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What is Gynecomastia?

Introduction

Gynecomastia is a medical condition characterized by the abnormal enlargement of glandular tissue in the chest of men, resulting in noticeable breast development. Usually, it occurs in both breasts with the presence of a rubbery mass, firm on touch, and at times extending from the nipples to other areas of the breasts causing tenderness and discomfort in some cases.   

A similar problem more commonly in obese males is Pseudogynecomastia, which is the development of a breast-like appearance of the chest caused by the deposition of fat without enlargement of glandular tissue. It can cause not only physical symptoms but also psychological issues ranging from a poor sense of self-esteem to suicidal thoughts in severe cases. 

Classification of the severity of gynecomastia is important for the decision-making process in treatment options.   The classification is based on the extent of breast enlargement and excess skin volume. 

  • Grade 1 gynecomastia is defined by minor breast enlargement with no excess skin
  • Grade 2a gynecomastia is defined by a moderate enlargement of the glandular gland with no significant excess skin 
  • In Grade 2b gynecomastia, excess skin is noticeable on examination, and glandular enlargement is moderate 
  • Grade 3 gynecomastia is characterized by significant breast enlargement with excess skin presentation. 

A publication by Seminars on Plastic Surgery described the histological forms of gynecomastia as florid, fibrous, and intermediate. The fibrous type is considered more common and also more resistant to medical treatment. 

Prevalence of Gynecomastia

There have been several surveys which have studied how common gynecomastia is, with determinant factors looking at age, lifestyle and regional data. This is common in infancy, with about 90% of newborns presenting with temporary gynecomastia due to the high production of estrogen derived from both the mother and the fetus as sources during pregnancy. This condition often resolves without any medical intervention within 3 months after delivery.

Gynecomastia during puberty occurs up to 69% and occurs mostly in younger adult males, aged 10- 12 years, due to estrogen levels that are too high. It that occurs during puberty should resolve within 18 months.  If it doesn’t resolve by 18 months, then the chances that the gynecomastia is permanent is extremely high.

In older males aged 50-80 years, it is estimated to occur in up to 65% of all men in this age range. The data from the studies in this age group is relatively complex because it can be caused by a number of factors including natural aging, age-related increase in estrogen production, decreased testosterone production, and the use of specific medication that has effects on hormone levels.

Causes of Gynecomastia 

Most cases result from a hormonal imbalance in males. Estrogen is the female hormone responsible for the development of feminine traits, such as breast development, while testosterone is responsible for masculine traits with muscular development being an example. 

Excess production of the estrogen in men leads to overstimulation and proliferation of the mammary glands, leading to gynecomastia. Testosterone can correct this abnormal enlargement of the mammary gland by exhibiting a mild inhibitory effect.   However, if there is a hormonal shift in favor of more estrogen then an imbalance of the testosterone to estrogen ratio occurs, which ultimately leads to gynecomastia. 

The known main causes of gynecomastia include:

1. Medication Use

Medication use is responsible for about 25% of cases. Drugs used in the management of other medical conditions can cause an imbalance in hormonal levels as mentioned previously. 

For example, spironolactone (a diuretic) increases the rate of conversion of testosterone to estrogen males and also decreases the level of testosterone production in the testes. Furthermore, spironolactone can also impair testosterone receptors and decrease its effects in males during puberty. 

Drug classes that may reduce testosterone production by the body and cause hormonal imbalances that lead to the gynecomastia in males include:

  • Anti-cancer drugs such as methotrexate, Imatinib, Vincristine, and Vinblastine.
  • Anti-hypertensive drugs such as nifedipine, verapamil, enalapril, digoxin, reserpine and bisoprolol.
  • Psychiatric drugs such as haloperidol, diazepam, fluoxetine, and amitriptyline

Other drugs can include amphetamine, domperidone, ethionamide, griseofulvin, and theophylline.

2. Hyperthyroidism

In hyperthyroidism, the thyroid gland produces an abnormally high hormone level of thyroxine. Thyroxine will increases the activity of aromatase, a hormone responsible for the conversion of testosterone to estrogen. This results in an increased level of estrogen, allowing for the development of glandular tissue in males leading to gynecomastia.

3. Malnutrition

Medical studies reveal that malnutrition is responsible for about 8% of cases. Malnutrition and starvation in men will reduce the level of testosterone in men but the level of  estrogen by the body is not affected, leading to a hormonal imbalance that can cause gynecomastia. Extreme dieting seen in preparing for bodybuilding competitions is a form of malnutrition.

4. Liver disease and Cirrhosis

The development of gynecomastia from cases of liver failure and cirrhosis is a bit more complex. There is an abnormal production of testosterone from the adrenal gland.  This is coupled with an increased conversion to estrogen in patients with liver failure, leading to gynecomastia. 

Other common causes include:

  • Male hypogonadism
  • Testicular tumors
  • Aromatase excess syndrome
  • Unmanaged Type 1 diabetes mellitus

Signs and Symptoms:

Patients with gynecomastia commonly present with other symptoms such as:

  • palpable tender, firm and disc-like mass of tissue formation behind the nipple and around the breast region
  • change in nipple size
  • nipple discharge with a negative breast cancer diagnosis
  • Sexual dysfunction 

A experienced physician can properly diagnose it. Diagnosis criteria include:

  • Increase in size of breast to at least 5cm
  • Presence of palpable and tender lumps
  • other signs of glandular tissue malignancy
  • A laboratory test to determine thyroxine levels, testosterone, and estrogen levels.
  • Image studies, including mammography, computed tomography imaging, and breast ultrasonography.

Treatment

Development of breast in males is a condition that can resolve spontaneously, especially in cases of physiologic gynecomastia seen in puberty. It can be treated with pharmacotherapy, surgery or a combination of both.

Pharmacotherapy

Pharmacotherapy is the use of medications as an approach to medical intervention. The use of pharmacotherapy is indicated in cases of recent onset, an untreatable underlying cause, and severe cases of rapid glandular proliferation. Types of medications used for treatment include:

  • Androgens (Testosterone, Danazol, and Dihydrotestosterone)
  • Anti-estrogens (Tamoxifen and Clomiphene)
  • Aromatase inhibitors (Letrozole and Anastrazole)

Gynecomastia Surgery

Surgical intervention is recommended when the use of medication fails in reversing breast development. Some surgical procedures currently used in the treatment include:

The prognosis improves significantly in cases of early detection because medical treatment can start early since the glandular tissues are not yet replaced by fibrous tissue.   Once the glandular tissue is replaced by fibrous tissue usually within 12-18 months, it becomes permanent and surgery is the only option.

Summary

In summary, Gynecomastia is a common condition in men with various causes. The condition is best treated when discovered early with medications but once fibrous tissue replaces the the glandular tissue, surgical intervention is the only permanent solution.

References 

Xsculpt, What is Gynecomastia?
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