Keywords
anabolic steroid - gynaecomastia - liposuction - bodybuilders
Introduction
The prevalence of gynecomastia has risen in the past few years. Parallelly, there
is growing abuse of anabolic androgenic steroids (AAS) to boost physical strength
and improve appearance as a serious public health problem worldwide. This increased
consumption of AAS points toward the possible cause of the increased prevalence of
gynecomastia.
Accurate estimation of AAS-associated gynecomastia is challenging to calculate and
prone to underestimation. Various reasons of underestimation include low social acceptance
and misdiagnosis. Among these reasons, low social acceptance plays a major role in
the underestimation of AAS consumption in gynecomastia patients.
What seems to us regarding AAS consumption in gynecomastia patients is just like the
tip of iceberg. Steroid (AAS) consumption is rising due to unhealthy lifestyle, in
gym, of bodybuilders. In this study, we aim to find correlation among gynecomastia
patients consuming steroid by calculating before and after surgery.
Accurate estimation is required to assess future healthcare, for prevention and appropriate
treatment. Patient in active sports or bodybuilders presenting with gynecomastia should
raise suspicion of steroid intake and accurate diagnosis should be made so that appropriate
management can be done.[7]
Patient and Methods
Aims and Objectives
Following are the aims and objectives of this article:
To calculate the steroid consumption in gynecomastia patients accurately so that appropriate
treatment can be given.
To find percentage of gynecomastia patients consuming steroid.
To identify the factors indicative of steroid consumption in gynecomastia patient.
To assess response to surgical and nonsurgical management.
Methods
This is a prospective study done in a tertiary care hospital from June 2019 to June
2022. All the gynecomastia patients treated during this period were included in the
study. A proforma was prepared to record preoperative data, intraoperative findings,
and postoperative data. At the time of presentation, patient's demographic data, weight,
height, body mass index (BMI), occupation, AAS usage details, history of other drugs
intake, alcohol abuse, symptoms of underlying systemic illness such as hyperthyroidism,
liver disease, or renal failure, hypogonadism, testicular carcinoma, and any family
history (androgen resistance syndrome, familial aromatase excess, estrogen producing
Sertoli cell tumor) were recorded. Patients, who gave positive history of anabolic
steroid intake, were advised to stop the drug and keep on follow-up. Among the AAS
users who did not get their symptoms resolved in 3 months of stoppage of AAS use were
operated. Rest of the patients with negative history of steroid intake underwent liposuction
and gland removal. At the time of surgery, intraoperative findings including amount
of fat aspirated, gland size, duration of surgery, and drain insertion were noted.
In the postoperative period, patients were examined for complications like surgical
site infection and seroma formation. All the patients were followed up for at least
3 months postoperatively. At 3 months postsurgery, patients with negative history
of AAS use were again enquired about the drug abuse to record any change in history.
Patients who changed their history regarding AAS usage helped in identifying exact
prevalence of steroid consumption in gynecomastia patients. After calculating the
true prevalence of AAS consumption in gynecomastia patients, two groups were prepared,
that is, non-AAS-associated gynecomastia and AAS-associated gynecomastia. Preoperative
and intraoperative data was compared in these two groups.
Results
In this prospective study, a total 74 patients of gynecomastia were treated. Most
common symptom was aesthetic concern (83%) and pain (43%). In preoperative period
out of 74 only 3 patients gave the history of recent steroid intake and they were
treated conservatively. Two of them developed resolution of symptoms with satisfactory
aesthetics. One patient that had partial decrease in breast size was operated later
on. Remaining 71 patients who did not give any positive history were operated. Operative
procedure includes liposuction and gland excision using intra-areolar incision. Age
group varies between 19 and 42 years and 65% patients were between 20 and 30 years
age group. There was no major complication recorded in postoperative period.
After 3 months of surgery, all patients with negative history of steroid intake were
again asked about history; out of 71 patients who refused about steroid intake initially,
26 gave the positive history of steroid intake making the real prevalence of 39.19%
which was much higher than that recorded in preoperative period, 4.05%.
Correlation between Various Parameters and AAS Use ([Table 1)]
Table 1
Comparison of various parameters among AAS users and Non AAS users
|
Parameters
|
AAS user
|
Non-AAS user
|
|
BMI
|
<25
|
12
|
32
|
|
>25
|
17
|
13
|
|
Body habitus
|
Bodybuilders
|
14
|
10
|
|
Non-bodybuilders
|
15
|
35
|
|
Amount of fat aspirated
|
<300
|
16
|
14
|
|
>300
|
13
|
31
|
|
Drain
|
Yes
|
26
|
40
|
|
No
|
3
|
5
|
Abbreviations: AAS, anabolic androgenic steroid; BMI, body mass index.
The AAS users were having higher average BMI (28.3vs. 24.6 kg/m, p = 0.02) and a greater proportion of patients were bodybuilders (48.2 vs. 22.2%, p < 0.01; [Fig. 1]).
Fig. 1 Correlation between body habitus and anabolic androgenic steroid use.
The AAS users had less lipoaspirate fat volume (250 vs. 600 mL, p < 0.05) and had more glandular tissue.
Drain was inserted in more than 80% patients in both the groups. We found no significant
difference in terms of drain insertion between these two groups.
