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Big Pecs, Little Breasts

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Sometimes the unrelenting pursuit of muscle can have damaging consequences. Here’s what you should know about avoiding and treating unsightly gynecomastia.

By Eric Velazquez, NSCA-CPT | Editor-at-Large

Bodybuilders know the price of physical perfection is pain. They know that rough sets, aching muscle bellies and torturous cravings are all part and parcel of being big and lean. But sometimes this pursuit can have much more damaging effects. The dog-eat-dog nature of the industry can be unforgiving, leading many to take shortcuts via the use of anabolic steroids. And while the side effects are always fodder for debate, there’s a clear and medically proven tie between the use of such drugs and one particular condition.

Gynecomastia, or the unsightly enlargement of male breast tissue, has a wide range of causes but chief among them is steroid use.

“While it’s estimated that somewhere between 40–75% of the male population has some form of this condition, and most of the time the cause is unknown, it generally occurs from an imbalance in hormones where there’s an excess of estrogen and a decrease in androgen,” says Sean Rice, MD, FRCSC, a Toronto-based cosmetic surgeon.

There’s no easy fix or wonder drug that can help mitigate this condition in adults. You may be willing to suffer the daily toil of the gym but unless you’re prepared to endure the physical and psychological fallout of a C-cup existence, it’s time to educate yourself on the pectoral scourge of a generation.

A Guy’s Guide to Gyno

In bodybuilding, building big pecs is part of the assault in the gym, why you spend hours on the bench press. There is, however, a wide difference between big pecs and the more unpleasant appearance of gyno, or “bitch tits.”

“Gynecomastia can occur in one or both breasts,” says Rice. “This enlargement can be due to excess of glandular tissue or excess fatty tissue. In my experience it’s generally a combination of the two.”

How do you separate cases of gyno from plain old, saggy, underdeveloped chest muscles? There are a few telltale markers.

“There can be great variability in the appearance of the breasts,” says Rice. “Those with mild conditions generally have some puffiness just under the areola, the dark area that surrounds the nipple. Those with more extreme cases can have breasts that closely resemble those of a female. The great majority of cases lie somewhere between the two extremes. In my experience those with very large breasts have an overabundance of fatty tissue. In mild cases it almost feels like a golf ball under the nipple — firm and hard. And in these cases, it’s almost always due to an excess of glandular tissue.”

(Bad) Chemical Romance

While it’s true that some cases are just the result of losing the genetic lottery, there’s a high incidence of gynecomastia in the drug-using bodybuilding population. It all has to do with your body’s hormonal responses.

“There’s a long list of drugs that have been associated with the development of gynecomastia,” says Rice. “But steroid use is a common reason for gynecomastia in bodybuilders. Generally what happens is that steroids are androgenic, or male-hormone based. When someone takes steroids, the body senses the abundance of male hormones and then turns down or stops its own natural production. Then when the person stops taking the steroids, it takes the body some time to start producing its own testosterone again and [previously existing low levels of] female hormones take over, causing gynecomastia. For some people, this abundance of breast tissue never goes away.”

Rice says that bodybuilders needn’t worry about the heightened risk for gyno, that is, as long as they’re clean. “Using steroids would increase your odds of developing gynecomastia significantly, particularly if you’re sensitive to female hormones,” he says, adding that said sensitivity is pretty impossible to predict.

Feeling the Fallout

Some guys might think the condition can be hidden, but indeed, even the most minor case can have huge psychological consequences.

“Gynecomastia can have drastic psychological ramifications on some men,” says Rice. “This can be manifested in issues of body image and self-esteem. Some men don’t want to take their shirts off in public places such as the beach. It can also affect sexual relations with one’s partner as the man feels embarrassed by his appearance. This is generally not a condition that men talk about, but I feel that it’s important for men to know these feelings aren’t uncommon amongst a good percentage of their peers.”

Some men will choose to shroud the problem socially by keeping their shirts on whenever possible. If no one else brings it up then it’s not really problematic, they rationalize. But gynecomastia can be a symptom of a problem that goes beyond the kits they keep in their gym bags or the way they look in fitted Ts.

“The first point men need to know is that there are medical conditions that need to be assessed and ruled out by anyone who has this disorder,” says Rice. “Men should first seek out the assistance of their family doctor to make sure there aren’t underlying serious medical conditions such as breast cancer or testicular disease and also assess whether some of the medications they’re taking may be a contributing factor of the disorder.”

If you pass snuff with your doc and neither breast cancer or testicular disease are the cause then, Rice says, it’s time to take a hard look in the mirror.

“Once all medical conditions have been ruled out, then the individual needs to look at his lifestyle,” he says. “If they use steroids or recreational drugs and don’t want to exacerbate the condition, then they need to ask themselves if this is something they should stop.”

