Brent S. Rushall, Ph.D.,R.Psy. and Guy Grant, M.B.,B.S.

[Reprinted by kind permission: Rushall, B. S., and Grant, G. (1998). Hgh, EPO, anabolic steroids, and testosterone in swimming. Australian Swimming and Fitness, , May-June, 42-44. Australian Swimming and Fitness is published by JP Publications of Caringbah, New South Wales, Australia. This article also appeared in the Swimming Science Bulletin (#19), which is a section of the Swimming Science Bulletin.]

Doping is an important and controversial issue in swimming. Education is one way of counteracting this negative influence. There is a tendency for most "experts" to assume that any drug or substance is performance enhancing in swimming. However, not all of them are even though they may have been shown to be "performance-enhancing" in other sports. This article briefly covers human growth hormone (hGH), erythropoietin (EPO), and androgenic anabolic steroids and testosterone, and their potential for improving swimming performances. Knowing the potential of these particular substances (hereafter called "drugs") will allow swimmers, parents, coaches, and officials to more effectively monitor swimmers' behaviors for signs of this destructive practice.

Differential responses to various drugs occur in swimming because its events are quite short in duration and neither energy nor oxygen depleting.

HGH is a hormone that affects general growth. No research reports using human or animal subjects have shown it to be related to specific performance improvements. The most common hGH, somatropin, acts on bones and muscles non-differentially. It does not selectively respond to only those parts of the body that are stimulated (fatigued) by the specific training effects of swimming. At best hGH might facilitate quicker overall recovery from general fatigue. It is understood that in triathlons and swimming hGH is used in conjunction with anabolic steroids. The steroids provide specific adaptation effects and hGH possibly assists recovery. HGH affects growth rate, has very beneficial medical uses, and in sports is generally used to "grow" larger but not better-functioning athletes. There is some suspicion that in sports where size is important (e.g., basketball, football) hGH users suffer a higher rate of injuries. Long term effects of use in sports are not known.

Although it is popular to discuss the need for a test to locate augmented hGH it possibly is more important to test for human chorionic gonadotrophin (HCG). HCG increases production of endogenous androgenic steroids in males and is considered to be equivalent to the exogenous administration of testosterone. Its use with females is largely unreported and not understood.

Medical side effects. HGH can have several adverse side effects including allergic reactions, diabetes, and depending on dosage, gigantism in teenagers and acromegaly in older athletes when used extensively. If the hGH preparation is extracted from cadaver brains it can cause the fatal neurological condition Creutzfeldt-Jacob Disease.

Use in swimming. It is likely that hGH would have little effect on swimming performance even if used for recovery enhancement. Swimming is a sport that embraces chronic overtraining and even further training could heighten the occurrence of over-use injuries (e.g., swimmer's shoulder). On the basis of verified knowledge, it is incorrect to assert that hGH will provide ergogenic benefits for competitive swimming performances.

The absence of established research in sports does not allow the description of practical symptoms indicating the use of this substance.

Given the minimal benefits and the considerable medical risks, hGH is not a drug worth considering for use in swimming if cheating is seen as an avenue for performance improvement.

EPO is a naturally occurring hormone produced in the kidney to regulate red blood cell formation. Augmented EPO increases red blood cell production to unnatural levels. The increase improves the oxygen-carrying capacity of the blood. Published reports have claimed improvements in endurance performance of up to 15% in some sporting activities.

EPO is produced in natural and synthetic forms and is readily available from veterinary sources where it is used with horses. Depending on how EPO is manufactured, it creates different antibodies. The testing difficulty is logging the signatures of all the different types/origins of EPO. If not all antibodies are assessed, some cheating might be missed. One individual might have a different signature antibody to another depending on who manufactured the synthetic EPO. Unless a test can detect all, and currently only some can be recognized, the test is considered to be unfair.

A second complicating factor is that introduced EPO only lasts in the body for a short time (as little as 24 hours) but its stimulus effect continues for as long as two weeks. Unless a test is conducted when the EPO is present, for example, one day in fourteen among consistent users, accurate testing will miss it. This reduced probability of positive testing makes its use particularly attractive to individuals who participate in dominantly aerobic fatiguing sports.

