The Errani Doping Case: An Embarassment

Today it was announced that Sara Errani, a top women's tennis player (currently 98th, but has been as high as 5th), has been suspended for 2 months for doping. The case illustrates much about what is wrong with anti-doping and the profound consequences that the failures of anti-doping have on elite athletes.

The ITF announced today:

An Independent Tribunal appointed under Article 8.1 of the 2017 Tennis Anti-Doping Programme (the "Programme") has found that Sara Errani committed an Anti-Doping Rule Violation under Article 2.1 of the Programme and, as a consequence, has disqualified the affected results and imposed a period of ineligibility of two months, commencing on 3 August 2017.

Ms. Errani, a 29-year-old player from Italy, provided a urine sample on 16 February 2017 as part of an Out-of-Competition test under the Programme. That sample was sent to the WADA-accredited laboratory in Montreal, Canada for analysis, and was found to contain letrozole, which is an aromatase inhibitor that is included under section S4 (Hormone and Metabolic Modulators) of the 2017 WADA Prohibited List, and therefore is also prohibited under the Programme.

Wow, that sure sounds serious! Another cheating athlete, it seems.

But lets take a closer look. All is not that it seems.

The drug that Errani is suspended for is call letrozole, which is an aromatase inhibitor meaning that it suppresses aspects of the human hormonal system.  In this case the thinking is that the drug increases the presence of testosterone in the human body, which may aid performance. Here is what the ITF says about the drug in its judgment on Errani (here in PDF):

There has been concern on the part of WADA that some bodybuilders were abusing letrozole and there was some anecdotal evidence online that female bodybuilders used it for that purpose. The substance has been banned for men since 2001 and for everyone since 2005, both in competition and out of competition without a valid TUE. 

Contrary to the thin "anecdotal evidence" cited here, the scientific literature on letrozole and aromatase inhibitors more generally published since 2005 indicates that these drugs do not offer a performance enhancing benefit to women.

For instance, Handlesman (2008) concludes, emphases added:

In summary, there is no convincing evidence that oestrogen blockers cause any consistent, biologically significant increase in blood testosterone concentrations in women. In the absence of direct testing of ergogenic or myotrophic properties, using blood testosterone as a surrogate marker suggests that drug-induced performance enhancement is most unlikely from oestrogen blockade. Nor is there any reason to believe that oestrogens have any other ergogenic effect whether directly on muscle, haemoglobin or indirectly via motivational effects in healthy pre-menopausal women. Finally, as oestrogen blockade for various indications is in wide, regular clinical use and poses no unusual medical risks to female athletes, there is no basis to ban oestrogen blockade in female athletes.

Handlesman (2006) concluded similarly:

In conclusion, there is no convincing evidence that either hCG or estrogen blockers (antiestrogens, SERMs, aromatase inhibitors) cause any consistent or biologically significant increase blood testosterone concentrations in women. In the absence of direct testing of ergogenic or myotrophic properties, blood testosterone is a reasonable surrogate maker, suggesting that drug-induced performance enhancement is most unlikely.

Both classes of agent are in regular clinical use and neither poses sufficient safety risks sufficient to warrant banning in sports on the basis of protecting female athletes safety.

Finally, the adverse privacy implications of hCG testing and the unjustified workload of extra TUEs for estrogen blockers in women suggest that the prohibition of these classes of agents should be restricted to men in whom they are well justified.

The peer-reviewed science is clear enough, but here is where things are a bit strange. The ITF agrees with these conclusions, writing in its Errani judgment (here in PDF), emphasis added:

However there is no evidence that letrozole would enhance the performance of an elite level tennis player. There is no evidence of any significant usage of letrozole amongst athletes in general and none was identified in respect of tennis players.

So we have a drug that no one is taking, that everyone agrees does not have performance-enhancing effects -- a conclusion which is well-supported by scientific research -- and yet 12-year old regulations based on out-dated assumptions are the basis for sanctioning an elite athlete.

Seriously, what are we doing here?