Gynecomastia and Anabolic Steroids: Red Badge of Courage or The Scarlet Letter?
The majority of men who suffer from gynecomastia develop the condition as a result of normal physiology run amok during that rocky transition from boy to man known as puberty. During those fateful years, hormonal fluctuations lead to waxing and waning of the levels of sex hormones, and in many cases, gynecomastia will develop transiently, with resolution in ninety-five percent of cases within three years from the time of onset. For that unfortunate five percent in whom the condition persists beyond puberty, resolution can only be achieved through surgery.
The majority of men who suffer from gynecomastia develop the condition as a result of normal physiology run amok during that rocky transition from boy to man known as puberty. During those fateful years, hormonal fluctuations lead to waxing and waning of the levels of sex hormones, and in many cases, gynecomastia will develop transiently, with resolution in ninety-five percent of cases within three years from the time of onset. For that unfortunate five percent in whom the condition persists beyond puberty, resolution can only be achieved through surgery. Realizing this fact, it’s hard to imagine that anyone would do something voluntarily that might result in the development of gynecomastia, but in the world of athletic performance enhancement and anabolic steroid use, this is indeed the case. This is most notable in the sport of bodybuilding, since the goal is to create the ideal male physique, and in the case of competitive bodybuilding, to display that physique before a cheering public. For some competitors, however, the tell-tale sign of gynecomastia is a giveaway that performance enhancing drugs were part of the athlete’s pre-contest regimen. Of course, many athletes in many sports use anabolic steroids, and today, with the abundance of gray-market sport supplements featuring “pro-hormone” ingredients, even non-competitive fitness enthusiasts may find themselves in the office of a plastic surgeon lamenting a recent purchase from their favorite supplement store.
What exactly is going on in these individuals? Essentially, anabolic steroids can recreate the hormonal fluctuations that occur during puberty. If an individual decides to take exogenous testosterone, one of the things that he does is to suppress his own testosterone production through a feedback loop. That’s not a problem when the hormone is started, though many men will comment that they feel some tingling or sensitivity in the nipple when they begin to use testosterone. At this point, there is a lot of testosterone floating around the body, which leads to strength gains, increases in lean mass, and other benefits of anabolic steroid supplementation. (It may also be accompanied by some side effects, such as acne, increased body hair, male-pattern baldness, increased aggressive behavior, and a few other bothersome problems.) Typically, steroids are taken in cycles in order to gain benefit from the extra testosterone for a given period of time, but afterwards, the extra hormone is stopped to allow the body to make it’s own testosterone for a while. While there is extra testosterone in the circulation, some of this is converted to estrogens by the enzyme “aromatase,” and while this is a normal process, in the presence of high levels of testosterone, higher than normal levels of estrogens may also be present. Again, this isn’t a big problem during the period of the cycle when the testosterone is high. When the individual comes off, however, that changes, and the body perceives an altered ratio between circulating testosterone and circulating estrogens. It’s that altered ratio that leads to stimulation of breast tissue, leading to the development of gynecomastia. This can also occur with the use of some of the “pro-hormone” supplement, such as androstenedione, popularized by the baseball player, Mark Maguire. With repeated use, some glandular tissue develops, but fibrous tissue is also laid down during the process, and after a while, an irreversible mass of tissue is present under the nipple-areola. Before long, the quest to become superman leads many steroid users to develop breast tissue that would make any young pubescent woman proud.
A single cycle may lead to reversible changes if the hormonal milieu is normalized promptly, or possibly with the addition of an “anti-estrogen” such as Arimidex or Femara. Nolvadex (Tamoxifen), which is also commonly sought after by bodybuilders as an anti-aromatase or anti-estrogen, can actually stimulate gynecomastia, possibly worsening rather than improving the condition. Unsophisticated steroid users are probably best off to just stop altogether, allow for normalization of their hormonal axis, followed by treatment of their gynecomastia if it doesn’t resolve. Regular users, on the other hand, are likely to take precautions to avoid developing gynecomastia, either though choice of the agents they use (some are more likely culprits to cause gynecomastia than others), or by taking anti-estrogens as well as the testosterone supplementation. As a plastic surgeon, while I am well-trained to treat the gynecomastia surgically, I do not provide “prophylactic” treatment with anti-estrogens in my practice, since this is not my area of expertise. Additionally, there is not much data from well-controlled studies looking at the efficacy of these drugs to treat or prevent anabolic-steroid-induced gynecomastia, so I generally refer patients to an endocrinologist for this sort of management, if it’s appropriate.
In any case, hormonal levels should be stable before proceeding with surgery, since surgery in the face of unstable levels could be followed by recurrence. Other drugs as causative agents for gynecomastia should also be identified. Particularly common in this patient group is the use of Propecia to prevent hair loss. This drug has a small potential for causing gynecomastia, and it’s appropriate to make sure that it’s not been a factor in the development of the condition in the first place. Patients can usually tell if any change occurred when they started the drug, and if not, they’re less likely to develop a problem later.
In terms of surgical management, it’s important for the patient to understand that even with comprehensive treatment of gynecomastia, using a combination of liposuction along with excision of the “gland,” a small remnant of tissue must be left behind on the underside of the nipple-areola complex, and this tissue contains receptors that could be stimulated with future use of anabolic steroids, leading to recurrence. No matter what claims are made by surgeons in terms of “complete gland removal,” unless they are removing the nipple and it’s underlying tissue, some gland is left behind. So, again, precautions should be taken to avoid steroid and pro-hormone use post-operatively. Patients should be particularly careful about using over-the-counter products that claim significant anabolic properties and don’t clearly market themselves as “hormonal” products. Some of these may be innocent, but many are not, and in particular, some products, which are labeled with ingredients under “proprietary blend” may be highly effective – and effective at causing a recurrence of gynecomastia – as a result of hormonally active ingredients.
In summary, the appearance of gynecomastia in bodybuilders is most commonly, though not always, the result of anabolic steroid use, a practice that can lead to hormonal fluctuations that mimic changes that the body experiences during puberty. Treatment principles are the same is with any gynecomastia patient, starting with the re-establishment of a “normal” hormonal milieu, followed by surgical resection. Recurrence is possible, due to the small amount of tissue that is left behind to support the nipple-areola complex, so avoidance of steroids is recommended post-operatively. For many bodybuilders who are committed to the steroid lifestyle, gynecomastia management is simply a rite of passage, a part of the price to be “huge.” Nonetheless, it remains a flaw, which needs to be corrected as they pursue the perfect physique.
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