001). Results remained significant in testosterone deficient sub-group analysis.

CLINICAL IMPLICATIONS

Men who use testosterone should be screened for and counseled about risks of depression and suicidality.

STRENGTHS AND LIMITATIONS

Strengths of this study include a large sample size, the ability to account for chronology of diagnoses, the use of propensity score matching to control for potentially confounding variables, and the consistency of results with sub-group analyses. Limitations include the potential for incorrect coding within the electronic health record, a lack of granular information regarding testosterone therapy adherence, the possibility that unrecorded testosterone or anabolic steroid use were prevalent but not captured within the control group, and a lack of data regarding testosterone withdrawal.

CONCLUSION

Testosterone use is independently associated with new-onset mental health disorders. Future studies are necessary to elucidate the role that androgen withdrawal plays and whether a causal relationship exists. Nackeeran S, Patel MS, Nallakumar DT, et al. Testosterone Therapy is Associated With Depression, Suicidality, and Intentional Self-Harm: Analysis of a National Federated Database. J Sex Med 2022;19:933-939.

Androstenedione (a Natural Steroid and a Drug Supplement): A Comprehensive Review of Its Consumption, Metabolism, Health Effects, and Toxicity with Sex Differences

Androstenedione is a steroidal hormone produced in male and female gonads, as well as in the adrenal glands, and it is known for its key role in the production of estrogen and testosterone. Androstenedione is also sold as an oral supplement, that is being utilized to increase testosterone levels. Simply known as "andro" by athletes, it is commonly touted as a natural alternative to anabolic steroids. By boosting testosterone levels, it is thought to be an enhancer for athletic performance, build body muscles, reduce fats, increase energy, maintain healthy RBCs, and increase sexual performance. Nevertheless, several of these effects are not yet scientifically proven. Though commonly used as a supplement for body building, it is listed among performance-enhancing drugs (PEDs) which is banned by the World Anti-Doping Agency, as well as the International Olympic Committee. This review focuses on the action mechanism behind androstenedione's health effects, and further side effects including clinical features, populations at risk, pharmacokinetics, metabolism, and toxicokinetics. A review of androstenedione regulation in drug doping is also presented.

Severe Cardiac and Metabolic Pathology Induced by Steroid Abuse in a Young Individual

Androgenic-Anabolic Steroids (AAS) abuse is known to play an important role in causing the systemic inflammatory response and multiple-organ dysfunction in healthy individuals. Although many of the undesirable effects of steroid abuse have been reported, at present, little is known about the effect of anabolic supplements and the correlation between cardiac and metabolic pathology. This paper presents a case of a 25 year old patient with a complex medical history after 6 months of steroid administration. Myocardial infraction, dyslipidemia, obesity, hyperuricemia, secondary diabetes, and chronic renal disease were identified after clinical and para-clinical examinations. The particularities of this case were interpreted in the context of a literature review, highlighting the effect of multi-organ damage as a result of the uncontrolled use of anabolic steroid supplements.

Androgen Misuse and Abuse

Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.

Imaging in gynecomastia

BACKGROUND

Gynecomastia (GM) is the benign proliferation of glandular tissue in the male breast. It is a common condition, which may occur physiologically and shows three age peaks during a male's lifespan: infancy, puberty, and senescence. An underlying pathology may be revealed in 45%-50% of adult men with GM, such as aggravating medications, systemic diseases, obesity, endocrinopathies, or malignancy.

OBJECTIVE

To discuss the role of imaging in the evaluation of GM and its contribution to therapeutic decision-making.

MATERIALS/METHODS

The current literature was reviewed through PubMed, Scopus, and CENTRAL electronic databases to identify the best available evidence concerning imaging modalities in patients with GM.

RESULTS

Most male breast lesions can be diagnosed on clinical grounds; however, in certain cases, when physical examination is inconclusive, imaging may be helpful.

DISCUSSION

The main purpose of evaluating a patient with GM is to establish the diagnosis and differentiate true GM from pseudogynecomastia, exclude breast cancer, and detect the possible cause. GM is seen in mammography as a subareolar opacity and three mammographic patterns of GM are described: nodular, dendritic, and diffuse, corresponding to florid GM of early onset, fibrous persistent GM, and GM due to exogenous estrogen administration, respectively. In ultrasound (US), florid GM is depicted as a disk-shaped, hypoechoic area underlying the areola, whereas echogenicity of the lesions increases as fibrosis develops. Data on the use of MRI in the evaluation of the male breast and GM are still limited. Imaging findings can be classified according to the BIRADS (breast imaging reporting and data system) based on their malignant potential.

