Detection and Effects on Serum and Urine Steroid and LH of Repeated

Home , Epitestosterone

Journal of Steroid Biochemistry & Molecular Biology 141 (2014) 113–120

Contents lists available at ScienceDirect

Journal of Steroid Biochemistry and Molecular Biology

j ournal homepage: www.elsevier.com/locate/jsbmb

Detection and effects on serum and urine steroid and LH of repeated

GnRH analog (leuprolide) stimulation

a,c,∗ a b b

David J. Handelsman , Amanda Idan , Janelle Grainger , Catrin Goebel ,

a a,c

Leo Turner , Ann J. Conway

Andrology Department, Concord Hospital, Sydney, NSW 2139, Australia

Australian Sports Drug Testing Laboratory, National Measurement Institute, Sydney, NSW 2139, Australia

ANZAC Research Institute, University of Sydney, Sydney, NSW 2139, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Non-steroidal drugs that increase endogenous testosterone (T) may be used to exploit ergogenic effects

Received 16 December 2013

of androgens in power sports. While superactive GnRH analog use is suspected, neither screening nor

Received in revised form 21 January 2014

detection tests are developed. This study aimed to determine if (a) stimulation for 5 days by leuprolide (a

Accepted 27 January 2014

superactive GnRH analog) of serum and urine steroids and urine LH is reproducible at a 2 week interval,

Available online 2 February 2014

(b) nandrolone decanoate (ND) co-administration masks responses to leuprolide administration, (c) per-

formance of urine measurement of leuprolide and M1, its major metabolite, as a detection test. Healthy

Keywords:

men were randomized into a 4 week parallel group, open label clinical study in which all men had daily sc

Leuprolide

injections of leuprolide (1 mg) for 4 days in the 1st and 3rd weeks with hormone-free 2nd and 4th weeks.

GnRH Analog

Testosterone In the 3rd week, men were randomized to either ND injections or no extra treatment. Serum steroids

Doping were determined by liquid chromatography, tandem mass spectrometry (LC–MS), urine steroids by gas

chromatography, mass spectrometry (GC–MS), urine leuprolide and M1 by high resolution LC–MS and

urine LH by immunoassay. Leuprolide stimulated striking, reproducible increases in serum and urine

LH and steroids (serum T, dihydroT (DHT), 3␣ diol; urine T, epitestosterone (E) and androsterone (A).

ND suppressed basal serum T, E2, 3␣ diol, and urinary E but did not mask or change the magnitude of

responses to leuprolide. Urine leuprolide and M1 measurement had 100% sensitivity and speciﬁcity in

detecting leuprolide administration up to one day after cessation of injections with the detection window

between 1 and 3 days after last dose. Screening using urine steroid and LH measurements, optimally by

urinary log10 (LHxT), correctly classiﬁed 82% of urine samples. It is concluded that leuprolide stimulation

of endogenous testosterone is reproducible after a 10-day interval, is not masked by ND and is reliably

detected by urine leuprolide or M1 measurement for at least 1 day after administration.

1. Introduction sport in the early 1970s, a prohibition now enforced by World Anti-

Doping Agency (WADA)-mandated urine detection testing based

The biological basis of androgen doping is the strong on highly sensitive and speciﬁc mass spectrometry assays with pos-

dose-dependence of muscle mass and strength on exogenous itive results attracting strong sanctions [5]. Yet despite the effective

testosterone extending from below to well above the male physio- elimination of androgen use from elite sports competition, their

logical range [1] together with additive effects of androgen-induced potent ergogenic efﬁcacy through increasing muscle mass, strength

increase in hemoglobin [2]. These explain men’s superior perfor- and hemoglobin creates an ongoing temptation for elite athletes

mance in power sports due to their 20–30-fold greater endogenous seeking fame and fortune at any cost to gain unfair advantage

testosterone production rate compared with women or children through drug cheating. The continuing impetus for exploitation of

[3]. Androgens remain the most potent and widely used class of illicit androgen doping has led to development of indirect androgen

ergogenic drugs abused for doping, especially in power sports [4]. doping [6], the use of non-steroidal drugs to increase endogenous

Consequently, androgen doping was banned in elite international testosterone and DHT production such as hCG or LH [7,8], LH recep-

tor agonists [9,10], estrogen blockers or aromatase inhibitors, GnRH

analogs together with other theoretical possibilities [4,6]. In addi-

∗ tion to potential ergogenic beneﬁts, such drugs may also conceal

Corresponding author at: ANZAC Research Institute, Sydney, NSW 2139,

use of exogenous T or other natural androgens by masking signiﬁ-

Australia. Tel.: +61 -2-9767 9100.