Also, a large number of AAS users were bodybuilders (48.2%) and having higher BMI
(58.6%).
Response to treatment: Three patients were managed conservatively and responded well with complete regression
in two patients and partial in one patient. Surgery was done in 72 patients and no
major complication was observed. There was no recurrence in patients whether they
are steroid abuser or not ([Figs. 2],[3],[4],[5]).
Fig. 2 Preoperative photo of gynecomastia patient.
Fig. 3 Intraoperative picture showing excised gland.
Fig. 4 Immediate postoperative picture of patient.
Fig. 5 Postoperative picture at 3 months.
Discussion
Gynecomastia is a benign condition that involves enlargement of male breast tissue.
There is a rubbery or firm mass extending concentrically and symmetrically from the
nipple.[1]
[2]
[3]
[4] It is the most common breast condition in males that is usually bilateral in nature
but may be unilateral also.[2]
[3]
[4] It can be true or pseudogynecomastia. Pseudogynecomastia involves fat deposition
without glandular proliferation that is more commonly seen in obese men.[3]
[5]
Simon et al in 1973 classified gynecomastia into three grades depending on the amount
of breast tissue and loose skin on top of the breast.[6]
The prevalence of gynecomastia varies between 32 and 65%, due to use of different
methods used for assessment and the analysis of males of different ages and with different
lifestyles, whereas autopsy data suggest a prevalence of 40%.[7] Koch et al[8] in their study done in 2020 in Denmark observed that the prevalence of gynecomastia
has drastically increased in the last two decades due to many reasons especially due
to sex hormone-related imbalances either naturally or by external use.
Goldman et al in their study reported the emerging epidemic of AAS use despite their
well-known adverse effects.[9]
This rise in prevalence of gynecomastia can be attributed to rising trend of increased
consumption of anabolic steroids in young population.
Various etiological factors for gynecomastia can be secondary to drugs, systemic illness
like chronic liver disease, hypothyroidism hypogonadism, testicular or adrenal neoplasia,
androgen resistance syndrome, familial aromatase excess, and estrogen producing Sertoli
cell tumor. Medications account for 25% of the cases of gynecomastia.[5]
[7] In a study by Sreelesh et al,[10] most common etiological factor was found to be hormonal imbalance (47.95%). Majumder[11] in his study demonstrates the role of estrogen in breast development in patients
seeking gender reaffirmation. AAS consumption presents a major cause in the development
of gynecomastia. It is converted into estrogen like compound within body and triggers
breast tissue enlargement. Steroid consumption in gynecomastia patients is prone to
underestimation just like prevalence of human immunodeficiency virus (HIV) and mental
illness because of low social acceptance regarding steroid intake in youngsters. Social
stigma is seen as a major herald in true estimation of few risk factors like steroid
consumption and diseases like HIV and mental illness. In this study, we found that
a large proportion of patients (26 out of 71) change their history regarding the steroid
consumption in postoperative period. Reason for this high acceptance is attributed
to the confidence/repo developed with doctor due to achievement of desired results
by patient.
So, young patients who are in body building profession or having the high BMI are
more likely to have the history of steroid abuse to meet their demands. Also, intraoperative
finding of less lipoaspirate fat is also associated with steroid consumption in gynecomastia
patient.
Treatment of gynecomastia involves nonsurgical and surgical methods. Nonsurgical management
involves the discontinuation of the culprit agent or hormonal therapy depending on
the etiology. Surgery is indicated in long-standing gynecomastia or patients who are
nonresponder to medical management. Gynecomastia associated with steroid is likely
to resolve spontaneously on withdrawal of the culprit drug. If it persists for more
than 1 year, instances of complete regression are low, due to the predominance of
dense fibrous tissue.[2]
[12]
de Luis[13] et al in their study in Spain concluded that there is high prevalence of gynecomastia
in the people having the history of anabolic steroid consumption and also observed
that there was high remission rate of gynecomastia in the patients who stop the steroid
consumption and start taking tamoxifen. In another study, Kanakis[14] et al recommended watchful waiting and discontinuation of substance in patients
with any underlying pathology associated to gynaecomastia. Surgery is recommended
for patients with long-term gynecomastia.
In our study, AAS-associated gynecomastia shows resolution of symptoms with mere stoppage
of drug intake, while few failed to regress completely and required surgery. AAS-associated
gynecomastia can resolve spontaneously on stoppage of the drugs. Surgery is not always
indicated in AAS-associated gynecomastia. It is done in patients who fail to respond
to wait and watch. Also, surgery in AAS-associated gynecomastia involves intraoperatively
extensive dissection and meticulous hemostasis as these patients are having more of
the glandular component.
Limitations
This study does not include any laboratory testing to assess the steroid intake in
patients.
Conclusion
The real prevalence of AAS-associated gynecomastia is much higher than the apparent
one. Patients with high BMI, athletic body, and history of recent weight gain should
raise the suspicion of anabolic steroid intake. These patients can be kept under observation
with suppression of anabolic steroid intake. Surgery is not always indicated in AAS-associated
gynecomastia. If gynecomastia persisted, surgery necessitates and it involves meticulous
intraoperative hemostasis and careful glandular excision to minimize recurrence and
achieve low complication rates.
