Gynecomastia as a result of performance-enhancing drugs

Gynecomastia can result from a number of causes and in most cases the cause can be determined by careful history, physical examination and appropriate laboratory evaluation.

In the patient I saw last week the etiology was easy to establish — yet another young man falling prey to the Internet ads for performance-enhancing potions. He had no idea what he was taking but they definitely increased his muscle mass. Until his breasts started to hurt! Back to the Internet to find out what to do, only to learn that there was no easy remedy. Mastectomy, not covered by any insurance in this circumstance, is the only approach that works. Stopping his drugs will likely stop further growth but the breasts will remain. A mammogram is essential to make certain that he does indeed have breast tissue (although it was obvious on examination) and that he does not have a malignancy. He will also need follow-up mammograms because his risk of breast cancer is increased — albeit only slightly.

Performance-enhancing drugs are the most common etiology I have seen in the past year. Persistence of pubertal gynecomastia is also a common etiology. Other causes to consider are cirrhosis, male hypogonadism and testicular tumors, each of which should be apparent on H&P. The literature suggests that a definite etiology cannot be determined in up to 25% of the cases. Rarely, and for reasons not clear to me, this can be seen in hyperthyroidism and in chronic renal failure. The clinical and laboratory evaluation of hormonal function in chronic renal failure can be quite difficult. In the later stages, muscle weakness and wasting is common, as is lethargy. Libido is not high on the list of concerns in such patients. Renal clearance of protein hormones is impaired as is diurnal rhythm and every lab abnormality has to be carefully evaluated in association with everything else going on in the patient.

I blogged recently about the female athlete triad as a consequence of trying to perform beyond inherent capabilities. Performance-enhancing drugs in men with the same goal is just as devastating in both the short and long term. Be careful what you wish for!