13 12

E-mail address: [email protected] (D.J. Handelsman). cant changes in specialized tests (T/E ratio or C /C isotope ratios)

114 D.J. Handelsman et al. / Journal of Steroid Biochemistry & Molecular Biology 141 (2014) 113–120

as well as being used attempting to counteract adverse effects of value × ((1.020 − 1)/(measured SG − 1)). All samples were assayed

androgen abuse (e.g. gynecomastia, hypospermatogenesis, sexual together in one batch (Figs. 1–4).

dysfunction).

Although a method is reported to detect urinary GnRH excretion

2.4. Reagents and chemicals

[11], native GnRH has a very brief duration of action so could be used

only for short-term masking and not ergogenic effects [12]. There

All reagents were of analytical or high performance liquid

is greater potential for doping use of GnRH analogs but no ﬁrm

chromatography (HPLC) grade. Acetonitrile, methanol and formic

evidence of their use by elite athletes nor have detection methods

acid were purchased from Biosolv (Valkenswaard, Netherlands).

been developed [7]. This study was undertaken to (a) determine the

High purity water was from a Milli-Q Direct 16 Water

pattern of serum and urine LH and T during intermittent GnRH ana-

Puriﬁcation System (Millipore, France). The reference stan-

log use, (b) determine whether nandrolone is an effective masking 1 2 3 4 5

dards of leuprolide (leuprorelin; pGlu -His -Trp -Ser -Tyr -

agent, (c) whether effective screening tests can be devised based d 6 7 8 9

Leu -Leu -Arg -Pro -NHC2H5, molecular mass 1209 daltons) and

on the serum and/or urine hormone proﬁles during GnRH ana- 5 6 7 8

its major penta-peptide metabolite M1 (Tyr -dLeu -Leu -Arg -

log administration and (d) whether, and if so, how long the GnRH 9

Pro -NHC2H5, molecular mass 670 daltons) were purchased from

analog or its metabolites are detectable in urine.

Auspep Pty Ltd, VIC, Australia.

2. Materials and methods

2.5. LC-HRMS

2.1. Participants

Urine samples were extracted using the method described

Healthy men over 18 years of age were recruited by local adver- by Thomas [15] whereby, in brief, samples were loaded onto a

tising and eligible participants were required to provide written, mixed mode weak cation exchange solid phase extraction cartridge

␮

informed consent prior to entry. Participants were reimbursed (Phenomenex STRATA-X-CW 33 m, 30 mg/1 mL), eluted with a

for time and travel costs of participation involving 16 visits over solution of methanol containing 5% formic acid, evaporated to dry-

4 weeks. The study was approved by the Sydney South West ness and reconstituted in high purity water. The reconstituted

Area Health Service Human Research Ethics Review Committee eluates were analyzed by LC-HRMS.

(Concord) consistent with National Health and Medical Research The liquid chromatographic separation was by a Thermo Sci-

Council guidelines for ethical research involving humans and reg- entiﬁc Dionex UltiMate 3000 Degasser, Pump, Auto Sampler and

istered at the Australian and New Zealand Clinical Trial Registry Column Heater compartment (Thermo, Bremen, Germany) using a

(ACTRN12609000629235). Acquity ultra-HPLC (UPLC) BEH C18 1.7 ␮m (2.1 mm × 50 mm) ana-

lytical column and a Acquity UPLC BEH C18 VanGuard pre-column

␮ ×

2.2. Study design 1.7 m (2.1 mm 5 mm), both from Waters (Milford, USA). The

mobile phases consisted of (A) 0.3% formic acid in water and (B)

