Editorials - March 1, 2001 - American Family Physician

Editorials

Ergogenic Aids: Powders, Pills and Potions to Enhance Performance

MARK B. STEPHENS, LCDR, MC, USN
Uniformed Services University of the Health Sciences
Bethesda, Maryland

See article on page 913.

Americans spend several billion dollars annually on nutritional supplements. Roughly one half of the U.S. population has used some form of nutritional supplement, often on an ongoing basis.¹ Supplement use extends from infancy into old age and crosses lines of gender and ethnicity. Nutritional supplements are used in attempts to balance the diet, prevent disease, ward off fatigue, enhance looks and improve performance. Supplements are also being used to augment physical appearance, enhance sexuality, delay aging and increase vitality.

In this issue of American Family Physician, Ahrendt² raises the particularly important issue of ergogenic supplements used to enhance athletic performance. The mnemonic SOLE (safety, outcomes, legal, ethical), derived from the model proposed by Williams,³ can help physicians effectively counsel patients about the safe and appropriate use of ergogenic supplements.

Is it safe? In 1994, Congress passed the Dietary Supplement Health and Education Act (DSHEA). This act was passed partly in response to public pressure calling for an increase in the availability of natural products designed to promote health and prevent disease. These dietary supplements are not subject to the arduous drug approval process of the U.S. Food and Drug Administration (FDA) and, therefore, do not have rigorous controls on claims of safety and efficacy.

While the risks of androgenic steroid use have been known for some time,⁴ safety data regarding most of the currently popular ergogenic supplements are purely anecdotal. Creatine was implicated in the deaths of several collegiate wrestlers, but the cause was difficult to prove. Gamma-hydroxybutyrate has been associated with seizures and mortality and has been placed under federal restriction as a controlled substance. Most accounts of adverse events associated with ergogenic supplement use have been reported as individual cases or small case series. Relatively little prospective data are available regarding the safety of most emerging ergogenic supplements.

What is the outcome? Studies of self-reported use show that 40 to 60 percent of young athletes have taken nutritional supplements to improve performance.⁵ A significant number of adolescents have also experimented with anabolic-androgenic steroid use.⁶ Most of the information that young athletes receive regarding the effectiveness of these products comes from the lay press, anecdotal evidence or word of mouth. Athletes are often reluctant to discuss ergogenic supplement use with their physicians. The medical community is to blame for any mistrust between athletes and physicians in this arena.

During the 1970s and 1980s, a credibility gap was established when physicians repeatedly told athletes that anabolic steroids did not improve strength or add muscle mass.⁷ Anecdote (and eventually science) proved the medical community wrong, and athletes have subsequently been reticent to approach physicians for information regarding the effectiveness of ergogenic supplements. While some supplements may be of some benefit to some individuals in some situations, there is little doubt that most products fail to meet purported claims of efficacy. Ahrendt¹ provides a useful table that summarizes the ergogenic claims of current supplements and the evidence for or against their effectiveness.

Is it legal? The list of supplements banned by the International Olympic Committee is extensive.⁸ Sports authorities have banned substances ranging from androstenedione to ephedrine. The rules vary among sports, and athletes continue to play "cat and mouse" with drug testing facilities to avoid detection. Some substances (such as anabolic steroids and human growth hormone) are patently illegal and are indicated for use only under the specific supervision of an attending physician for an accepted medical indication.

Is it ethical? Athletes are particularly vulnerable to the pressures of victory and are often blind to the consequences of vanity when competing to win. The recent success of Mark McGwire in baseball's home run derby has fueled an ethical debate surrounding ergogenics and sports performance. Androstenedione has been banned by the National Collegiate Athletic Association, the International Olympic Committee and the National Football League, but not by Major League Baseball. (Interestingly, the office of Major League Baseball has recently funded a study to examine androstenedione supplementation and testosterone levels in young men.⁹) While technically "legal" in baseball, androstenedione is a steroid precursor and the ethics of its use as a natural supplement are debatable.¹⁰

To overcome the challenges presented by the haphazard or uneducated use of ergogenic supplements, physicians should be aware of what supplements young athletes are taking, how the supplements are being taken and why they are being taken. Physicians must also know what the supplement can do to the athlete or for the athlete. The preparticipation physical examination and routine health care maintenance examinations represent excellent opportunities for family physicians to inquire about the use of ergogenic supplements and counsel patients about potential risks and benefits of supplement use.