Breast-ling with Treatment

It’s wrong to think that actual gyno can be corrected by simple dieting or doing more cardio. While fat can be reduced through proper food intake and regular exercise, gyno is a different case.

“As the fatty component of the breast decreases, even small amounts of glandular breast tissue can be noticeable,” says Rice. “This can be very troublesome to some men as they work hard on their appearance.”

So what’s the answer? Stop taking your anabolic cocktail, if you’re willing and able, seems like an easy first fix, but even then you may not be out of the woods.

“Even in certain cases when these drugs are stopped, existing gynecomastia may not regress,” says Rice. “When all medical causes are ruled out the only treatment left is surgery.”

Going under the knife may not seem like a viable or desirable option — no one likes being cut into and, at the very least, such a procedure will keep you out of the gym for some time. But Rice sees surgery as a safe and effective way to correct the condition.

“Once all medical causes of gynecomastia have been ruled out, the condition is now an aesthetic one,” he says. “If the man decides against surgery, there’s generally no danger in leaving the condition alone.”

So what are the surgical options, and does the severity of the case dictate the approach by the surgeon?

“There are many different surgical treatments for it,” he says. “In my personal experience, the treatment depends on two main factors. First, the ratio between the amount of fatty tissue and breast tissue and second, the amount of excess skin. In my experience, for the majority of men I’ve had in my clinic, we’ve had excellent results using a combination of laser-assisted liposuction and water-assisted liposuction.”

This technique uses a combination of laser energy to melt the more troublesome glandular tissue as well as the fatty breast tissue, and then uses the water to wash it away.

“In cases of solid breast tissue alone, sometimes only a direct, surgical excision of the glandular tissue works,” says Rice. “This is performed by making an incision from the 3 o’clock to the 9 o’clock position around the areola. This way the scar is generally well-hidden. I find the toughest conditions to treat are those men with very large breasts that closely resemble those of a woman. In these cases there’s generally an excess of skin, fat and glandular tissue and in extreme cases a mastectomy procedure may need to be performed.”

After the Surgery

“I treat a lot of men who are hardcore gym users who want to return to pumping weights as soon as possible,” says Rice. “They need to remember they just had surgery and they need to give their body time to heal and recover. The biggest issue with returning to the gym too early is that it may cause bleeding or excessive swelling that can prolong their recovery time and affect the aesthetics of their results.”

So those chest-crushing loads on the bench taken to just below your nipple may not be such a good idea for several months — unless you want to revisit the emotional stress and physical pain caused by having gynecomastia.

The good news is that if you do have to have breast tissue removed, chances are you’re out of the woods, barring extreme weight gain or a return to the use of substances that may have contributed to the gyno in the first place.

“Once the glandular tissue is removed, the recurrence rate for gynecomastia is low,” says Rice. “On the other hand, if someone was to put on excessive weight there’s a chance that’ll increase the fatty component of the breast again.”

So while there are many cases of men who had no choice in the matter, Rice’s warning is clear: If you use anabolic substances, then you may have to cope with the consequences. And that may mean keeping that torso you’re working so hard to show off under wraps … permanently.

Sean Rice, MD, FRCSC, is a Toronto-based cosmetic surgeon. For more information on his scope of practice, visit www.doctorseanrice.com.

Common Forms of Gyno

Find out what category your man boobs fall into with this quick guide

Puffy Nipples

  • Extremely common.
  • Marked by glandular tissue accumulation under and around the areola.
  • In advanced cases, it can spread, forming a dome or cone-shaped appearance of the areola.

AAS Gynecomastia

  • Anabolic-androgenic steroid-induced gynecomastia.
  • Considered to be “pure” gyno because most of the tissue is glandular, not fatty.
  • Only known treatment is excision, or surgical removal, of the tissue.
  • In rare cases, liposuction is also necessary.

Congential Gynecomastia

  • Usually evident in adolescence (12–18 years) for boys.
  • 30–60% of boys suffer from the condition.
  • Up to 30% may live with it for the rest of their lives; in many it will recede with age.
  • Can require intervention to stem social and psychological fallout.

Pseudogynecomastia

  • Very closely resembles common forms of gynecomastia.
  • Marked by enlarged areola but is absent of glandular tissue.
  • May be treatable through diet and exercise.
  • Surgery’s only necessary when lifestyle changes are ruled ineffective.

Bodybuilder Beware

The following is a condensed list of products have been linked to a increased incidence of gynecomastia:

Androstenedione
Ephedrine
Equipoise
Deca-Durabolin
Sustanon
Dianabol
19-Norandrostenedione
Norandrostenediol
Growth Hormone
Insulin
Estrogen
IGF-1

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