Overview
Definition:
Gynecomastia, the abnormal enlargement of male breast tissue, can occur in adolescents due to exogenous anabolic-androgenic steroid (AAS) use
This condition arises from the hormonal disruption caused by AAS, which can mimic or enhance estrogenic effects or block androgenic action.
Epidemiology:
The prevalence of AAS use among adolescent athletes is significant, though precise figures for steroid-induced gynecomastia are difficult to ascertain
However, it is a commonly recognized adverse effect, particularly with prolonged or high-dose AAS cycles
Age of onset for AAS use in sports is often early to mid-adolescence.
Clinical Significance:
For pediatricians and adolescent medicine specialists, recognizing steroid-induced gynecomastia is crucial due to its association with dangerous drug use
It signals a potential need for intervention not only for the physical condition but also for addressing substance abuse, mental health concerns, and educating patients and families about health risks.
Clinical Presentation
Symptoms:
Development of palpable breast tissue under the nipple-areola complex
Tenderness or pain in the breast area
Feeling of fullness or heaviness in the chest
Visible breast enlargement
Adolescents may also report concomitant symptoms related to AAS use, such as mood swings, acne, testicular atrophy, or decreased libido.
Signs:
Palpable glandular tissue, typically disc-like, measuring at least 0.5 cm in diameter, located centrally beneath the areola
This tissue is distinct from pseudogynecomastia (adipose tissue)
Absence of significant nipple discharge
In some cases, signs of virilization or de-virilization may be present depending on the specific AAS used.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on physical examination findings of glandular breast tissue in an adolescent male
A strong suspicion of AAS use, often confirmed by patient history or reported by parents/peers, is key
Hormonal assays may be used to assess for underlying endocrine disorders but are often normalized in AAS-induced gynecomastia unless drug use is ongoing or recent.
Diagnostic Approach
History Taking:
Detailed history of AAS use, including specific compounds, dosages, duration, and cycling patterns
Inquiry about other performance-enhancing drugs or supplements
Family history of breast cancer or endocrine disorders
Sexual maturation stage
Any symptoms of hypogonadism or hyperestrogenism
Substance use history including recreational drugs
Past medical history and current medications.
Physical Examination:
Thorough examination of the breast tissue for consistency, size, and location of glandular tissue
Palpation for tenderness
Examination of the testes for size and consistency
Assessment of secondary sexual characteristics including pubic hair distribution, voice pitch, and presence of acne
Examination of other organ systems for potential AAS-related effects.
Investigations:
Hormonal assays: Serum testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, estradiol, and sex hormone-binding globulin (SHBG) may be considered, especially if AAS use is uncertain or to rule out other causes of gynecomastia
However, these may be unreliable if AAS use has ceased
Ultrasound of the breast can help differentiate glandular tissue from fat
Liver function tests and lipid profiles may be indicated due to potential AAS-related organ toxicity.
Differential Diagnosis:
Idiopathic gynecomastia
Pubertal gynecomastia (physiological)
Hypogonadism (primary or secondary)
Klinefelter syndrome
Adrenal tumors
Testicular tumors
Medications (e.g., spironolactone, cimetidine)
Obesity (pseudogynecomastia)
Familial gynecomastia
Hyperthyroidism
Liver cirrhosis
Renal failure.
Management
Initial Management:
Discontinuation of anabolic-androgenic steroid use is paramount
Counseling regarding the harmful effects of AAS and potential long-term health consequences
Addressing any immediate withdrawal symptoms or psychological distress.
Medical Management:
If gynecomastia is mild and recent, observation may be sufficient, as it can sometimes regress after AAS cessation
Pharmacological agents like tamoxifen or aromatase inhibitors (e.g., anastrozole) may be considered in select cases under specialist guidance, although their efficacy in established AAS-induced gynecomastia is debated and often less effective than in pubertal gynecomastia
Dosages and treatment durations should be individualized.
Surgical Management:
Surgical intervention (mastectomy or liposuction-assisted mastectomy) is indicated for persistent, bothersome gynecomastia that has not regressed after AAS cessation or for significant cosmetic deformity
This is usually performed by a plastic surgeon or a surgeon experienced in breast surgery.
Supportive Care:
Psychological support for body image concerns and self-esteem issues
Nutritional counseling
Education on safe and healthy methods for achieving fitness goals
Referral to substance abuse counseling or addiction services if indicated.
Complications
Early Complications:
Psychological distress, anxiety, depression related to body image concerns
Potential for sexual dysfunction due to hormonal imbalances
Risks associated with continued AAS use, including cardiovascular events, liver damage, and psychiatric disorders.
Late Complications:
Persistence of gynecomastia requiring surgical intervention
Infertility due to long-term hypogonadism
Increased risk of certain cancers (e.g., testicular, prostate) with chronic AAS use
Potential for serious cardiovascular events, thromboembolism, and hepatic dysfunction.
Prevention Strategies:
Comprehensive education and counseling on the risks and dangers of AAS use for adolescents and young adults involved in sports
Promoting healthy and safe alternatives for performance enhancement
Open communication channels between healthcare providers, parents, and young athletes.
Prognosis
Factors Affecting Prognosis:
Duration and dosage of AAS use
Age at initiation of AAS use
Individual hormonal response
Promptness of AAS cessation
Presence of underlying endocrine disorders
Whether surgery is required.
Outcomes:
With prompt cessation of AAS and appropriate management, mild gynecomastia may regress
However, significant or long-standing gynecomastia may require surgical correction
Long-term health consequences of AAS use can be serious and may persist even after drug cessation.
Follow Up:
Regular follow-up with a pediatrician or endocrinologist is essential after AAS cessation to monitor for regression of gynecomastia, assess hormonal status, and screen for other AAS-related health issues
Psychological support should be ongoing as needed.
Key Points
Exam Focus:
Steroid-induced gynecomastia is a consequence of hormonal disruption by anabolic-androgenic steroids
Key is a detailed history of drug use
Discontinuation of AAS is the first-line management
Persistent or severe cases may require surgery.
Clinical Pearls:
Always consider anabolic steroid use in adolescent males presenting with new-onset gynecomastia, especially if they are involved in sports
The diagnosis is often clinical
hormonal investigations may be less helpful if AAS use has stopped
Emphasize the dangers of AAS to patients and their families.
Common Mistakes:
Failing to elicit a history of anabolic steroid use
Attributing gynecomastia solely to physiological pubertal changes without a thorough drug history
Delaying referral for surgical evaluation in cases of persistent or cosmetically concerning gynecomastia
Underestimating the long-term health risks associated with AAS abuse.