ERGOGENIC AIDSAndy McGown, MD

Definition:Definition:

• Ergo = workErgo = work• Gennan = to produceGennan = to produce• Any substance or method used to enhance Any substance or method used to enhance

performance through increased energy performance through increased energy utilization:utilization:» productionproduction» controlcontrol» efficiencyefficiency

HistoryHistory

• 3000 Years ago the Greeks ate “substances” to 3000 Years ago the Greeks ate “substances” to improve athletic performance including improve athletic performance including Strychnine. Used recently in 1904 and 1992 Strychnine. Used recently in 1904 and 1992 OlympicsOlympics

• 776 BC (1776 BC (1stst Olympiad) Olympiad)» Hallucinogenic mushrooms and sesame seedsHallucinogenic mushrooms and sesame seeds

• 1889 11889 1stst Self-administered Steroids Self-administered Steroids» Brown-Sequard “Testicular extracts”Brown-Sequard “Testicular extracts”

• 1935 Testosterone Synthesized1935 Testosterone Synthesized

Goldman’s PollGoldman’s Poll

• Two questions posed to 198 aspiring Two questions posed to 198 aspiring olympians during the 1990’solympians during the 1990’s» Take banned substance if guaranteed to win a Take banned substance if guaranteed to win a

medal and not be caughtmedal and not be caught» Take banned substances and not be caught and Take banned substances and not be caught and

win every competition for the next 5 years but win every competition for the next 5 years but die an early death from side effectsdie an early death from side effects

ClassificationClassification

• Drugs:Drugs:» HormonesHormones

» StimulantsStimulants

» NarcoticsNarcotics

» DiureticsDiuretics

» B-BlockersB-Blockers

• ““Supplements”:Supplements”:» Prohormones?Prohormones?

» Amino AcidsAmino Acids

» MetalsMetals

» AntioxidantsAntioxidants

» HerbsHerbs

Prevalence:Prevalence:

• Estimated Use Estimated Use » AdolescentsAdolescents

• 11% male (most start < 16yo)11% male (most start < 16yo)

• 2.5% female 2.5% female

» Adult ~ 15%Adult ~ 15%• Usually recreational athletesUsually recreational athletes

• Swimming, Cycling, Weight lifting, Track and Swimming, Cycling, Weight lifting, Track and FieldField

• Billion Dollar IndustryBillion Dollar Industry

““There is no room for second place. There is There is no room for second place. There is only one place in my game, and that’s first only one place in my game, and that’s first place.”place.”

-Vince Lombardi-Vince Lombardi

Reasons: Reasons:

• Have to use them to be competitiveHave to use them to be competitive• Need the edgeNeed the edge• Not genetically giftedNot genetically gifted• Dissatisfaction with size/ weightDissatisfaction with size/ weight• Peer/ Team PressurePeer/ Team Pressure

Human Growth HormoneHuman Growth Hormone

• Naturally secreted by the pituitaryNaturally secreted by the pituitary• Normal function of GH is growth and Normal function of GH is growth and

development of every body system, including development of every body system, including bone and musclebone and muscle

• Can be stimulated by propanolol, vasopressin, Can be stimulated by propanolol, vasopressin, clonidine, and levodopaclonidine, and levodopa

• Synthetic growth hormoneSynthetic growth hormone

Side Effects:Side Effects:

• Acromegaly (may be irreversible)Acromegaly (may be irreversible)• Peripheral NeuropathyPeripheral Neuropathy• Coronary Artery DiseaseCoronary Artery Disease• CardiomyopathyCardiomyopathy• Diabetes, Hypothyroidism, arthritisDiabetes, Hypothyroidism, arthritis• No available urine test available, but banned by No available urine test available, but banned by

NCAA and IOCNCAA and IOC

ErythropoietinErythropoietin

• Hormone released by the kidneys in response to Hormone released by the kidneys in response to low Hctlow Hct

• Stimulates RBC production from bone marrowStimulates RBC production from bone marrow• Has recently been manufactured by recombinant Has recently been manufactured by recombinant

DNA techniqueDNA technique• Can increase Hct in renal patients by up to 35%, Can increase Hct in renal patients by up to 35%,

lasting up to 7 monthslasting up to 7 months• Used most by cyclistsUsed most by cyclists