CONCLUSION

Both mammography and US are sensitive and specific to diagnose GM and distinguish it from breast cancer. When clinical findings are suggestive of malignancy or imaging findings are inconclusive, a histological confirmation should be sought.

A model for evaluating the economic value of prevention programs for illicit use of anabolic androgenic steroids

BACKGROUND

The illicit use of anabolic androgenic steroids (AAS) has become a societal concern. We developed a decision-analytic model for assessing the cost-effectiveness of preventive interventions targeting AAS-use. We used scenario analyses to demonstrate: a) the potential health economic consequences of AAS use in Sweden, and b) the cost-effectiveness of a hypothetical preventive intervention.

METHODS

A population-based cohort model compared a hypothetical preventive intervention targeting AAS with a 'no intervention' scenario, from a limited societal perspective. The model simulated how a cohort of 18 year-old males transitioned between different states and predicted their health status and complications until the age of 41. Health outcomes were estimated as quality-adjusted life-years (QALY). Costs included intervention costs, drug costs, and costs of complications.

RESULTS

Total yearly costs related to AAS use amounted to nearly half a million US$, with the largest cost borne by the healthcare sector. Results suggest that AAS prevention could entail large costs and benefits with a mean incremental cost-effectiveness ratio of $550 per QALY, in a scenario where the intervention would decrease the probability of initiating AAS use by 5%.

CONCLUSION

Results show large AAS related costs, and suggest that the implementation of a preventive intervention could offer good value for money given different effectiveness scenarios. This model can be used to estimate the value of interventions targeting AAS use.

Analysis of pharmaceutical products and dietary supplements seized from the black market among bodybuilders

Substandard/counterfeit drugs are a growing global problem. According to the World Health Organisation, counterfeit medicines are medicines that are mislabelled deliberately and fraudulently regarding their identity and/or source. In high income countries, drugs seized are mainly represented by performance and image enhancing drugs (PIEDs). The aim of this study was to present the qualitative and quantitative results of toxicological analyses of pharmaceutical and dietary supplements seized from the black market among bodybuilders in France. All dietary supplements and pharmaceuticals seized from the black market and addressed to the laboratory for a qualitative and quantitative analysis between January 2016 and December 2019 were included in the study. A screening was carried out by gas chromatography-mass spectrometry and liquid chromatography-high resolution mass spectrometry. Identified compounds were quantified by liquid chromatography-tandem mass spectrometry. One hundred and ten products were seized and submitted to the laboratory for identification of active compounds and quantification: 75 pharmaceuticals and 35 dietary supplements. This included 39 oily and 3 aqueous solutions for intramuscular injection, 34 tablets, 13 capsules, 14 powders, 4 liquids and 3 lyophilizates. Among the pharmaceuticals, 25/75 (33%) were substandard (dosage not on the acceptable range defined for original products), 24/75 (32%) were counterfeit (qualitative formulation does not match the label) and 14/75 (19%) were original (qualitative formulation and levels of active ingredients fully matches the declared formulation. The analysis of the 12 remaining products revealed a correct qualitative content for 11/75 (15%), but quantitation could not be carried out because of the lack of reference standards at the time of the analysis. Fifty-four pharmaceuticals contained anabolic-androgenic steroids (AAS). Four out of 54 (7.4%) AAS were found as original, 8/54 (15%) could not be quantified (one with wrong active ingredient), corresponding to 43/54 (80%) AAS being non-original. In contrast, only 1/35 dietary supplement (3%) was adulterated, with a doping substance (1,3-dimethylbutylamine, DMBA). This work allows to show that France is not spared by the trafficking of PIEDs. The use of counterfeit drugs in mainstream population is an underestimated public health issue.

