SCIENCE FOR EVERYONE
When most people hear “enhancement,” they think of substances and elite sport. But the science of enhancement is really the science of helping your body perform, recover, and function at its best, whatever that looks like for you.
Enhancement is any evidence-based intervention that moves you closer to your goals. It could be hormonal, nutritional, technological, behavioural. The starting point isn’t a substance — it’s a question.
WHAT ARE YOUR GOALS?
This is the key question to ask before considering any enhancement. Your goals determine your protocol, not the other way around.
PERFORMANCE
Break a world record
Get stronger
Run faster
Build lean muscle
Improve endurance
HEALTH & LONGEVITY
Live longer
Manage chronic conditions
Better metabolic health
Support healthy ageing
RECOVERY & WELLBEING
Recover from injury
More energy
Better sleep
Improved mobility
BODY COMPOSITION
Lose weight
Reduce body fat
Improve bone density
HOW CAN YOU ACHIEVE YOUR GOALS
Whether your goal is to get stronger, live longer, recover from injury, or improve your metabolic health, real results come from a coordinated approach. Enhancement is a system, not a shortcut.
WHAT ARE PERFORMANCE ENHANCING SUBSTANCES?
Performance-enhancing substances (PES) are drugs, medications or compounds that improve the body’s ability to produce, utilise, or recover energy. They are commonly used to enhance attributes such as speed, strength, endurance, coordination, and recovery.
PES are all around us — from everyday compounds like caffeine and creatine, to more potent substances like testosterone and human growth hormone. Some of these substances occur naturally in the body and are either extracted or bioidentically synthesised to be taken in doses to enhance or optimise function. Others are synthetic compounds designed to mimic, amplify, or modify the effects of natural substances or physiological mechanisms in the body.
The degree to which a PES impacts the body can vary significantly, which is why certain substances have a ‘controlled’ status, and require medical supervision to ensure safe use. Importantly, many of the PES commonly used by athletes are also legally prescribed in clinical medicine to treat legitimate health conditions, and are approved by regulatory agencies such as the FDA.
(IQVIA, 2024)
One of the most common questions about performance-enhancing substances is whether they are safe. To answer that, we first need to understand what determines safety.
The safety of any substance depends on how it is used. Even paracetamol – one of the most widely available over-the-counter medications in the world – can cause harm when taken outside of dosing guidelines. Ibuprofen, caffeine, and alcohol all carry well-documented health risks when used irresponsibly.
Performance-enhancing substances are no different. The risks most commonly reported in the media (cardiovascular events, hormonal disruption, organ damage) are overwhelmingly linked to unsupervised use: incorrect dosing, contaminated compounds, no clinical monitoring, and no medical oversight.
There is a fundamental difference between use of a substance with medical supervision, and misuse of a substance without it.
WHAT IS MEDICAL SUPERVISION?
Medical supervision is a structured, evidence-based framework for managing substance use that safeguards both short- and long-term health. It means making medically informed decisions that optimize for your goals and safeguard your health.
PRE-SCREENING
Health assessments before any substance use begins, including any imaging and blood tests considered appropriate by the supervising physician or monitoring team.
Doses and substances selected according to the individual’s unique physiology, health and goals.
Regular biomarker tracking and clinical follow-up both during and after use.
PHARMACEUTICAL-GRADE
MEDICATION SUPPLY
Access to regulated, quality-assured substances with known purity and strength, avoiding the risks of unregulated products.
WHAT IS UNSUPERVISED USE AND WHY IS IT RISKY?
The health risks associated with PES are driven by specific, identifiable factors – many of which can be reduced or avoided with medical guidance.
Products obtained outside of medical contexts may be contaminated, mislabelled or contain a different dose from the one stated.
Substances and doses may not be suited to the individual’s physiology, health, or goals.
Without medical oversight, warning signs may be missed or left untreated.
Multiple substances may be combined without a clear clinical reason or enough safety data.
Other drug use may add further risk and make it harder to identify the cause of any health problem.