The study aimed to determine whether (a) a superactive GnRH 0.3% formic acid in acetonitrile. The elution gradient commenced

analog leuprolide (Lucrin, Abbott, Australasia) stimulation of serum at 87.5% A for 2 min, decrease to 72.0% A in 21 min, then to 20.0%

and urine LH and steroids was reproducible when repeated at a A in 23 min, returning to 87.5% A in 25 min and held at 87.5% A for

2 week interval, (b) co-administration of nandrolone decanoate a further 4 min to equilibrate. A constant ﬂow rate of 0.3 mL/min

(Deca-Durabolin, MSD, Australia) inﬂuenced serum and urine LH was maintained.

and steroid responses to leuprolide, (c) serum and urine LH and The liquid chromatograph was coupled to an Exactive Plus

steroid levels provide an effective screening test and (d) leuprolide high resolution Orbitrap based mass spectrometer (Thermo, Bre-

and its major metabolite M1 can be detected in urine. Using a paral- men, Germany) with a HESI II electrospray source. The instrument

lel group, open label design, leuprolide (1 mg) was injected sc once was operated in positive full scan ion mode at 35,000 resolving

daily at the same time of day for each participant between 08:00 power. The sheath gas (nitrogen) ﬂow rate was set to 70 (arbitrary

and 10:00 for 4 days in the 1st (days 1–4) and 3rd (days 15–18) week units), the auxiliary gas (nitrogen) ﬂow rate was set to 10 (arbi-

◦

with no leuprolide injections in the 2nd and 4th weeks. In the 3rd trary units) and the capillary temperature was 250 C. The spray

week, men were randomized to either ND injections (200 mg on voltage was set to 4.5 kV. Data was evaluated by extracting the

day 12 and 100 mg on day 17) or no extra treatment. accurate mass traces ( 5 ppm) of the protonated ion of the main

charge state for leuprolide and M1 metabolite. The limits of detec-

2.3. Steroid and LH assay methods tion were 0.05 ng/mL (0.04 pmol/L) for leuprolide (leuprorelin) and

0.10 ng/mL (0.15 pmol/L) for M1 and their coefﬁcients of variation

␣ ␤

Serum T, DHT, E2, E1, 3 and 3 diols were measured by (at 5 ng/mL) were 10.0% and 12.0%, respectively.

LC–MS within a single run without derivatization as described [13]

and calibrated directly against the National Measurement Institute

2.6. UGT2B17 genotyping

certiﬁed reference standards for T and DHT. The assay limits of

detection, limits of quantiﬁcation and within-run and between-

The deletion polymorphism in the uridine glucosyl transferase

run coefﬁcients of variation (%) were testosterone (35 pmol/L,

(UGT) 2B17 gene was detected by duplex PCR which deﬁned both

90 pmol/L, 2.0%, 3.9–6.5%), DHT (10 pmol/L, 0.69 nmol/L, 8.1%,

the wild-type (C) and mutant (J) alleles as described [16].

6.7–13.4%) and estradiol (4 pmol/L, 18 pmol/L, 6.6%, 4.8–8.6%). To

convert to mass units, divide testosterone by 3.47, DHT by 3.45

and estradiol by 3.67. Urine steroids (urine T, epitestosterone 2.7. Data analysis

(E), androsterone (A)) were measured at the Australian Sports

Drug Testing Laboratory using gas chromatography mass spec- Data were analyzed by mixed model ANOVA. Analysis used time,

trometry (GC–MS) and urine LH by Immulite 1000 immunoassay treatment (ND vs nil) and genotype (CC, CJ, JJ) as main effects with

as described [8,14]. Urine concentrations of each variable were age, height and weight as covariates. Data that had a markedly

adjusted to a standard concentration (speciﬁc gravity (SG) of non-Gaussian distribution were log-transformed for analysis but

1.020) according to the formula SG-adjusted value = measured depicted using the natural scale in ﬁgures. The optimal cutpoint for

D.J. Handelsman et al. / Journal of Steroid Biochemistry & Molecular Biology 141 (2014) 113–120 115 Testosteron e DHT

8.0 1.0

Nan drolone Nandrolone Con trol Control 7.0 0.8 6.0

5.0 0.6

4.0 ng/mL ng/mL 0.4 3.0

2.0 0.2 1.0 N N N N 0.0 0.0 1 2 3 4 5 8 10 12 1516171819 22 24 1 2 3 4 5 8 10 12 1516171819 22 24

Time (days) Time (days)