Adverse Effects of Anabolic-Androgenic Steroids: A Literature Review

Anabolic-androgenic steroids (AASs) are a large group of molecules including endogenously produced androgens, such as testosterone, as well as synthetically manufactured derivatives. AAS use is widespread due to their ability to improve muscle growth for aesthetic purposes and athletes’ performance, minimizing androgenic effects. AAS use is very popular and 1–3% of US inhabitants have been estimated to be AAS users. However, AASs have side effects, involving all organs, tissues and body functions, especially long-term toxicity involving the cardiovascular system and the reproductive system, thereby, their abuse is considered a public health issue. The aim of the proposed review is to highlight the most recent evidence regarding the mechanisms of action of AASs and their unwanted effects on organs and lifestyle, as well as suggesting that AAS misuse and abuse lead to adverse effects in all body tissues and organs. Oxidative stress, apoptosis, and protein synthesis alteration are common mechanisms involved in AAS-related damage in the whole body. The cardiovascular system and the reproductive system are the most frequently involved apparatuses. Epidemiology as well as the molecular and pathological mechanisms involved in the neuropsychiatric side-effects of AAS abuse are still unclear, further research is needed in this field. In addition, diagnostically reliable tests for AAS abuse should be standardized. In this regard, to prevent the use of AASs, public health measures in all settings are crucial. These measures consist of improved knowledge among healthcare workers, proper doping screening tests, educational interventions, and updated legislation.

Nandrolone Decanoate: Use, Abuse and Side Effects

Background and Objectives: Androgens play a significant role in the development of male reproductive organs. The clinical use of synthetic testosterone derivatives, such as nandrolone, is focused on maximizing the anabolic effects and minimizing the androgenic ones. Class II anabolic androgenic steroids (AAS), including nandrolone, are rapidly becoming a widespread group of drugs used both clinically and illicitly. The illicit use of AAS is diffused among adolescent and bodybuilders because of their anabolic proprieties and their capacity to increase tolerance to exercise. This systematic review aims to focus on side effects related to illicit AAS abuse, evaluating the scientific literature in order to underline the most frequent side effects on AAS abusers’ bodies. Materials and Methods: A systematic review of the scientific literature was performed using the PubMed database and the keywords “nandrolone decanoate”. The inclusion criteria for articles or abstracts were English language and the presence of the following words: “abuse” or “adverse effects”. After applying the exclusion and inclusion criteria, from a total of 766 articles, only 148 were considered eligible for the study. Results: The most reported adverse effects (found in more than 5% of the studies) were endocrine effects (18 studies, 42%), such as virilization, gynecomastia, hormonal disorders, dyslipidemia, genital alterations, and infertility; cardiovascular dysfunctions (six studies, 14%) such as vascular damage, coagulation disorders, and arteriosus hypertension; skin disorders (five studies, 12%) such as pricking, acne, and skin spots; psychiatric and mood disorders (four studies, 9%) such as aggressiveness, sleep disorders and anxiety; musculoskeletal disorders (two studies, 5%), excretory disorders (two studies, 5%), and gastrointestinal disorders (two studies, 5%). Conclusions: Based on the result of our study, the most common adverse effects secondary to the abuse of nandrolone decanoate (ND) involve the endocrine, cardiovascular, skin, and psychiatric systems. These data could prove useful to healthcare professionals in both sports and clinical settings.

Periodontal clinical status, microbial profile, and expression of interleukin-1β in men under androgenic anabolic steroids abuse

OBJECTIVES

Androgenic anabolic steroids (AAS) abuse is a serious health problem associated to several systemic complications. Here, we evaluated the periodontal clinical status, microbial profile, and expression of total protein (TP) and interleukin (IL)-1β in men using AAS.

MATERIALS AND METHODS

Men using AAS were recruited (case group) and matched for age with men who had never used AAS (control group) but also performed physical activities. Plaque index (PI), marginal bleeding (MB), probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BoP) were evaluated. Crevicular fluid and subgingival biofilm were collected from healthy and diseased sites (PD ≥ 4 mm with CAL ≥ 1 mm and BoP) and evaluated for TP, IL-1β, and proportions of 40 bacterial species.

RESULTS

Thirty patients were included (n = 15/group). AAS consumers had significantly higher mean PD and higher percentage of diseased sites; sites with PD ≥ 4 mm or with CAL ≥ 1 mm than non-consumers. Also, AAS users showed a more dysbiotic biofilm containing lower proportions of host-compatible species and higher proportions of pathogens. IL-1β expression was statistically higher in diseased than in healthy sites only in the control group. A statistically positive correlation was detected between periodontal pathogens and IL-1β expression. The number of AAS cycles was positively associated with higher percentages of periodontal pathogens, but not with IL-1β or total protein concentrations.