Medical side effects. EPO commonly "thickens" blood which causes additional circulatory strain as well as damming (clotting) in smaller blood vessels. EPO use is dangerous as it stresses elements in the circulation and quite often is sufficient to precipitate systemic failures that otherwise would function normally under natural levels of stress.

Use in swimming. EPO effects extended performance in events that are largely total body and endurance-dominant (e.g., road cycling, distance and ultra-distance running). It is likely that no benefits will be derived from EPO use because of the short-duration and/or restricted muscular demands of pool-swimming events. Oxygen availability in normal blood is not a factor that limits swimming performance. No improvements would be gained from an oversupply of oxygen.

The absence of established research in sports does not allow the description of practical signs indicating the use of EPO.

Given the doubtful benefits and the great medical risks, EPO is not a drug worth considering for use in swimming if cheating is seen as an avenue for performance improvement.

AASs are specialized derivatives of the male hormone testosterone. They increase protein synthesis and when coupled with training and proper nutrition increase lean muscle mass.

There are many types of AASs for different medical uses. Not all AASs are performance enhancing. Some AASs enhance swimming strength, tolerance for anaerobic work, and shorten recovery time. They respond differentially to specific exercise stresses producing augmentations in locally stressed body functions. Their effects in females and adolescent males are dramatic. In mature male swimmers, AAS effects are markedly reduced. These are still the drugs chosen by modern-day cheaters and cheating nations in swimming. Developments in their use have progressed even during this current decade.

It is now possible to use water-soluble AASs or equivalent substances that can be radically purged from the body within 24 hours. High body fluid turnover causes an erratic presence of these AASs in swimmers. However, it is felt that water-soluble substances are not as effective as those that are fat-soluble. The current trend is to return to using fat-soluble AASs because of their more reliable and lasting presence in the body under high levels of exercise stress. When fat-soluble AASs are used it often is necessary to use masking agents, principally diuretics, to dilute the concentration of prohibited substances in urine, and to accelerate their purging from the body prior to testing. Very recent Russian and Chinese cheats have tested positive for using diuretic masking agents. To completely avoid detection, it is necessary to stop using fat-soluble AASs often several months before a competition where drug testing will be performed.

One difficult feature of AAS administration is it should be used as close as possible to competitions. Since individuals have different response rates to both AASs and purging, unless every athlete performs a carefully evaluated and verified regimen it is likely that some mistakes will be made. For example, the mere fact that four Chinese swimmers tested positive at the 1998 Perth World Championships for the masking agent triamterene does not necessarily mean they were the only ones using drugs on that occasion. They were possibly the only ones "unlucky" enough to be caught because of inexact preparatory schedules. At those championships the Chinese refused to be tested on a Thursday night because the testers from the Australian Sports Drug Authority did not produce official credentials. Testing was delayed until the following day. It would have been interesting to see if more Chinese swimmers would have tested positive on the Thursday. The extra day's delay could have had great effects on the level of purging effectiveness for other individuals.

Testosterone. Testosterone is available in natural and synthetic forms. Synthetic forms have different arrays of carbon-13 atoms to natural testosterone. A normal balance of testosterone to epitestosterone expressed as a ratio (T/E) is roughly 1:1, slightly higher for males and lower for females. Pathological disorders often increase the ratio to as high as 3:1. Drug testing uses the criterion of 6:1 for declaring a positive result, which indicates an exceptionally high concentration of augmented natural or synthetic testosterone. With positive results, reasons of medical pathology are sought but without evidence of any condition, the result is treated similarly to detected AASs.

Substances such as alcohol and birth control pills affect the T/E ratio. At best it is a "shotgun" approach to locating signs of cheating. If a positive test is revealed, then the athlete must really be "juiced" on testosterone or a new derivative. When there are no tests for specific forms of steroids it is possible to pass the T/E test but still be cheating. Alternatively, it is possible to test positive for an anabolic steroid but pass the T/E ratio test. To avoid T/E positives, some cheats also increase epitestosterone levels (through injection or topical application) to reduce the ratio since both substances will be elevated but in acceptable balance.