Estradiol 3α diol

70.0 0.7 Nan drolone

Nandrolone Con trol 60.0 Con trol 0.6

50.0 0.5

40.0 0.4

pg/mL 30.0 ng/mL 0.3

20.0 0.2 N N

10.0 0.1 N N N N 0.0 0.0 1 2 3 4 5 8 10 12 1516171819 22 24 1 2 3 4 5 8 10 12 1516171819 22 24

Time (days) Time (days)

Fig. 1. Effects of leuprolide with or without nandrolone decanoate on serum steroids over time. Plot of mean (±SEM) serum testosterone, DHT, estradiol and 3␣-diol.

To convert mass to molar units, multiply testosterone by 3.47, DHT by 3.45, estradiol by 3.67 and 3␣-diol by 3.42. Daily leuprolide injections are indicated solid bar and

nandrolone injections by an N. Filled circles indicate men randomized to nandrolone and open circles to those not during the second period of leuprolide injections.

classiﬁcation in a receiver operating characteristic (ROC) analysis (expressive aphasia, limb dysesthesia, visual disturbance) without

was determined using Youden’s index [17]. headache. An MRI scan showed an enlarged, hyperdense pituitary

suggestive of hemorrhage into a microadenoma but no focal cere-

3. Results bral features. Visual ﬁelds and pituitary function were normal,

neurological symptoms resolved spontaneously and he remained

Among the 19 healthy volunteers entering the study, 3 dis- well without treatment 4 months later. The diagnosis of pituitary

continued for personal reasons before completing all study visits. apoplexy in an undiagnosed pituitary microadenoma was classiﬁed

Subsequent analysis was conﬁned to the 16 men (median [range], as a serious adverse reaction possibly related to the study medica-

age 31 [20–58] years; height 179 [161–192] cm; weight 78.5 tion.

[62–116] kg; BMI 25.5 [20.4–35.9] kg/m ) completing all 16 visits Daily injections of leuprolide for 4 days stimulated increases

␣

including two men who participated in the study a second time in serum T, DHT, 3 diol and urine LH and T, E & A which

after an interval of at least 3 months. were sustained for 4 days. The second stimulation cycle produced

There were no adverse effects reported during the study. One increases in urine LH and steroids of similar magnitude except for

man who participated twice presented 5.5 months after his sec- serum DHT which did not increase in the 2nd treatment period

ond participation with recent onset of transient cerebral symptoms (Table 1).

116 D.J. Handelsman et al. / Journal of Steroid Biochemistry & Molecular Biology 141 (2014) 113–120 LH Tes tosterone

120.0 250.0

100.0 Nandrolone 200.0 Control Nandrolone Control 80.0 150.0 /mL 60.0 /mL ng ng 100.0 40.0

50.0 20.0 N N N N

0.0 0.0

1 2 3 4 5 8 10 12 1516171819 22 24 1 2 3 4 5 8 10 12 1516171819 22 24 Time (days) Time (days)

Epitestosterone T E Ratio

140.0 3.0

Nandrolone 120.0 2.5 Nandrolone Control Control 100.0 2.0 80.0 /mL /mL 1.5

ng 60.0 ng 1.0 40.0

20.0 0.5 N N N N

0.0 0.0

1 2 3 4 5 8 10 12 1516171819 22 24 1 2 3 4 5 8 10 12 1516171819 22 24

Time (days) Time (days)

Fig. 2. Effects of leuprolide with or without nandrolone decanoate on urine steroids over time. Plot of mean (±SEM) urine LH, testosterone, epitestosterone and T/E ratio. To

convert mass to molar units, multiply testosterone and epitestosterone by 3.47. Daily leuprolide injections are indicated solid bar and nandrolone injections by an N. Filled

circles indicate men randomized to nandrolone and open circles to those not during the second period of leuprolide injections.

There was no signiﬁcant response to leuprolide admin- urinary E and serum T as well as all other measured steroids (data

istration in serum DHEA, urinary T/E ratio or A/E ratio. not shown).