CONCLUSIONS

AAS intake can worsen clinical and immunological periodontal conditions and the biofilm composition in healthy sites.

CLINICAL RELEVANCE

Dental care professionals should perform full mouth periodontal screening and schedule regular follow-up appointments for patients under AAS use.

Overview of the analysis, occurrence and ecological effects of hormones in lake waters in Asia

Hormones are natural and synthetic compounds that are now being detected in the aquatic environment. Many lakes in Asia are important water sources that may be affected by these emerging contaminants. Lakes are drains and reservoirs of watersheds that are altered by changing land use and environmental conditions. While there are several studies on the detection of hormones in lakes, these studies were mostly done in China. Limited information is available on the presence of these contaminants in the lakes in other Asian countries. Hormones in the lake water come from discharge waters in urban areas, farm runoffs, and effluents of wastewater and sewage treatment plants. Hormones contamination in water has been shown to affect the reproduction and growth of certain aquatic organisms. In this review, a background on the chemical nature and physiological functions of hormones is provided and the existing knowledge on the occurrence and ecological impacts of hormones in lakes is described. The available analytical methods for sampling, analyte extraction and instrumental analysis are outlined. This overview provides insights on the current conditions of lakes that may be impacted by hormones contamination. Understanding the levels and possible ecological consequences will address the issues on these emerging contaminants especially in the Asian environment. This will elicit discussions on improving guidelines on wastewater discharges and will drive future research directions.

The effects of supraphysiological levels of testosterone on neural networks upstream of gonadotropin-releasing hormone neurons

OBJECTIVES

Several pathological conditions are associated with hyper-production of testosterone; however, its impacts are not well understood. Hence, we evaluated the effects of supraphysiological levels of testosterone on gonadotropin-releasing hormone (GnRH) system in the hypothalamus of male rats. Also, we assessed the expression of two excitatory (kisspeptin and neurokinin-B) and two inhibitory (dynorphin and RFamide-related-peptide) neuropeptides upstream of GnRH neurons as possible routes to relay androgen information.

MATERIALS AND METHODS

Gonadectomized (GDX) male rats received single injection of 100, 250 or 500 mg/kg testosterone undecanoate and three weeks later, posterior (PH) and anterior (AH) hypothalamus was dissected for evaluation of target genes using quantitative RT-PCR.

RESULTS

We found that GnRH mRNA in the PH was high in GDX rats and 500 mg/kg testosterone reduced GnRH level expression. Finding revealed extremely high level of Kiss1 mRNA in the PH of GDX rats. However, in GDX rats treated with different levels of testosterone, Kiss1 expression was not significantly different than control. We also found that testosterone replacement increased the Kiss1 mRNA level in the AH. Moreover, neurokinin-B mRNA level in PH of GDX rats was similar to control. However, excess testosterone levels were effective in significantly inducing the down-regulation of neurokinin-B expression. The basal level of dynorphin mRNA was increased following testosterone treatments in the AH, where we found no significant difference in the level of RFamide-related-peptide mRNA between the experimental groups.

CONCLUSION

Excess levels of testosterone could act differently from its physiological concentration to regulate hypothalamic androgen sensitive neurons to control GnRH cell.

Possible Protective Role of Whey Protein on the Rat's Liver Tissues Treated with Nandrolone decanoate

BACKGROUND AND OBJECTIVE

Nandrolone and whey protein are used as supplementary food and athletic food. The aim of this study was to evaluate the possible histological and ultrastructural alterations in the liver of adult rats after treatment of the anabolic androgenic steroids (Nandrolone decanoate) and whey protein.

MATERIALS AND METHODS

Twenty eight Wistar Albino male rats were used in the present study divided into 4 groups: Control group received 0.5 mL of saline solution by oral, Nandrolone group injected intramuscular (10 mg kg-1 b.wt./week for 3 months), whey protein group treated by oral (5 mg kg-1 b.wt./week for 3 months) and Nandrolone and whey protein group. At the end of the experimentation, all the rats were sacrificed and liver samples were processed for histological and ultrastructural examination. Haematoxylin and eosin stains for general histological examination and Mallory trichrome stain for collagen fibers.