Testosterone esters are especially important since they are undetectable alternatives that maintain the effects of steroid use during the period prior to competition testing when continued steroid use would produce positive tests. The East Germans perfected this by using repeated intramuscular injections. It accounts for the ability of almost all East German athletes to avoid detection. This procedure is still used today in other countries.

Three cases of swimmers' excessive T/E ratios have been recorded by FINA. There have been many other times when measured ratios have approached but not surpassed the 6:1 ratio. For example, at the Hiroshima surprise testing of Chinese swimmers in October 1994, when five swimmers recorded positive test results, a further five swimmers measured close to the 6:1 ratio.

The T/E test was regularly performed by East German sports medicine officials on swimmers. On August 9, 1989 (Swimming World and Junior Swimmer, December, 1994, p. 51), the celebrated Kristin Otto returned a reading of 17:1, Daniela Hunger 12.5:1, Dagmar Hase, 10:1, and Heike Friedrich 8.8:1, each being a part of the now confirmed institutional use of AASs in East German swimming.

Related Substances. Beta agonists are found in commonly prescribed asthma treatments and primarily are stimulants. However, some substances have anabolic properties, especially when taken orally or by injection. Those properties are lessened when taken by inhalation. With written permission, some beta-agonists are allowed only in inhaled form.

Medical risks and symptoms. AASs interfere with the interactions between hypothalamic, pituitary, and gonadal functions producing dangerous effects that in extreme cases lead to tumors and psychiatric syndromes. Symptoms may be:

• In adult males: Acne, increase in aggressiveness and sexual appetite, eventual impotence, kidney and liver dysfunction, testicular atrophy and sperm reduction, breast enlargement, baldness, prostate gland enlargement and inflammation.
• In adolescent males: Severe facial and body acne, premature closure of long bone epiphyses therefore stunting growth.
• In females: Masculinization, abnormal menstruation, excessive hair growth, clitoral enlargement, voice deepening, kidney and liver dysfunction. [Effects in females are more likely to be permanent than in males.]

Use in swimming. AASs are the most frequently used drugs for enhancing training and competitive performances. There are several behavioral symptoms that indicate the use of AASs.

Among competitive swimmers, the types of AASs and the number of positive tests recorded are as follows: unknown (22), testosterone (2), methandienone (6), dihydrotestosterone (6), nandrolone (1), methyltestosterone (1), and mesterolone (1). The large number of unknowns is due to the inability of this writer to gain access to original reports.

A problem with testing for hGH, EPO, and anabolic steroids and testosterone is that each is very different to the others. A unique strategic research and test-development approach is warranted. A scientist knowledgeable about steroids and testosterone might know little about the other substances. Steroids and testosterone are present in urine in much greater quantities for longer periods of time than either hGH or EPO. The small steroid molecules are more suited to mass spectrometry than the larger molecules of EPO or hGH.

Although hGH, EPO, and anabolic steroids and testosterone are commonly discussed in swimming circles, only anabolic steroids and testosterone seem capable of direct performance enhancement. The best controls appear to be independent surprise testing. Research has shown that the more likely is surprise testing, the less is the use of banned substances. The best time for surprise testing is in the three months prior to major competitions when cheats try to use anabolic steroids or testosterone as close to the competition as possible.

When a nation embraces the use of drugs (e.g., China, Russia, and the former East Germany), honest evaluations of drug use are not possible.

The status of swimming as a desirable sport has declined rapidly and extensively in the 1990s through the increased use of banned substances. The international governing body's inability to control, and reluctance to confront, this problem threatens the desirability of swimming as a competitive and recreation activity.

Dr. Brent Rushall is Professor of Exercise and Nutritional Sciences at San Diego State University. He has experience with elite athletes covering more than 40 years and has been involved with the National Swimming Teams of Australia, the USA, and Canada. He is certified as an Elite-international Coach of Swimming.

Dr. Guy Grant is a Tasmanian medical practitioner who has worked with numerous international athletes. He was on the Medical Panel of the National Council of the SLSAA, the inaugural medical officer of the Australian Weightlifting Team, and is well known for his use of hypnosis to enhance sporting performances. He was Editor-in-Chief of the Australian Journal of Clinical Hypnosis, and co-authored Superpsych: The power of hypnosis.

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