ND suppressed basal serum T, E2, 3␣ diol, and uri- Leuprolide and its M1 metabolite were detectable in every urine

nary E but did not change the magnitude of the 2nd sample from the start of administration until and including the

stimulation. sample a day after last leuprolide dose but no urine sample had

Men with the homozygous UGT2B17 deletion genotype (JJ) any detectable leuprolide or M1 3 days after the last dose. No urine

exhibited extremely low urinary T and T/E ratio but had normal was collected on 2nd day after last leuprolide dose.

Table 1

Reproducibility of serum and urine responses to the ﬁrst and second administration of leuprolide.

Difference Serum Urine

(mean ± SEM)

T (ng/mL) DHT (ng/mL) E2 (pg/mL) T (ng/mL) Epi (ng/mL) T/E LH (IU/L) log10 (LHxT) 2

(log10 (IU nmol/L ))

Cmax 0.8 ± 0.5 0.15 ± 0.09 14 ± 5 28 ± 30 0.9 ± 12 0.15 ± 0.32 27 ± 15 0.27 ± 0.12

Tmax (days) 0.4 ± 0 0.1 ± 0.4 0.1 ± 0.3 0.3 ± 0.3 0.2 ± 0.3 0.4 ± 0.4 0.3 ± 0.2 0.1 ± 0.2

To convert mass to molar units, multiple testosterone by 3.47, DHT by 3.45, estradiol by 3.67, epitestosterone by 3.47.

Difference between 1st and 2nd stimulation. Bold indicates signiﬁcant difference.

D.J. Handelsman et al. / Journal of Steroid Biochemistry & Molecular Biology 141 (2014) 113–120 117

Serum Testosterone Urine Testosterone

10 160

140 8 CC CC 120 CJ CJ JJ JJ 100 6

80 ng/mL ng/mL 4 60

40 2 20

0 0 1 2 3 4 5 8 10 1 2 3 4 5 8 10

Time (days) Time (days)

Urine Epitestosterone Urine T E Ratio

140 3.5

120 3.0 CC CC CJ 100 2.5 CJ JJ JJ 80 2.0

ng/mL 60 1.5

40 1.0

20 0.5

0 0.0 1 2 3 4 5 8 10 1 2 3 4 5 8 10

Time (days) Time (days)

Fig. 3. Effects of leuprolide on steroids over time according to UGT2B17 genotype. Plot of mean (±SEM) serum testosterone, urine testosterone, urine epitestosterone and

urine T/E. To convert mass to molar units, multiply testosterone and epitestosterone by 3.47. Daily sc leuprolide injections indicated solid bar. The UGT2B17 genotype is

indicated by ﬁlled circles for the homozygous normal (CC), shaded circles for the heterozygous (CJ) and open circles for the homozygous deletor (JJ).

Using urine steroids and LH measurements, the optimal repeat increases in serum and urine LH and T. Although the present

screening for leuprolide administration was provided by urinary ﬁndings suggest that further stimulation cycles of endogenous

log10 (LHxT) which, using a cutpoint of 1.96 as determined by testosterone production may also be effective, whether further

Youden’s index, correctly classiﬁed 82% of samples. On the day repeated stimulations continue to increase endogenous testos-

after last leuprolide dose, 33/36 (92%) urine sample exceeded this terone and how variations in the duration of stimulation and

criterion. recovery inﬂuence such increases, were not addressed in this study.

Stimulation of pituitary LH and testicular T secretion is a class-

4. Discussion speciﬁc feature of the superactive, but not pure antagonist, GnRH

analogs [18]. Following the Nobel Prize-winning characterization

This study reveals that the expected stimulation of serum of the decapeptide GnRH in 1971, numerous peptide analogs were

and urine levels of testicular steroids and urine LH produced by synthesized with 7 marketed as superactive agonists (buserelin,

daily sc injection of leuprolide for 4 days is reproducible when deslorelin, goserelin, histrelin, leuprolide, nafarelin and triptore-

repeated after a 10 day drug-free interval. Hence this time allows lin). These superactive analogs initially stimulate LH secretion

for recovery of pituitary GnRH receptor desensitization caused before producing paradoxical downregulation of LH secretion dur-

by non-physiological, sustained stimulation allowing for effective ing prolonged dosing (>2–3 weeks), due to desensitization of