These are the opinions of the author and should not be viewed as official policy of the Department of the Navy or the Department of Defense.

Mark B. Stephens, LCDR, MD, USN, is assistant professor of family medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md.

Address correspondence to Mark B. Stephens, LCDR, MC, USN, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814-4799.

REFERENCES

Ervin RB, Wright JD, Kennedy-Stephenson J. Use of dietary supplements in the United States: 1988-1994. Vital Health Stat 1999;244(i-iii):1-14.

Ahrendt DM. Ergogenic aids: counseling the athlete. Am Fam Physician 2000;63:913-22.

Williams MH. The ergogenics edge. Champaign, Ill.: Human Kinetics, 1998.

Blue JG, Lombardo JA. Steroids and steroid-like compounds. Clin Sports Med 1999;18:667-89.

Sobal J, Marquart LF. Vitamin/mineral supplement use among high school athletes. Adolescence 1994;29:835-43.

Yesalis CE, Barsukiewicz CK, Kopstein AN, Bahrke MS. Trends in anabolic-androgenic steroid use among adolescents. Arch Pediatr Adolesc Med 1997;151:1197-206.

Issetts BJ. Preparing community educational presentations on ergogenic drug use. Am J Hosp Pharm 1989;46:2028-30.

uente RJ, Rosenberg JM, eds. Athletic Drug Reference '99: complies with NCAA and USOC rules. Fuente RJ, Rosenberg JM, eds. Durham, N.C.: Glaxo Wellcome; Clean Data, 1999.

Leder BZ, Longcope C, Catlin DH, Ahrens B, Schoenfeld DA, Finkelstein JS. Oral androstenedione administration and serum testosterone concentrations in young men. JAMA 2000;283:779-82.

Matheson GO. Is Mark McGwire a hero? Phys Sportsmed 1998;26:5.

Evaluating Children for Possible Sexual Abuse

JOYCE A. ADAMS, M.D.
Department of Pediatrics, University of California San Diego, School of Medicine
San Diego, California

See article on page 883.

In this issue of American Family Physician, Lahoti and colleagues¹ provide a useful approach to the medical evaluation of the child victim of alleged sexual abuse. Over the past 20 years, much has been learned about the presentation of sexual abuse. The vast majority of children who are sexually abused do not have severe injuries of the genitalia or anus; therefore, the examination does not reveal specific signs of injury. Studies of nonabused children have reported that many of the variations in appearance of the hymen and the anus initially believed to be associated with abuse are, in fact, normal or nonspecific findings.^2-5

The most common error made by physicians who are not used to examining children's genitalia and anal areas with magnification is to call normal or nonspecific findings abnormal or suspicious for abuse. If the child has given no history of sexual abuse and is being examined for another reason, the misdiagnosis of sexual abuse can be extremely traumatic and sometimes tragic for everyone involved. A recent study⁶ presented a review of cases in which the child gave no history of sexual abuse, but the physician thought the genital or anal examination findings were suspicious for abuse. Only 14 percent of these children were found by the experts at the sexual abuse evaluation center to have findings that were concerning for abuse: the remainder of the evaluations were within normal limits, or the child had some other condition that was unrelated to abuse.

Table 1 in the article¹ represents an abbreviated version of a new classification system that I have published and revised several times since 1992. In the past, an "enlarged hymenal opening" had been considered concerning for sexual abuse; however, this was removed from that category in my last classification scale. A lack of studies of nonabused children of various ages, using different examination techniques and incorporating accurate measurement techniques, does not allow us to know what size of hymenal opening should be considered "enlarged." In my study⁷ of sexually abused girls who had described penile-vaginal penetration and whose perpetrators had confessed or pled guilty to sexual abuse, the mean diameter of the hymenal opening was not significantly larger than that in nonabused girls of the same age.