DopingDoping

• Attributed to the Dutch word “dop” which Attributed to the Dutch word “dop” which was a narcotic mixture of opium used to was a narcotic mixture of opium used to stimulate racing horsesstimulate racing horses

Blood DopingBlood Doping

• Autologous Reinfusion Autologous Reinfusion » 2 units blood removed 4-8 wks prior to competition2 units blood removed 4-8 wks prior to competition

» Frozen w/ glycerolFrozen w/ glycerol

» Reinfusion 1-7 days prior to eventReinfusion 1-7 days prior to event

• 1 U PRBC>>500 ml / min increase in O2 carrying 1 U PRBC>>500 ml / min increase in O2 carrying capacitycapacity

• Can produce 25% improvement in enduranceCan produce 25% improvement in endurance» The poorer the athletes conditioning the greater the The poorer the athletes conditioning the greater the

benefitbenefit

Side EffectsSide Effects

• Blood TransfusionsBlood Transfusions» HeterologousHeterologous

• transfusion rxn (3-10%), Hepatitis (10%), HIV (?%)transfusion rxn (3-10%), Hepatitis (10%), HIV (?%)

» Autologous Autologous • bacterial infectionsbacterial infections

• r-EPOr-EPO» PolycythemiaPolycythemia

• increased viscosity >>CHF, HTN, CVAincreased viscosity >>CHF, HTN, CVA

DetectionDetection

• Blood Doping and r-EPOBlood Doping and r-EPO» Banned by IOCBanned by IOC

• No Direct TestNo Direct Test» Hct >50Hct >50» Serum Fe and BiliSerum Fe and Bili

• Detecting post-transfusion hemolysisDetecting post-transfusion hemolysis

» Legal issuesLegal issues

Anabolic SteroidsAnabolic Steroids

• The The ultimateultimate ergogenic aid aka “Juice” ergogenic aid aka “Juice”

• Creates the Superhuman AthleteCreates the Superhuman Athlete

• Testosterone derivatives (cholesterol)Testosterone derivatives (cholesterol)

• Produced in the adrenal/ testesProduced in the adrenal/ testes

Anabolic/Androgenic SteroidsAnabolic/Androgenic Steroids

• Anabolism - ConstructiveAnabolism - Constructive

• Catabolism - DestructiveCatabolism - Destructive

• Anabolic effects : inc. skeletal mm massAnabolic effects : inc. skeletal mm mass

• anticatabolismanticatabolism

• Androgenic effects: secondary sexual Androgenic effects: secondary sexual characteristics - pubic hair, genital sizecharacteristics - pubic hair, genital size

• No Pure Anabolic SteroidsNo Pure Anabolic Steroids

History of SteroidsHistory of Steroids

• First Available - 50’s (Dianabol)First Available - 50’s (Dianabol)• Drug Banned - 60’sDrug Banned - 60’s• Testing Initiated- ‘76Testing Initiated- ‘76• Athletes Banned - ‘83 Pan Am GamesAthletes Banned - ‘83 Pan Am Games• Schedule III Controlled Substance - ‘90 Schedule III Controlled Substance - ‘90

Anabolic Steroid Control ActAnabolic Steroid Control Act• US Dietary Supplement Act - ‘94 no US Dietary Supplement Act - ‘94 no

FDA approval if no “drug intent”FDA approval if no “drug intent”

Administration:Administration:

• Athletes may take up to 40-100x therapeutic dose Athletes may take up to 40-100x therapeutic dose (200-2000 mg/ wk)(200-2000 mg/ wk)

• IM adm bypasses the liver/ PO does notIM adm bypasses the liver/ PO does not• ““Stacking”: using various aids in combinationStacking”: using various aids in combination• ““Cycling” : gradual inc. then taper over 6-10 Cycling” : gradual inc. then taper over 6-10

weeks, 1-3 cycles /year, “bridging” betweenweeks, 1-3 cycles /year, “bridging” between• Illicit - Nandrolone, Stanozolol (Winstrol), Illicit - Nandrolone, Stanozolol (Winstrol),

Methelone, Tibolone, OxandroloneMethelone, Tibolone, Oxandrolone• Medical - Testosterone, Enanthate, Undelanoate, Medical - Testosterone, Enanthate, Undelanoate,

Dehydrotestosterone (patch)Dehydrotestosterone (patch)

Desired Effects:Desired Effects:

• Increase in strengthIncrease in strength

• Increase in weightIncrease in weight

• Increase in aggressivenessIncrease in aggressiveness

• Increased capability of sustaining repetitive, Increased capability of sustaining repetitive, high intensity workoutshigh intensity workouts

• Enhanced performanceEnhanced performance

Side Effects:Side Effects:

• CV: MI - hypertension, inc. LDL, dec. HDL, CV: MI - hypertension, inc. LDL, dec. HDL, cardiac hypertrophy, thrombosiscardiac hypertrophy, thrombosis

• Endocrine: virilization, testis atrophy, azospermia, Endocrine: virilization, testis atrophy, azospermia, priapism, prostatic hypertrophy/ CA, priapism, prostatic hypertrophy/ CA, gynecomastia, erectile dysfct, libidogynecomastia, erectile dysfct, libido

• Liver : peliosis hepatitis, hyperplasia, adenoma, no Liver : peliosis hepatitis, hyperplasia, adenoma, no carcinoma, elevated LFTscarcinoma, elevated LFTs

• MS: epiphyseal closure, inc. bone density, dec. MS: epiphyseal closure, inc. bone density, dec. tendon strengthtendon strength

Side Effects (cont’d):Side Effects (cont’d):

• Skin: acne, hirsuitism, striae, androgenic Skin: acne, hirsuitism, striae, androgenic alopecia, inc. sebaceous glandsalopecia, inc. sebaceous glands

• Metabolic: hypernatremia, kalemia, Metabolic: hypernatremia, kalemia, phosphatemia, calcemia, “prediabetic”phosphatemia, calcemia, “prediabetic”

• Psychiatric : aggressiveness, extreme mood Psychiatric : aggressiveness, extreme mood swings - depression/ mania, dependence, swings - depression/ mania, dependence, other drug use, “Reverse Anorexia”other drug use, “Reverse Anorexia”

• Long Term - dec. life spanLong Term - dec. life span

Specific Side EffectsSpecific Side Effects

• Women: Virilzation:Women: Virilzation:» Clitoril enlargement, Clitoril enlargement,

Deepening of voice, Deepening of voice, Male pattern baldness, Male pattern baldness, dec. breast size, libido dec. breast size, libido

• Children: premature Children: premature closure of growth closure of growth plate in long bones & plate in long bones & short statureshort stature

““Prohormones”Prohormones”

• Androstenedione Androstenedione • DHEADHEA• AndrostenediolAndrostenediol• NorandrostenedioneNorandrostenedione• NorandrostendiolNorandrostendiol

AndrostenedioneAndrostenedione

• 1/2 of the “ Mark McGuire Special” 1/2 of the “ Mark McGuire Special” • A natural steroid hormone found in all animals A natural steroid hormone found in all animals

and some plantsand some plants• Metabolite of DHEAMetabolite of DHEA• Precursor of testosteronePrecursor of testosterone• Synthesized in Adrenals/ GonadsSynthesized in Adrenals/ Gonads• Metabolized in the liver to testosteroneMetabolized in the liver to testosterone

Effects:Effects:

• Benefits: Same as TestosteroneBenefits: Same as Testosterone» Increased energyIncreased energy» Enhanced recovery and growth from exerciseEnhanced recovery and growth from exercise» heightened sexual arousal and functionheightened sexual arousal and function» greater sense of well-beinggreater sense of well-being

• Plasma levels of testosterone increased from 140% Plasma levels of testosterone increased from 140% to 330% of normal levels after 50mg and 100mg to 330% of normal levels after 50mg and 100mg dosesdoses

• SE’s : Same as TestosteroneSE’s : Same as Testosterone• Banned by IOC, NCAA, NFLBanned by IOC, NCAA, NFL

DHEA DHEA (Dehydroepiandrosterone)(Dehydroepiandrosterone)

• What it is: A hormone produced by adrenal What it is: A hormone produced by adrenal glandgland

• Claims: Anabolic effectClaims: Anabolic effect

• What is does: Increases testosterone levelsWhat is does: Increases testosterone levels

• Banned by the NCAA, NFLBanned by the NCAA, NFL

StimulantsStimulants

• CaffeineCaffeine• AmphetaminesAmphetamines• CocaineCocaine• EphedrineEphedrine

AmphetaminesAmphetamines

• WWIIWWII» Soldiers used them to counteract fatigueSoldiers used them to counteract fatigue

