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On Treating Athletes with Banned Substances: The Relationship Between Mild Traumatic Brain Injury, Hypopituitarism, and Hormone Replacement Therapy

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Abstract

Until recently, the problem of traumatic brain injury in sports and the problem of performance enhancement via hormone replacement have not been seen as related issues. However, recent evidence suggests that these two problems may actually interact in complex and previously underappreciated ways. A body of recent research has shown that traumatic brain injuries (TBI), at all ranges of severity, have a negative effect upon pituitary function, which results in diminished levels of several endogenous hormones, such as growth hormone and gonadotropin. This is a cause for concern for many popular sports that have high rates of concussion, a mild form of TBI. Emerging research suggests that hormone replacement therapy is an effective treatment for TBI-related hormone deficiency. However, many athletic organizations ban or severely limit the use of hormone replacing substances because many athletes seek to use them solely for the purposes of performance enhancement. Nevertheless, in the light of the research linking traumatic brain injury to hypopituitarism, this paper argues that athletic organizations’ policies and attitudes towards hormone replacement therapy should change. We defend two claims. First, because of the connection between TBI and pituitary function, it is likely many more athletes than previously acknowledged suffer from hormone deficiency and thus could benefit from hormone replacement therapy. Second, athletes’ hormone levels should be tested more rigorously and frequently with an emphasis on monitoring TBI and TBI-related issues, rather than simply monitoring policy violations.

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Notes

  1. For instance, in the British Journal of Sports Medicine’s “Consensus Statement on Concussion in Sports” there is no mention of this issue, nor is there any mention throughout the entire issue, despite the fact that it is dedicated to concussion in sports [51].

  2. As of February 27, 2014 the Nevada State Athletic Commission no longer considers applications for TUEs for TRT [52].

  3. Nevertheless, in a recent prospective study Kelly et  al. [44] examined the relationship between hormone dysfunction, concussion, and quality of life in retired NFL players. Surprisingly, they did not find that the amount of NFL games played and the number of reported concussions correlated with an increase in hormone dysfunction. Although the exact cause of hormone dysfunction in these players is unknown, the results suggest that hormone dysfunction contributes to poor quality of life. It should be noted, however that there were several notable limitations in this study. For instance, the sample size of NFL players with hormone dysfunction was significantly lower than the sampe size of NFL players without hormone dysfunction. Additionally, it is notoriously difficult to monitor the concussion history and steroid use history in athletes [44].

  4. It is important to emphasize that GH deficiency is a serious problem for both men and women [53] and that both men and women can benefit from GH replacement therapy [54–56].

  5. It should be noted that women can suffer with TBI-related hypogonadism [11]. However, in most studies it is either the case that estradiol, rather than testosterone, concentration is used to test for the occurrence of hypogonadism in women [1–3], or that sex steroids are only tested in the men involved in the study [5, 33]. To our knowledge, there is no data linking TBI and low testosterone levels in women, and so TBI-related hypogonadism in women may specifically involve hypoestrogenism. Because of this, and because of the fact that hypogonadism in women is typically treated with a combination of estrogen and progesterone [57], prescribing HRT for female athletes suffering from TBI-related hypogonadism may not run into issues concerning performance enhancement, since estrogen and progesterone are not generally used for this purpose.

  6. It should be noted that it is unlikely that the ARP takes each reason to be independently sufficient for the ban. Rather, it seems that they hold that each reason is necessary to conclude for the ban.

  7. There are strong reasons to question the legitimacy of a distinction between natural and unnatural treatment. It is notoriously difficult to draw a clear distinction between these terms and even if such a distinction could be made, it is unclear that natural things are always good and unnatural things are always bad. [48]. However, for the purposes of this paper, we shall assume that such a distinction is clear and appropriate.

  8. Note that these conditions are closely related to the four general concerns raised about performance enhancing drugs in sports. They are: (1) unnatural, (2) unfair, (3) coercive, and (4) dangerous. See [46, 47].

  9. (C) is not a common reason for needing TRT because the majority of contact sport athletes tend to be younger, and age-related hypogonadism usually does not begin until mid-forties in men [43]. Thus, if a younger athlete is suffering with low testosterone it is unlikely due to age-related causes. Additionally, it should be noted that the prevalence of age-related low testosterone has likely been overstated by the media [58]. Some researchers attribute the cause of decreased testosterone levels in aging men to other causes, such as illness and weight gain, and do not think that age itself is a significant factor [59, 60].

  10. Additionally, it should be noted that in many contact sports, including boxing and MMA, athletes are allowed to treat tendon injury with steroid or analgesic injections—even though these treatments can be performance enhancing. This raises further questions about why the ARP is specifically prohibiting HRT and not these other treatments as well.

  11. Note that one might argue that if it could be shown that the probable cause of Tom’s low testosterone levels was steroids, then it would be justifiable to deny him a TUE for TRT. Although we do think there are ways to counter these arguments so that it ends up being justifiable for Tom to receive a TUE regardless of his past history, we will not discuss this issue here because it concerns the legitimacy of performance enhancement in sports more generally, rather than the legitimacy of using performance enhancing drugs from treating TBI-related conditions.

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Acknowledgments

The authors would like to thank the following people for their help with this paper: Nathan Adams, Jason Gardner, Tyler Paytas, Gualtiero Piccinini, Shane Reuter, and Christopher Heath Wellman.

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Authors and Affiliations

  1. The Department of Philosophy, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130-4899, USA

    Nicholas Baima

  2. The Department of Philosophy, Philosophy-Neuroscience-Psychology program, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130-4899, USA

    Sarah Malanowski

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The authors contributed equally to this paper. Thus, the names are merely in reverse alphabetical order.

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Malanowski, S., Baima, N. On Treating Athletes with Banned Substances: The Relationship Between Mild Traumatic Brain Injury, Hypopituitarism, and Hormone Replacement Therapy. Neuroethics 8, 27–38 (2015). https://doi.org/10.1007/s12152-014-9215-2

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