WHAT IS Gynecomastia | Chicago, IL

What is Gynecomastia?

The female appearance of breasts in males is called “gynecomastia”. Gynecomastia commonly occurs during adolescence due to hormonal changes during puberty. Although gynecomastia is a physical disease, it is the emotional feelings of embarrassment and lack of self confidence that is the devastating part of this problem.

During adolescence, gynecomastia can reduce in size at the end of puberty generally requiring no treatment. However, if it continues into adult life it is mostly likely permanent and can lead to low self-esteem and a lack of confidence. Surgery then becomes the only option to solve the problem.

GYNECOMASTIA: WHAT IS IT?

Gynecomastia is derived from the Greek words gynec meaning feminine and mastos that means breasts. Literally, the term “male breast” is relative to a condition that results in excessive growth and enlargement of breast tissue in men. 

The male breast consists of both glandular tissue which is composed of ductal and stromal elements, as well as adipocytes or “fatty tissue”. The excessive growth of glandular tissue results in overgrown breasts in males that are unsightly and embarrassing for men. Patients with severe gynecomastia may have excess skin leading to considerable ptosis (or sagging) of the breast.

CHANGES ARE SEEN AT A CELLULAR LEVEL

Gynecomastia is derived from the Greek words gynec meaning feminine and mastos that means breasts. Literally, the term “male breast” is relative to a condition that results in excessive growth and enlargement of breast tissue in men. 

The male breast consists of both glandular tissue which is composed of ductal and stromal elements, as well as adipocytes or “fatty tissue”. The excessive growth of glandular tissue results in overgrown breasts in males that are unsightly and embarrassing for men. Patients with severe gynecomastia may have excess skin leading to considerable ptosis (or sagging) of the breast.

Pathophysiology

Male breast tissue contains receptors of not just androgens but also estrogen. The function of estrogen is to help in the development of glandular structures of the breast, whereas androgens prevent it’s development. Imbalances between the levels of these two hormones act as a key feature in the development of gynecomastia.. However, gynecomastia is a disease that arises from several causes, so there can be different underlying pathologies resulting in this condition.

95% of free circulating testosterone is secreted by the testicles. The testicles are also responsible for 15% of estradiol as well as 5% of estrone on a daily basis. These two compounds are responsible for the estrogenic effects in the body. 

80% of the estrogen in males is produced by the conversion of testosterone, with the help of the enzyme aromatase. This enzyme acts on breast and subcutaneous fat, liver, skin, kidneys as well as on your muscles by converting testosterone into estrogen. Both age and higher levels of body fat percentage are responsible for enhanced activity of the aromatase enzyme because the enzyme is found mainly in fat cells.

The testosterone to estrogen ratio can get imbalanced in the following conditions:

On the other hand, the imbalance can also be due to the following reasons:

Studies have been done that suggested exposure to certain substances in the environment that have weak estrogen effects can induce the condition of gynecomastia. Air pollutants, radiations, organochlorine pesticides, fuels, and plasticizers are some of those chemicals that are known to cause gynecomastia. 

There are other hormones aside from estrogen that may cause gynecomastia. The male breast contains receptors of luteinizing hormone as well as human chorionic gonadotropin hormone. Activation of these receptors can decrease the protective testosterone effect on breast tissue. Another hormone, progesterone, acts with insulin growth factor-1 to cause proliferation of the glands of the breast. Increase in progesterone in males can be seen in conditions such as hyperthyroidism and in liver cirrhosis. Therefore, in patients with these conditions plus gynecomastia it is important to test their progesterone levels.

Signs and Symptoms

Although not a deadly condition, gynecomastia can be difficult to deal with especially if it is also accompanied by pain. The major symptom of gynecomastia is swelling of the male breast tissue. This swelling is the proliferation of the breast gland tissue rather than the fat tissue itself. The breast gland often has a firm or rubbery texture.
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Gynecomastia commonly occurs on both sides but in some cases can also be one-sided. Even if it occurs bilaterally, it isn’t uncommon for one side to be larger than the other.. If pain does occur, it is usually mild with some tenderness and sensitivity.