• 1959 Study shows Performance Enhancing 1959 Study shows Performance Enhancing PotentialPotential

• Used in Sports where Speed, Power and Used in Sports where Speed, Power and Endurance are RequiredEndurance are Required

Side Effects:Side Effects:

• Predominantly CNSPredominantly CNS» Insomnia, agitation and restlessnessInsomnia, agitation and restlessness» Confusion, paranoia, hallucinationsConfusion, paranoia, hallucinations» DyskinesiasDyskinesias

• especially in facial musclesespecially in facial muscles

• Cardiac Cardiac » HTN, arrhythmiasHTN, arrhythmias

• GI GI » DiarrheaDiarrhea

• Rebound Fatigue and DepressionRebound Fatigue and Depression

CaffeineCaffeine

• A Methylxanthine: same class as theophylline and A Methylxanthine: same class as theophylline and theobrominetheobromine

• Exerts its’ effects by:Exerts its’ effects by:» Translocation of Calcium for more muscular Translocation of Calcium for more muscular

availabilityavailability» Increase in cAMP by inhibition of Increase in cAMP by inhibition of

phosphodiesterasephosphodiesterase» Blockage of adenosine receptors, blocking the Blockage of adenosine receptors, blocking the

sedative properties of adenosinesedative properties of adenosine

Caffeine (cont’d)Caffeine (cont’d)

• Is banned by IOC and NCAA in large dosesIs banned by IOC and NCAA in large doses• Legal limit = 15 micrograms / mlLegal limit = 15 micrograms / ml• Equal to 6-8 cups of coffee at one sitting, with Equal to 6-8 cups of coffee at one sitting, with

testing within 2-3 hourstesting within 2-3 hours• Beneficial most in endurance events, such as Beneficial most in endurance events, such as

cyclingcycling• Doses up to 5 mg / kg were required to see Doses up to 5 mg / kg were required to see

benefits. Doses of 17 mg/kg produce the benefits. Doses of 17 mg/kg produce the maximum legal limit.maximum legal limit.

Side Effects:Side Effects:

• Similar to s/e of other stimulants:Similar to s/e of other stimulants:» insomnia, irritability, nervousnessinsomnia, irritability, nervousness» Tachcardia, arrthymias, and possibly death!Tachcardia, arrthymias, and possibly death!

http://healthydevil.studentaffairs.duke.edu/images/ephedra_products.gif

EphedrineEphedrine

• What it is: Is a drug found in herbal products What it is: Is a drug found in herbal products containing Ma haung, anti-asthmatic medications, containing Ma haung, anti-asthmatic medications, and many cold and cough products.and many cold and cough products.

• Claims: Increases body fat lossClaims: Increases body fat loss• What really does: Acts as a CNS stimulant, delays What really does: Acts as a CNS stimulant, delays

fatigue by sparing body glycogen reserves. fatigue by sparing body glycogen reserves. Increase in B/p respiratory, heart rate, insomnia, Increase in B/p respiratory, heart rate, insomnia, and nervousnessand nervousness

• Max dose : 24 milligams per day!!!!!!Max dose : 24 milligams per day!!!!!!

Amino AcidsAmino Acids

• CreatineCreatine• L-CarnitineL-Carnitine• CholineCholine• InosineInosine• HMB (B-OH-B-HMB (B-OH-B-

Methylbutyrate)Methylbutyrate)

Amino AcidsAmino Acids

• Essential amino acids: found in a balanced dietEssential amino acids: found in a balanced diet• Recommended protein intake: 0.8 g /kg/dayRecommended protein intake: 0.8 g /kg/day• Athletes may benefit from up to 1.4 -2.4 g/kg/dayAthletes may benefit from up to 1.4 -2.4 g/kg/day• Most beneficial for athletes on a poor diet, or Most beneficial for athletes on a poor diet, or

vegetariansvegetarians• In endurance athletes, up to 10% of energy In endurance athletes, up to 10% of energy

expenditure is from protein breakdownexpenditure is from protein breakdown

CreatineCreatine

• The Other 1/2 of the Mark McGuire The Other 1/2 of the Mark McGuire “Cocktail” “Cocktail”

• Sales topped $200 million in 1998Sales topped $200 million in 1998

» 13% of HS athletes13% of HS athletes

» 50% of NFL players50% of NFL players

» Vast majority of Olympic sprinters and Vast majority of Olympic sprinters and cyclistscyclists