RESULTS

Light microscopy examination of the liver of the nandrolone group showed bleeding and widening of the blood sinusoids. Degeneration, vacuolation, coagulative necrosis and pyknotic nuclei were observed. In addition, increased collagen fibers were detected. Whey protein group showed more or less normal hepatocytes, blood sinusoids and collagen fibers. The nandrolone and whey protein group illustrated normal appearance of hepatocytes with vacuolation in some of the hepatocytes and normal blood sinusoids and collagen fibers were noticed. Electron microscopic examination of the nandrolone group showed depletion of the nuclear chromatin, damaged mitochondria, increased of lysosomes, some lipid droplets, damaged blood sinusoids and space of Disse and increased of Kupffer cells, whereas the whey protein group appeared normal. The nandrolone and whey protein group showed well developed hepatocytes, regular space of Disse and normal hepatic sinusoids.

CONCLUSIONS

Whey protein may be ameliorate the hepatic architecture after treatment with nandrolone.

Comprehensive review of cardiovascular toxicity of drugs and related agents

Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.

Bipolar disorder, comorbid anxiety disorders, gynecomastia and dental pain: case analysis with literature review

Bipolar disorder with comorbid anxiety disorders frequently requires rational polypharmacy, including use of serotonergic psychotropics. These may result in adverse effects, influencing adherence, complicating treatment and confounding diagnoses. Serotonergic non-adherence is associated with discontinuation syndromes. In this complex case with an on/off/on/off design, both dose-dependent buspirone-induced gynecomastia and buspirone discontinuation syndrome with dental pain are reported. Clinicians and patients should consider these findings to maximise treatment adherence, minimise any unnecessary interventions and address unusual adverse effects. Since patients may not voluntarily disclose specific adverse effects and often do not acknowledge non-adherence, clinician-directed questions are required. This case further emphasises the importance of medication and symptom timelines to guide determination of causation for adverse effects. Although findings from this case cannot be generalised, they suggest the need for continued clinician and patient education, as well as the benefit from detailed case reports.

DECLARATION OF INTEREST

None.

Anabolic androgenic steroids and carcinogenicity focusing on Leydig cell: a literature review

Anabolic androgenic steroids (AAS) are some of the most common drugs used among athletes, frequently in combination with resistance training, to improve physical performance or for aesthetic purpose. A great number of scientific reports showed the detrimental effects of anabolic androgenic steroids on different organs and tissues. In this literature review, we analyzed the AAS-mediated carcinogenicity, focusing on Leydig cell tumor.

AAS-induced carcinogenicity can affect DNA transcription through two pathways. It can act directly via the androgen receptor, by means of dihydrotestosterone (DHT) produced by the action of 5-a-reductase. It can also work through the estrogen receptor, by means of estradiol produced by CYP19 aromatase. In addition, nandrolone and stanazolol can activate the PI3K/AKT and PLC/PKC pathways via IGF-1. This would result in cell proliferation in Leydig cell cancer, or magnify cyclin D1 concentration inducing breast cell proliferation.

AAS abuse is becoming a serious public health concern in view of the severe health consequences secondary to AAS abuse. The negative role of AAS in supraphysiological dosage impairs the expression of enzymes involved in testosterone biosynthesis. Abnormal synthesis of testosterone plays has a negative effect on the hormonal changes/regulation, and might be involved in certain carcinogenic mechanisms. At the light of this review, it could become very interesting to perform an information campaign more strengthened in gyms and schools in order to prevent male fertility impairment and other tissues damage.

Non-allowed Pharmacologically Active Substances in Physical and Sexual Performance Enhancing Products

Background:

Recently, a large amount of physical and sexual performance enhancing products have started to be freely sold mainly on internet web sites as dietary supplements. However, there a high suspicion that pharmacologically active substance, prohibited in these products, can be present to provide the expected effect.

Methods:

A simple and rapid systematic toxicological analysis by gas chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry has been applied after a liquid-liquid extraction at acidic, neutral and alkaline pH with chloroform-isopropanol (9:1 v/v). The assays were validated in the range from 10 mg to 250 mg/g products showing a good linearity for the calibration curves (r2 ≥0.99). Mean extraction recoveries of analytes from different products were always higher than 90% and intra-assay and inter-assay precision and accuracy were always better than 15%.

Results:

The developed method was applied to the analysis of products with a high percentage of sales in websites and smart and sexy shops. In twelve of eighty supplements, anabolic steroids, anti-estrogenic drugs, psychoactive substances and sildenafil and analogs were identified and quantified.