It is important to differentiate gynecomastia from male breast cancer. Cancer generally involves one side, not necessarily centered surrounding the nipple, and can be associated with skin dimpling, nipple inversion, and nipple discharge. Advanced cases may have enlargement of the lymph nodes of the underarms.

GYNECOMASTIA: COMMON CAUSES

Gynecomastia is caused mainly by a greater reduction in the protective effects of testosterone, as compared to estrogen. This can occur due to blockage of testosterone effects, decreased testosterone levels, or an increase in estrogen levels.

Hormonal Changes

Gynecomastia is caused mainly by a greater reduction in the protective effects of testosterone, as compared to estrogen. This can occur due to blockage of testosterone effects, decreased testosterone levels, or an increase in estrogen levels.

Although estrogen and testosterone are mainly female and male hormones, both hormones are present in both sexes. Estrogen is more in quantity in females and testosterone in males. When the hormones become imbalanced and higher levels of estrogen are present in males as compared to testosterone, the result will be conditions such as gynecomastia.

Medications

Breast enlargement due to hormones can affect males as infants (because of mother’s estrogen), during puberty when the hormonal levels can be imbalanced, and in adulthood at the age of 50 to 69 often as side effects of certain medicines. Medications that can cause gynecomastia includes:

Supplements

Herbal supplements containing phytoestrogen can cause gynecomastia.

Physiological or non-physiological ailments

Conditions that disrupt the testosterone to estrogen ratio can also cause gynecomastia. Some examples of these conditions are:

Diagnosis

An examination done by a certified and trained physician of the male breast in gynecomastia usually reveals a firm, mobile mass that is a disc-like positioned centrally and behind the nipple-areola complex. There is commonly fat surrounding the gland of various amounts.

Gynecomastia is the presence of true glandular tissue in male breasts around the nipple. If there’s an excess of fat tissue deposition without a gland it is called “pseudo- (false) gynecomastia”. In patients with “pseudogynecomastia”, there is an accumulation of subareolar fat and no gland is appreciated. Pseudogynecomastia is more commonly seen in obese men. If the physical examination reveals diffuse breast enlargement without a palpable mass behind the nipple then an additional workup is not needed.

Gynecomastia generally affects both sides, though patients might have asymmetrical or one-sided findings. 

Breast cancer should be suspected when a palpable mass is felt and is:

In such a case, a thorough evaluation is recommended.

The following steps may be required to confirm a diagnosis of true gynecomastia: 

GYNECOMASTIA: RISK FACTORS

Gynecomastia is caused mainly by a greater reduction in the protective effects of testosterone, as compared to estrogen. This can occur due to blockage of testosterone effects, decreased testosterone levels, or an increase in estrogen levels.

Although estrogen and testosterone are mainly female and male hormones, both hormones are present in both sexes. Estrogen is more in quantity in females and testosterone in males. When the hormones become imbalanced and higher levels of estrogen are present in males as compared to testosterone, the result will be conditions such as gynecomastia.

Complications

Gynecomastia does not have any serious or long-term complications, though its emotional component is disturbing. It’s appearance often leads to the development of a low sense of self-worth, poor social behavior, lack of self-confidence, depression, and other psychological issues.

Management of Gynecomastia

Gynecomastia is not always permanent. It typically advances through several phases and then resolves. In the inflammatory phase, most people feel some breast tenderness. The inflammation then settles within approximately 6 to 12 months and sometimes scar tissue is left behind. Many cases require no or little treatment. 

Specific treatment will be required if gynecomastia has occurred due to a medical condition such as a pituitary gland tumor or liver disease. If any medications are causing gynecomastia, your physician may be able to switch to an alternative medication or discontinue it.

Pharmacological therapy is possibly helpful if started early before the glandular tissue is replaced by fibrous tissue.

Medical treatment is attempted if gynecomastia

There are 3 categories of medical treatment for gynecomastia:

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If you have concerns about gynecomastia or have any other risk factor for breast cancer, you should discuss with your primary care doctor or surgeon to make sure that your treatment plan and follow-up program are suitable for your needs. 

Despite maximal medical treatment, if your gynecomastia remains persistent and/or casues you pain or discomfort, surgery might be the best option for permanent treatment.