CreatineCreatine

• Methylguanidine-acetic acid - made from glycine, Methylguanidine-acetic acid - made from glycine, arginine & methioninearginine & methionine

• Estimated Daily requirement: 2gmsEstimated Daily requirement: 2gms• Available in meats and fish (1/2 EDR)Available in meats and fish (1/2 EDR)• Sold as Creatine MonohydrateSold as Creatine Monohydrate• Stored in Skeletal MMStored in Skeletal MM

Mechanism of Action :Mechanism of Action :

• Methylguanidine-acetic acid - made from glycine, Methylguanidine-acetic acid - made from glycine, arginine & methioninearginine & methionine

• Estimated Daily requirement: 2gmsEstimated Daily requirement: 2gms• Available in meats and fish (1/2 EDR)Available in meats and fish (1/2 EDR)• Sold as Creatine MonohydrateSold as Creatine Monohydrate• Stored in Skeletal MMStored in Skeletal MM

Benefits:Benefits:

• Improved performance in repeated bouts of Improved performance in repeated bouts of high intensity strength work and sprintshigh intensity strength work and sprints

• Single sprint activity results are equivocalSingle sprint activity results are equivocal• Does not enhance endurance exerciseDoes not enhance endurance exercise• More work with less lactic acid productionMore work with less lactic acid production• No studies on competetion benefitsNo studies on competetion benefits• 1998 ACSM meeting: 19/19 studies 1998 ACSM meeting: 19/19 studies

showed significant ergogenic benefitshowed significant ergogenic benefit

Dosing:Dosing:

• Phase: 20-30 gm/d, x 5 -7 daysPhase: 20-30 gm/d, x 5 -7 days• Maintenance phase: 2-5 gm/dayMaintenance phase: 2-5 gm/day• Loading increases PCr stores by 10-40%Loading increases PCr stores by 10-40%• Normal resting levels of creatine: 100-150 Normal resting levels of creatine: 100-150

mM/kgmM/kg• Most striking benefits occur in subjects with lower Most striking benefits occur in subjects with lower

resting Cr levelresting Cr level• After saturation of tissues, excessive After saturation of tissues, excessive

supplementation is renally excretedsupplementation is renally excreted

Side Effects:Side Effects:

• Muscle CrampingMuscle Cramping• DiarrheaDiarrhea• DizzinessDizziness• DehydrationDehydration• Biggest danger: getting “impure” creatineBiggest danger: getting “impure” creatine• Significant WEIGHT GAIN common 2nd to water Significant WEIGHT GAIN common 2nd to water

retentionretention

The Perfect Supplement?The Perfect Supplement?

• ““The secret is to find something that is effective in The secret is to find something that is effective in improving performance, but not against the rules, improving performance, but not against the rules, and with no side effects” and with no side effects”

• “…“…no clear evidence of harmful side effects of no clear evidence of harmful side effects of creatine use has emerged…”--The Physician and creatine use has emerged…”--The Physician and Sportsmedicine, June 1998Sportsmedicine, June 1998

• Long term effects of Creatine not yet studied: Long term effects of Creatine not yet studied: Concerns focus on effects to kidney, pancreas, and Concerns focus on effects to kidney, pancreas, and liver. liver.

Counseling your patientsCounseling your patients• Creatine may or may not improve Creatine may or may not improve

performanceperformance• Weight gain will occurWeight gain will occur• Side effects (especially long-term) not well Side effects (especially long-term) not well

knownknown• Take a thorough medical historyTake a thorough medical history• Monitor renal and liver fct.Monitor renal and liver fct.• Make sure they’re taking reccomended doseMake sure they’re taking reccomended dose

• Synthesized in Liver/ Kidney from Lysine & Synthesized in Liver/ Kidney from Lysine & MethionineMethionine

• found in meats & dairy productsfound in meats & dairy products• Assists in Fat transportation into muscle Assists in Fat transportation into muscle

mitochondria for oxidation, sparing Glycogen & mitochondria for oxidation, sparing Glycogen & may prevent lactic acid accumulationmay prevent lactic acid accumulation

• Improved endurance performance not shown in Improved endurance performance not shown in studiesstudies