Conclusion:

Eventual health hazards caused by the hidden presence of pharmacologically active substances in physical and sexual performance enhancing products are reported.

Physiological basis behind ergogenic effects of anabolic androgens

Anabolic androgenic steroids (AAS) are widely abused by the sporting community. Demonstrating performance enhancing effects of AAS in rigorous scientific studies is fraught with difficulty. In controlled studies, AAS have consistently been reported to increase muscle mass and strength. The clinical evidence that these anabolic effects are independent of, and additive to exercise are supported by preclinical studies suggesting that AAS and exercise affect muscle by overlapping, yet distinct mechanisms. AAS may also improve performance by their actions on other organ systems, such as the vasculature, and the erythropoietic and central nervous system, although this evidence is less strong. While most of the actions of AAS are thought to be mediated via classical androgen receptor-mediated genomic signalling, AAS may also produce rapid effects via non-genomic mechanisms.

Strategies that athletes use to avoid detection of androgenic-anabolic steroid doping and sanctions

Androgenic-anabolic steroids (AAS) are potent and widely used performance-enhancing substances (PES). Since the International Olympic Committee (IOC) began testing athletes for AAS in the 1970s, athletes and their teams have endeavored to beat the system to avoid doping violations and/or sanctions derived from positive test results. This review will discuss the strategies used to avoid detection based on the pharmacology, biochemistry, and genetics of AAS metabolism and testing principles. Another strategy used is to dope with testosterone under the guise that the athlete has a true medical condition that requires testosterone treatment, using the therapeutic use exemption (TUE) mechanism. Misrepresentation in TUE applications is extending to amateur athletes, as testosterone prescription outside of FDA guidance increases and sport organizations broaden their efforts to police doping at all levels of competition. Strict criteria are enforced under which a TUE for testosterone use may be granted, to maintain the integrity of sport. The challenge of upholding a zero-tolerance policy for AAS abuse, despite popular misconceptions of androgen physiology and pervasive attempts to dope among athletes and physicians, remains a daunting and evolving task for the anti-doping community.

Adverse health effects of androgen use

Anabolic androgenic steroids (AAS) are performance enhancing drugs commonly used by athletes and bodybuilders to improve appearance and athletic capability. Unfortunately, these testosterone derivatives can be associated with serious and potentially irreversible side effects, and can impact multiple organ systems. It is important that physicians be familiar with these adverse consequences so that they can appropriately counsel patients whom they suspect of AAS-abuse. In this chapter, we will review the negative effects of these compounds on various organ systems in men using AAS.

Sex steroid hormones and brain function: PET imaging as a tool for research

Sex steroid hormones are major regulators of sexual characteristic among species. These hormones, however, are also produced in the brain. Steroidal hormone-mediated signalling via the corresponding hormone receptors can influence brain function at the cellular level and thus affect behaviour and higher brain functions. Altered steroid hormone signalling has been associated with psychiatric disorders, such as anxiety and depression. Neurosteroids are also considered to have a neuroprotective effect in neurodegenerative diseases. So far, the role of steroid hormone receptors in physiological and pathological conditions has mainly been investigated post mortem on animal or human brain tissues. To study the dynamic interplay between sex steroids, their receptors, brain function and behaviour in psychiatric and neurological disorders in a longitudinal manner, however, non-invasive techniques are needed. Positron emission tomography (PET) is a non-invasive imaging tool that is used to quantitatively investigate a variety of physiological and biochemical parameters in vivo. PET uses radiotracers aimed at a specific target (eg, receptor, enzyme, transporter) to visualise the processes of interest. In this review, we discuss the current status of the use of PET imaging for studying sex steroid hormones in the brain. So far, PET has mainly been investigated as a tool to measure (changes in) sex hormone receptor expression in the brain, to measure a key enzyme in the steroid synthesis pathway (aromatase) and to evaluate the effects of hormonal treatment by imaging specific downstream processes in the brain. Although validated radiotracers for a number of targets are still warranted, PET can already be a useful technique for steroid hormone research and facilitate the translation of interesting findings in animal studies to clinical trials in patients.

UHPLC-HRMS Analysis for Steroid Profiling in Serum (Steroidomics)

The extraction and untargeted UHPLC-HRMS analysis of endogenous steroids in serum samples is described in this protocol. The employed full-scan acquisition mode provides the adequate sensitivity to highlight the main endogenous steroids present in blood, including mineralocorticoids, progestogens , and androgens. Technical aspects for both chromatography and mass spectrometry are discussed in detail, together with a proposition of setup for sample sequence and data analysis. Furthermore, general comments are given to help the assessment of data quality and system performance.