WHAT DOES THE RESEARCH ACTUALLY SAY?
Most existing research into health outcomes associated with PES use is retrospective and observational, and its findings are shaped by the conditions in which the research was carried out.
These studies look back at what has already happened. Researchers review medical records, surveys or self-reported histories and look for patterns. These studies can show that two things happened together, but they cannot fully control for other factors. This means they cannot reliably prove what caused the outcome.
These studies are designed in advance, and examples include randomized controlled trials. Researchers assign participants to a treatment or placebo, control the conditions and follow them over time. Because more variables are controlled, these studies are better able to show whether a substance caused an outcome rather than simply occurring alongside it.
When people say that PES use is risky, medically supervised use is often grouped together with unsupervised use. They are very different.
This is why cited health risks associated with steroids (here meaning anabolic-androgenic steroids such as testosterone and its derivatives) are primarily linked to long-term, unsupervised supraphysiological doses, and chronic use in observational or retrospective studies (Wenbo & Yan, 2013; Momoh, 2024) – these conditions are very different to medical supervision. Additionally, over half of steroid users report also using recreational or illicit drugs (Smit et al., 2020, 2022), potentially confounding observed health risks in general population studies – which, again, are typically observational and retrospective.
The studies that generate the most alarming headlines often involve people for whom PES use is only one of several risk factors. This makes it difficult to attribute poor health outcomes to any one factor. It is a major limitation of the existing evidence.
Even within the retrospective literature, drug-related serious adverse events in athletes appear extremely rare. A landmark analysis of 1,866 sudden deaths among young competitive athletes in the United States between 1980 and 2006 found just 2% were categorised as “illicit drug use” without specifying the type of drug – meaning performance-enhancing substances likely accounted for a fraction of that figure (Maron et al., 2009). Most sudden deaths were linked to pre-existing cardiovascular conditions.
IN CLINICAL MEDICINE
Many substances discussed in the context of performance enhancement are not experimental or underground compounds. They are FDA-approved medicines routinely prescribed for recognised medical conditions, with decades of safety data under medical supervision.
For example, testosterone is the most widely prescribed PES and one of the most extensively studied hormones in medicine. Over 11 million testosterone prescriptions were dispensed in the United States in 2024 alone (IQVIA, 2024). It is prescribed for hypogonadism, hormone optimisation, and a growing number of clinical indications.
Testosterone has been used in medicine and studied extensively since it was first synthesised in 1935. As prescribing rates have increased in recent decades, its safety – particularly its cardiovascular safety – has received greater scientific scrutiny. This led to the TRAVERSE trial, the largest randomised controlled trial conducted on this question (Lincoff et al., 2023). Published in the New England Journal of Medicine in 2023, the trial included 5,246 men aged 45–80 who had symptoms of hypogonadism and either existing cardiovascular disease or a high risk of developing it. Testosterone replacement therapy was no more likely than placebo to cause major adverse cardiac events (Lincoff et al., 2023). There was also no increase in prostate cancer or prostate-related events.
The European Expert Panel for Testosterone Research later published a position statement confirming that these findings were consistent with earlier meta-analyses. These concluded that testosterone therapy, when appropriately prescribed and monitored, does not increase cardiovascular risk (Zitzmann et al., 2025).
The findings were persuasive enough for the FDA to remove class-wide boxed-warning language about increased cardiovascular outcomes in 2025. At the same time, the FDA required stronger warnings about increased blood pressure.
SO, ARE PES SAFE?
The key question is whether performance-enhancing substances can be used safely when prescribed and monitored by a physician. Decades of clinical evidence show that they can. When used without supervision, at uncontrolled doses, or from unregulated sources, they carry risk – but the same is true of almost any medicine.
Everything Enhanced provides, whether for consumers pursuing health goals or athletes pursuing performance, is clinically prescribed and medically supervised. This is fundamentally different from the unsupervised use that drives much of the risk reported in existing research.
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