How to Prevent Gynecomastia

Gynecomastia is not  completely preventable. Gynecomastia due to medical conditions can be prevented if the underlying health conditions are treated. Gynecomastia caused by hormonal imbalances that occur during puberty or aging often cannot be prevented. However, controlling a few factors may decrease their risk:

There are 3 categories of medical treatment for gynecomastia:

GRADES OF GYNECOMASTIA

The surgical options for gynecomastia depends on the severity of the condition. The severity of gynecomastia can be divided into four grades. These grades are based on how much glandular and breast tissue are present (in grams).

Grade I (< 250 grams)

Grade I is characterized by an increased diameter and slight protrusion of the breast gland but limited to the areolar and nipple region. Since this enlargement is due to the growth of the breast gland tissue without any surrounding fatty tissue, glandular excision without liposuction under local anesthesia is the best surgical approach.

Grade II (250–500 grams)

Grade II gynecomastia is characterized by moderate enlargement of the breast tissue along with the nipple and areola placed above the inframammary fold. The best line of treatment in this case is liposuction of the fatty breast tissue with high definition sculpting of the underlying chest muscle followed by surgical excision of the breast gland. The breast gland is removed through an incision that follows the border of the areola to hide the incision.

Grade III (> 500 grams)

Grade III shows a large amount of breast tissue rising off the underlying muscle with the breast gland starting to point downwards.. The nipple and areola is located at the same height up to 1 cm below the inframammary fold in this grade. The surgical procedure for grade III gynecomastia starts with liposuction followed by excision of the gland through a cosmetic incision in the border of the areola. Drains may or may not be required to remove the excessive fluid buildup that can occur after surgery. A skin reduction surgery may be required in the future if skin contraction postoperatively is not adequate.

Grade IV

Grade IV is characterized by a large amount of breast enlargement along with excessive skin. There is severe drooping of the breast. The nipple and areola can be seen more than 1 cm below the inframammary fold. The surgical approach to grade IV gynecomastia that would achieve the best cosmetic result would be a bilateral mastectomy (breast removal) with free nipple grafting. In this procedure, the entire breast fat, gland, and excess skin is excised. The nipple is removed, made smaller, and replaced back to a position on the middle chest. Drains are usually required for about 4-6 days

Gynecomastia surgery

Your surgeon will determine the best treatment plan that will cater to your specific degree of gynecomastia and expectations. An all-around surgical approach is used for gynecomastia correction. We use either local anesthesia or sedation anesthesia depending on the grade of gynecomastia. Liposuction is first used to remove the fatty component, then direct resection is done for the glandular tissue.

Surgical intervention would be recommended if:

Surgical Techniques

There are different surgical techniques used to treat gynecomastia.  A subcutaneous mastectomy is often done by surgeons not trained in liposuction. This procedure for male breast reduction includes resection of both fatty breast and glandular tissue using a periareolar or transareolar approach.  The cosmetic result after a subcutaneous mastectomy is not to be ideal due to the extensive dissection, larger incisions, scar tissue, and asymmetry that often develops.

Tumescent liposuction with gland excision using cosmetic incisions is a minimally invasive surgical approach that is associated with the fewest complications and a faster recovery. The smaller incisions produce less scarring and result in better cosmesis.   If the breast enlargement is primarily because of excess fatty tissue without significant glandular hypertrophy (pseudogynecomastia), then liposuction alone may be enough.

Reduction mammoplasty, better known as “breast reduction surgery” is used for long-term, severe cases of gynecomastia with excessive skin stretching where skin removal along with the breast tissue would be required to obtain a flat, male appearing chest.  The incisions used for reduction mammoplasty tend to be noticeable after surgery and the recovery longer than the conventional types of gynecomastia procedures.

SUMMARY

The assessment of a male suffering from gynecomastia can be complex. A good history and physical examination can prevent the need for an extensive workup. Laboratory tests and specialized imaging can help secure the diagnosi and also rule out possible breast cancer and other tumors. 

If you are suffering with gynecomastia that has caused you embarrassment, shame, and a poor sense of self-confidence, consider surgery as a permanent solution.

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