Structural elucidation of major selective androgen receptor modulator (SARM) metabolites for doping control

Elucidated and validated structure of the major SARM doping drug metabolites.

Genomic and non-genomic effects of androgens in the cardiovascular system: clinical implications

The principle steroidal androgens are testosterone and its metabolite 5α-dihydrotestosterone (DHT), which is converted from testosterone by the enzyme 5α-reductase. Through the classic pathway with androgens crossing the plasma membrane and binding to the androgen receptor (AR) or via mechanisms independent of the ligand-dependent transactivation function of nuclear receptors, testosterone induces genomic and non-genomic effects respectively. AR is widely distributed in several tissues, including vascular endothelial and smooth muscle cells. Androgens are essential for many developmental and physiological processes, especially in male reproductive tissues. It is now clear that androgens have multiple actions besides sex differentiation and sexual maturation and that many physiological systems are influenced by androgens, including regulation of cardiovascular function [nitric oxide (NO) release, Ca²⁺ mobilization, vascular apoptosis, hypertrophy, calcification, senescence and reactive oxygen species (ROS) generation]. This review focuses on evidence indicating that interplay between genomic and non-genomic actions of testosterone may influence cardiovascular function.

Dose-response effects of sex hormone concentrations on body composition and adipokines in medically castrated healthy men administered graded doses of testosterone gel

OBJECTIVE

Serum sex steroid concentrations may alter body composition and glucose homoeostasis in men in a dose-response manner. We evaluated these end-points in healthy men rendered medically castrate through use of a gonadotrophin-releasing hormone antagonist (acyline) with incremental doses of exogenous testosterone (T) gel.

DESIGN

Subjects (n=6-9 per group) were randomly assigned to injections of acyline every 2 weeks plus transdermal T gel (1.25 g, 2.5 g, 5.0 g, 10 g or 15 g) daily or double placebo (injections and gel) for 12 weeks.

PATIENTS

Healthy men, ages 25-55 years, with normal serum total T concentrations.

MEASUREMENTS

Serum T, dihydrotestosterone (DHT) and oestradiol (E2) were measured at baseline and every 2 weeks. Body composition was analysed by dual-energy X-ray absorptiometry at baseline and week 12. Fasting serum adiponectin, leptin, glucose and insulin concentrations were measured at baseline and week 10.

RESULTS

Forty-eight men completed the study. A significant treatment effect was observed for change in lean mass (ANOVAP=.01) but not fat mass (P=.14). Lean mass increased in the 15 g T group relative to all lower dose groups, except the 10 g T group. When all subjects were analysed together, changes in lean mass correlated directly and changes in fat mass correlated inversely with serum T, E2 and DHT. No changes were noted in serum glucose, insulin or adipokine levels.

CONCLUSIONS

In healthy men, higher serum concentrations of T, DHT and E2 were associated with greater increases in lean mass and decreases in fat mass but not with changes in serum glucose, insulin or adipokines.

Recent advances in the study of 11β-Hydroxysteroid dehydrogenase type 2 (11β-HSD2)Inhibitors

11β-Hydroxysteroid dehydrogenase (11β-HSD), which interconverts hormonally active cortisol and inactive cortisone in multiple human tissues, has two distinct isoforms named 11β-hydroxysteroid dehydrogenase 1 (11β-HSD1) and 11β-hydroxysteroid dehydrogenase 2 (11β-HSD2). 11β-HSD2 is an NAD⁺-dependent oxidase which lowers cortisol by converting it to cortisone while 11β-HSD1 mainly catalyzes the reduction which converts cortisone into cortisol. Selective inhibition of 11β-HSD2 is generally detrimental to health because the accumulation of cortisol can cause metabolic symptoms such as apparent mineralocorticoid excess (AME), fetal developmental defects and lower testosterone levels in males. There has been some advances on the study of 11β-HSD2 inhibitors and we think it necessary to make a summary of the characteristics and inhibiting properties of latest 11β-HSD2 inhibitors. As another review on 11β-HSD2 inhibitors has been issued on 2011 (see review (Ma et al., 2011)), this mini-review concerns advances during the last 5 years.