118 D.J. Handelsman et al. / Journal of Steroid Biochemistry & Molecular Biology 141 (2014) 113–120

Log LH x T 4.0 10

3.0

2.0 Nandrolone Control

1.0

N N 0.0 1 2 3 4 5 8 10 12 1516171819 22 24 Time (days)

Leuprolide 10.0 24.0 Leuprolide M1

8.0 20.0

16.0 6.0

12.0 g/ 4.0 ng/mL 8.0

2.0 4.0

N N N N 0.0 0.0 1 2 3 4 5 8 10 12 1516171819 22 24 1 2 3 4 5 8 10 12 1516171819 22 24 Time (days)

Time (days)

Fig. 4. Effects of leuprolide on urine leuprolide and M1 and the optimal screening test over time. Plot of mean (±SEM) log10 (urine LHxT), urine leuprolide and urine leuprolide

metabolite M1. To convert mass (ng/mL) to molar (pmol/L) units, multiply leuprolide by 0.83 and M1 by 1.49. Daily sc leuprolide injections indicated solid bar and nandrolone

injections by an N along the x axis.

GnRH receptors from sustained, non-physiological (non-pulsatile) dependent cancers or benign disorders. As sustained suppression

stimulation. Subsequently, 4 pure GnRH antagonist (abarelix, of endogenous testosterone would diminish power sports perfor-

cetrorelix, degarelix and ganirelix) analogs, that inhibit GnRH- mance [22], such depot products have no signiﬁcant abuse potential

dependent LH secretion without any transient stimulatory phase, for doping. Subsequently, pure GnRH antagonists were developed

were marketed. These analogs were developed on the basis that, to induce medical castration without the transient “ﬂare”, although

whereas the native decapeptide had blocked N (pyro-glutamic acid) depot GnRH agonists remain widely used.

and C (glycinamide) termini resistant to exopeptidases, its rapid The “ﬂare” reaction, identiﬁed as a transient adverse effect dur-

metabolism in the circulation [12] was via mid-molecule cleavage ing initiation of medical castration for prostate cancer, is present

by renal endopeptidases [19]. The present study used leuprolide for up to 15 days of daily injections of superactive GnRH ago-

D 6 10

( -Leu , desGly GnRH) the ﬁrst, most widely marketed superac- nists [23]. Flare-induced increases in serum LH and testosterone

tive GnRH analog, a nonapeptide with 2 structural modiﬁcations can produce deleterious androgen-dependent clinical manifesta-

to enhance GnRH receptor binding afﬁnity and block proteoly- tions such as enlargement of prostate cancer metastases causing

sis that enhance and prolong bioactivity [19]. Prior to recognizing pain, spinal damage or acute urinary obstruction [24] or death

that GnRH stimulation of sustained physiological gonadotrophin [25]. These necessitate routine co-administration of an antiandro-

secretion required intermittent GnRH delivery [20], superactive gen when starting GnRH agonist treatment [26]. This short-term

GnRH analogs were designed to potently stimulate reproductive “ﬂare” has also been exploited advantageously in the initiation

function; however, sustained pituitary LH, and thereby testicular of an IVF ovarian hyperstimulation cycle to enhance ovarian fol-

T, secretion requires an intermittent GnRH stimulation whereas licle harvest [27]. However, repeated “ﬂares” at regular intervals

continuous stimulation ultimately produces GnRH receptor desen- have no known medical application. Our ﬁndings verify that

sitization and decreased GnRH-dependent gonadotropin secretion intermittent use of soluble (but not depot) superactive GnRH

[21]. In practice, superactive GnRH agonists produced only tran- analogs might exploit the short-term “ﬂare” phenomenon repeat-

sient stimulation (“ﬂare”) followed by sustained suppression edly to increase endogenous T production aiming to enhance sports

of gonadal function meant that the superactive agonists were performance and/or mask abuse of exogenous T. Illicit doping

developed for their medical castration effects. In clinical practice, schemes often involve intermittent or cyclical drug use however

1–6 months depot injectable forms of superactive GnRH ago- the extent of indirect androgen doping using GnRH analogs is not

nists are widely used to induce medical castration for hormone known.

D.J. Handelsman et al. / Journal of Steroid Biochemistry & Molecular Biology 141 (2014) 113–120 119

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