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 running amok during that rocky transition from boy to man known as puberty. During those fateful years, fluctuating hormone levels lead to the waxing and waning of testosterone levels, and in many cases, gynecomastia will develop transiently, with resolution in 95% of cases within three years from the time of onset. For that unfortunate 5% in whom gynecomastia and male breast tissue persist beyond puberty, resolution can only be achieved through surgery. Read on to learn more about the use of anabolic steroids, their adverse effects, hormone levels, and gynecomastia.

Bodybuilding and Gynecomastia

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. Anabolic steroid use 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, gynecomastia and breast development are 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 sports supplements featuring “pro-hormone” ingredients, even non-competitive fitness enthusiasts may find themselves in the office of a plastic surgeon with male breast enlargement.

Why Do Anabolic Steroids Cause Gynecomastia?

What exactly is going on in these individuals? Essentially, anabolic steroids can recreate the hormone changes that occur during puberty. If an individual decides to take exogenous testosterone, one of the things he does is suppress his own testosterone production through a feedback loop, leading to estrogen excess and the growth of male breast tissue. 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 muscle 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 afterward, the extra hormone is stopped to allow the body to make its own testosterone for a while. While there is extra testosterone in circulation, some of this is converted to estrogen by the enzyme aromatase. While estrogen synthesis is a normal process, in the presence of high testosterone levels, elevated serum estrogen levels may also be present. Again, this isn’t a big problem during the period of the cycle when testosterone is high. When the individual comes off, however, that changes and the body perceives an altered ratio between circulating testosterone and estrogen. It’s that altered androgen ratio that leads to stimulation of breast tissue, leading to the development of gynecomastia.

Pro-Hormone Supplements and Gynecomastia

This can also occur with the use of some “pro-hormone” supplements, 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. After a while, an irreversible mass of male breast tissue is present under the nipple-areola in one or both breasts.

Anti-Estrogen Drugs and Gynecomastia

A single cycle may lead to reversible changes if the hormone changes are 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 and breast tissue, possibly worsening rather than improving breast tissue growth.

Hair Loss Drugs and Gynecomastia

Particularly common in this patient group is the use of Propecia to prevent hair loss. Using this drug has a small potential to develop gynecomastia, and it’s appropriate to make sure that it’s not been a factor in the development of gynecomastia in the first place. Patients can usually tell if any change in one or both breasts occurred when they started the drug, and if not, they’re less likely to develop male breast enlargement later.

How to Treat Drug Induced Gynecomastia

Unsophisticated steroid users are probably best off to just stop altogether, allowing for normalization of their hormone levels, 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 through the choice of the agents they use (some are more likely culprits to cause gynecomastia than others) or by taking anti-estrogens as well as testosterone supplementation.

Gynecomastia Surgery

As a plastic surgeon, while I am well-trained to treat 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.

Preparing for Gynecomastia Surgery

Hormone balance 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.

Gynecomastia Surgery Considerations

In terms of surgical management, it’s important for the patient to understand that, even with a comprehensive treatment of gynecomastia using a combination of liposuction along with excision of the breast tissue, a small remnant of breast tissue must be left behind on the underside of the nipple-areola complex. This breast 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 breast tissue removal,” unless they are removing the nipple and its underlying breast tissue, some breast tissue is left behind.

Preventing the Recurrence of Drug Induced Gynecomastia

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. 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.

Conclusion

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 fluctuating hormone levels that mimic changes that the body experiences during puberty. Treatment principles are the same as with any gynecomastia patient, starting with the re-establishment of a “normal” hormone balance, followed by surgical resection of breast tissue. Recurrence is possible, due to the small amount of breast 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.

To learn more about gynecomastia treatment with a board-certified plastic surgeon, schedule an appointment with Dr. Miguel Delgado through this contact form.