L-CarnitineL-Carnitine

HMBHMB

• Metabolite of KIC (ketoisocaproate) which Metabolite of KIC (ketoisocaproate) which is a metabolite of leucineis a metabolite of leucine

• Leucine & KIC found to have anticatabolic Leucine & KIC found to have anticatabolic effectseffects

• decreased mm proteolysis, inc. lean mm decreased mm proteolysis, inc. lean mm mass, inc. strengthmass, inc. strength

• no known side effectsno known side effects

CholineCholine

• Precursor for the neurotransmittor Acetyl Precursor for the neurotransmittor Acetyl Choline & the lipoprotein Lecithin Choline & the lipoprotein Lecithin (Phosphattidylcholine)(Phosphattidylcholine)

• choline depletion in marathonerscholine depletion in marathoners

• no studies supportingno studies supporting

InosineInosine

• Increases myocardial contractilityIncreases myocardial contractility

• no performance enhancement in runners/ no performance enhancement in runners/ cyclistscyclists

Metals/ MineralsMetals/ Minerals

• ChromiumChromium• MagnesiumMagnesium• BoronBoron• VanadiumVanadium

ChromiumChromium

• Insulin CofactorInsulin Cofactor• inc. AA uptake into mm cellsinc. AA uptake into mm cells• increase mm mass, dec. body fatincrease mm mass, dec. body fat• found in meats, grains, raisins, apples, & found in meats, grains, raisins, apples, &

mushroomsmushrooms• SE’s: anemia, chromosomal damage, SE’s: anemia, chromosomal damage,

cognitive impairment & interstitial nephritis cognitive impairment & interstitial nephritis in excessive dosesin excessive doses

MagnesiumMagnesium

• Involved in ptn synthesis & mm contractionInvolved in ptn synthesis & mm contraction

• + effects on oxygen consumption & lactate + effects on oxygen consumption & lactate productionproduction

• no change in performanceno change in performance

BoronBoron

• Originally thought to inc. testosterone levelsOriginally thought to inc. testosterone levels

• not born out in studiesnot born out in studies

VanadiumVanadium

• What it is: Non-essential trace mineralWhat it is: Non-essential trace mineral

• Claims: Anabolic effect, enhances insulin Claims: Anabolic effect, enhances insulin actionaction

• What it does: No studies to show anabolic What it does: No studies to show anabolic effect. Doses>10gms/day causes abd. Pain, effect. Doses>10gms/day causes abd. Pain, cramps, green tongue,diarrhea, wt. losscramps, green tongue,diarrhea, wt. loss

AntioxidantsAntioxidants

• Vitamins E & CVitamins E & C

• potential damage from free oxygen radicals potential damage from free oxygen radicals produced by lipid peroxidation in exerciseproduced by lipid peroxidation in exercise

• exercise performance is not improvedexercise performance is not improved

HerbsHerbs

• GinsengGinseng• YohimbeYohimbe• Tribulus TerresterisTribulus Terresteris• Ma haungMa haung

GinsengGinseng

• What it is: A root from an Asian plant (panax What it is: A root from an Asian plant (panax ginseng).ginseng).

• Claims: Enhanced performance. Improved Claims: Enhanced performance. Improved recovery rate.recovery rate.

• What it really does: Acts as an adaptogen- may What it really does: Acts as an adaptogen- may boost immune system and protect cells. May cause boost immune system and protect cells. May cause insomnia, and should not be used if B/p is insomnia, and should not be used if B/p is elevated.elevated.

• Dose: 100-200mg per day used occ.2-3 weeks on Dose: 100-200mg per day used occ.2-3 weeks on 1-2 weeks off1-2 weeks off

• What it is: Supplement derived from tree What it is: Supplement derived from tree bark.bark.

• Claims: Anabolic effect, Increased virilityClaims: Anabolic effect, Increased virility

• What it does: Stimulant effect, no anabolic What it does: Stimulant effect, no anabolic effect. Can cause nervousness, HA, nausea, effect. Can cause nervousness, HA, nausea, Vomiting, increased B/P Vomiting, increased B/P

YohimbeYohimbe

• What is it: A plant hormoneWhat is it: A plant hormone

• Claims: Anabolic effectClaims: Anabolic effect

• What it does: Increases testosterone levelsWhat it does: Increases testosterone levels

• Banned by NFLBanned by NFL

Tribulus TerresterisTribulus Terresteris

Thank You Very Thank You Very MuchMuch