Women Athletes & Elevated Testosterone: A Pharmacological View

By Josh Bloom — Jul 10, 2018
South African track star Caster Semenya is in the middle of a controversy that she had no part in making. Her testosterone levels are naturally very high, and the International Association of Athletics Federations won't let her run certain races unless she takes medication to lower her testosterone. Should she have to take performance detracting drugs?
Now We Have Performance Detracting Drugs? Photo: @Diamond_League/Twitter

My colleagues Erik Lief and Chuck Dinerstein have each weighed in with companion pieces, which you'll find below, about a highly controversial rule by the International Association of Athletics Federations (I.A.A.F.), which governs international track and field competition. 

South African Caster Semenya, a two-time Olympic champion in the 800 meters has unusually high levels of testosterone for a woman. While this no doubt plays some part in her success Semenya is not accused of doping; her body just makes more testosterone (1), which I.A.A.F. claims gives her an unfair advantage. So much so that they have established another classification female athletes called "differences of sexual development" (DSDs). The I.A.A.F established a maximum concentration of 5 nanomoles (a little more than a milligram) per liter (nM/L) of testosterone in blood for women who compete in the 400 m, 800 m, and 1,500 m events (2). The normal range in women is 0.12 to 1.79 nM/L.

At least they're not being too unreasonable.

Athletes will not be required to undergo surgery to lower their hormone levels


That leaves Semenya with three choices; not compete, compete against men, or take medication to lower her testosterone levels. It is the last of these that strikes me as rather strange. Should we be forcing athletes to take powerful medications to "correct" whatever advantage they were born with? And if so, there are certainly plenty of genetic advantages that determine size, strength, and endurance. Lung capacity is determined by both genetic and environmental factors and athletes with greater lung capacity will excel in sports like running and swimming. Michael Phelps has a lung capacity that is twice that of a normal man. Clearly, this gives him a competitive advantage, but is it unfair? Is the Phelps case all that different from the Semenya case? Is Semenya being required to take medicine because it is feasible while cutting out one of Phelps' lungs is not? Where do we draw the line?

RELATED ARTICLE: Deciding Where The 'Gender Line' Is In Track & Field

The powerful medicine that Semenya would need to take is hormone replacement therapy (HRT), which is used most commonly by women who are going through menopause and are experiencing unpleasant symptoms, such as hot flashes and also to fight osteoporosis. 

There are two types of HRT - estrogen-only and estrogen plus progesterone (3). Estrogen plus progesterone is used in women who still have a uterus (4) (have not undergone a hysterectomy) Semenya would be presumably taking estrogens to make herself "more female." 

Will HRT therapy for some period of time before a competition be harmful? Probably not. Young women with certain conditions are treated with the drugs. But this would be the first time an athlete would be required to take a drug to decrease performance. 

And there is a bit of irony here. Cheating is an Olympic sport in the Olympics. This lead the International Olympic Committee to form the World Anti-Doping Agency (WADA) in 1999. WADA's mission is to ensure that performance-enhancing drugs stay out of sports. The agency is rather strict about what to ban or limit, for example, asthma medications, diuretics, growth hormones, decongestants, and anti-inflammatory steroids (prednisone), to name a few.

And Tamoxifen, which blocks the action of estrogen. So, in track and field, a woman with too much testosterone is required to take estrogen to compete while in the Olympics it's illegal to take another drug that blocks estrogen.

Pretty crazy, no?

RELATED ARTICLE: The Effect Of Endogenous Androgens In Elite Female Athletes


(1) The condition that causes elevated testosterone in women is called hyperandrogenism. 

(2) The limit used to be 10 nM/L

(3) There is no such thing as "estrogen." The term refers to a family of related female hormones, the most important being estradiol. 

(4) Estrogen-only therapy increases the risk of cancer of the endothelial lining of the uterus. 

Josh Bloom

Director of Chemical and Pharmaceutical Science

Dr. Josh Bloom, the Director of Chemical and Pharmaceutical Science, comes from the world of drug discovery, where he did research for more than 20 years. He holds a Ph.D. in chemistry.

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