The finding of genital warts or condylomata acuminata in a child older than two years who gives no history of sexual contact is listed in my revised classification scale as indicating "possible" abuse. New studies using DNA hybridization to identify human papillomavirus DNA have reported that this virus is much more ubiquitous than was previously known, and it is likely that it can be transmitted by means other than sexual contact, regardless of age.

A new study by Berenson and colleagues⁸ compared the genital findings in magnified photographs from two distinct groups of girls between three and eight years of age. The first group included children who had given a history of digital or penile-vaginal penetration and were examined at a sexual abuse evaluation center. The second group, recruited to obtain age- and race-matched controls, were children from a well-child clinic who were thoroughly screened by child interview, parent interview and behavioral questionnaires, and who gave no indication of past sexual abuse. Few differences in the physical findings were evidenced between these two groups; an equal number of girls from each group had clefts in the posterior hymen extending up to 50 percent of the hymenal width.

So, what is the family physician to do? If a child relates a history of being sexually abused, a report to child protective services and a law enforcement agency must be made. If a child gives no history of abuse but is found to have signs of acute trauma to the genital or anal area with bruising and/or bleeding, this child should be referred to a subspecialist who is experienced in the evaluation of children for sexual abuse--if one is available.

A child who has a vaginal discharge should have cultures obtained to test for gonorrhea, Chlamydia and trichomonas infections. Until the culture results are available, a report to protective services need not be made if the child gives no history suggesting abuse (unless, of course, a parent or caretaker reports a history of sexual abuse). Most cases of vaginal discharge are not caused by sexually transmitted infections. If the examining physician evaluates a child and believes that the genital or anal area looks unusual or abnormal, but the child gives no history of sexual abuse, the physician should refer this patient to a local subspecialist for evaluation before a report of suspected sexual abuse is made.

Every family physician who examines children needs to know where to refer a child who should be evaluated by a subspecialist in child sexual abuse medical evaluation. Many times, this physician is based at an academic medical center, a children's hospital or a freestanding child advocacy center.

An accurate diagnosis of injuries from sexual abuse trauma is vitally important, not only as far as the legal system is concerned, but also for the child and family. Most children will not have physical injuries, and many children with unusual genital or anal findings will not have a history of sexual abuse. It is the responsibility of the family physician to assure that children with questionable diagnoses are referred to a subspecialist before the specter of sexual abuse is unnecessarily raised.

Joyce A. Adams, M.D. is professor of clinical pediatrics in the Department of Pediatrics, University of California, San Diego.

Address correspondence to Joyce A. Adams, M.D., UCSD Medical Center Pediatrics, Mailcode 8449, 200 West Arbor Dr., San Diego, CA 92103-8449 (e-mail: jadams@ucsd.edu).

REFERENCES

Lahoti SL, McClain N, Girardet R, McNeese M, Cheung K. Evaluating the child for sexual abuse. Am Fam Physician 2001;63:883-92.

McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for non-abuse: a descriptive study. Pediatrics 1990;86:428-39.

McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for non-abuse: a descriptive study. Child Abuse Negl 1989;13:179-93.

Berenson AB, Heger AH, Hayes JM, Bailey RK, Emans SJ. Appearance of the hymen in prepubertal girls. Pediatrics 1992;89:387-94.

Berenson AB, Heger AH, Andrews S. Appearance of the hymen in newborns. Pediatrics 1991;87: 458-65.

Bowen K, Aldous MB. Medical evaluation of sexual abuse in children without disclosed or witnessed abuse. Arch Pediatr Adolesc Med 1999;153:1160-4.

Adams JA, Harper K, Knudson S, Revilla J. Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics 1994;94:310-7.

Berenson AB, Chacko MR, Wiemann CM, Mishaw O, Friedrich WN, Grady JJ. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol 2000;182:820-34. *

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