Gynecomastia | Chicago, IL

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.

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What is Gynecomastia?

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 seen at cellular level

Glandular changes seen at cellular levels are different at different stages of this disease. In early stages of gynecomastia (within six months), there is increased epithelial proliferation of the breast ducts, an increase in the supporting stromal as well as the connective tissue that surrounds the ducts. The area surrounding the ducts is marked with signs of inflammation, edema (fluid accumulation) as well as proliferation of fibroblasts in the area. These changes are often accompanied by pain and tenderness in the area. This is often called a “flare-up” and often can be treated with medications.

After 12 months, tough scar-like fibrous tissue develops. There is also an increase in the number of ducts. The inflammation and epithelial proliferation is not much in the later stages of this disease. This is important because the development of that fibrous tissue means that the gynecomastia has become irreversible and surgical intervention is the only option to permanently treat the gynecomastia.

This is why it is very important to be aggressive with gynecomastia treatment within the first 6 months as it is reversible during this time. After 1 year, medical management will fail because of the development of the fibrous tissue within the breast gland.

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:

  • Adrenal glands or the testicles secreting too much estrogen into the blood.
  • Decreased breakdown of estrogen in the body.
  • Exposure to estrogen-like chemicals from the environment.
  • Products consumed in diet that exhibit estrogen-like effects.
  • Use of certain drugs that releases estrogen from sex-hormone binding proteins, and then attaching testosterone to these sites. This increases the levels of free estrogen in the blood and decreases the amount of available testosterone.
  • Increased conversion of estrogen precursors to estroge.
  • Estrogen secreting tumors in the body.
The testosterone to estrogen ratio can get imbalanced in the following conditions:
  • Decreased production of testosterone by the testicles
  • Alterations in the metabolism of testosterone.
  • Defects in the receptors of testosteorne.
  • Increase in removal of testosterone from its receptors in the male breast tissue, thereby losing it’s protective property.
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.

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.

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

Characteristics in men and women are controlled by hormones such as testosterone and estrogen. Testosterone is primarily the male sex hormone whereas estrogen is the female hormone. It then follows that testosterone is responsible for male attributes e.g. body hair, muscle mass, etc., while estrogen is responsible for female characteristics including greater breast size. 

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:
  • Anti-androgens used for the treatment of enlarged prostate, prostate cancer, etc. E.g. finasteride (Proscar, Propecia), flutamide, and spironolactone (Aldactone, Carospir).
  • Anti-anxiety medications – diazepam (Valium)
  • Antibiotics
  • Steroids and androgens
  • Antiretroviral therapy used for the treatment of HIV AIDS can cause Gynecomastia. Efavirenz (Sustiva) is mostly associated with gynecomastia as compared to other HIV medications.
  • Tricyclic antidepressants
  • Ulcer medications e.g. cimetidine (Tagamet HB).
  • Cancer treatment
  • Heart medications – calcium channel blockers and digoxin (Lanoxin)
  • Stomach-emptying medications – e.g. metoclopramide (Reglan)
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:
  • Hypogonadism: Normal testosterone production is disturbed, e.g. Klinefelter syndrome, pituitary insufficiency
  • Aging: The process of aging involves hormonal changes, usually decreasing testosterone, that can cause gynecomastia, particularly in overweight men.
  • Tumors: Tumors involving glands that are involved in hormone production such as the testicles, adrenal glands, or pituitary gland can alter the hormone balance.
  • Diet e.g. dairy products may play a role in gynecomastia development
  • Hyperthyroidism. high levels of the hormone thyroxine can lead to gynecomastia
  • Kidney failure and dialysis. Patients undergoing dialysis experience gynecomastia due to the dysfunction of Leydig cells of the testicles causing low testosterone.
  • Liver failure. Medications for liver disease can produce hormonal imbalance causing gynecomastia. Cirrhosis can cause increased estrogen levels leading to gynecomastia development.
  • Malnutrition. Gynecomastia can occur due to a drop in testosterone when your body is not getting enough nutrition while estrogen levels are unaffected. Breast enlargement can also occur when malnutrition is reversed due to the resulting hormone imbalance.
  • Stress. Adrenal glands secrete excessive amounts of estrogen and cortisol during stress. Furthermore, increased cortisol causes testosterone production to decrease. The combination of increased levels of estrogen and cortisol and lower testosterone, lead to the development of gynecomastia.
  • Aromatase excess syndrome. This is due to a congenital defect, which results in excessive production of estrogen. This condition not only leads to gynecomastia, but also several other physical manifestations such as reduced height due to premature epiphyseal fusion of bones.
  • Ectopic production of hCG. Some tumors like large-cell lung carcinoma, gastric carcinoma, renal cell carcinoma as well as liver tumors (hepatomas) can cause an increased production of hCG, which can result in gynecomastia.

Diagnosis

An examination 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:
  • One-sided
  • Hard
  • Fixed to the skin or muscle
  • Away from the nipple
  • Appears with nipple discharge, enlarged lymph nodes, or skin changes
In such a case, a thorough evaluation is recommended.
The following steps may be required to confirm a diagnosis of true gynecomastia:
  • A detailed medical history including the use of alcohol, medications and other conditions
  • A careful physical examination
  • Mammogram – if breast cancer is suspected. Mammography can distinguish between true gynecomastia from a mass that requires a biopsy to rule out malignancy. It is found to be reasonably accurate in differentiating malignant and benign male breast conditions, considerably decreasing the need for biopsies.
  • Mammogram – if breast cancer is suspected. Mammography can distinguish between true gynecomastia from a mass that requires a biopsy to rule out malignancy. It is found to be reasonably accurate in differentiating malignant and benign male breast conditions, considerably decreasing the need for biopsies.
  • Hormonal testing measuring the levels of testosterone, estradiol, luteinizing hormone, prolactin, and hCG. These results can help point towards pituitary, genital, and extragenital endocrine problems as well as cancers.

Risk Factors

  • Puberty- It is seen that around 50 to 60% of males in puberty experience a bulge in their chest. This can be due to the hormonal changes that the body goes through at this time, altering the testosterone to estrogen ratio. This usually does not persist and often disappears within a year or two.
  • Older age- 24 to 69% of older men have gynecomastia. It can either be due to increased fat deposition, aging, or medication us resulting in gynecomastia
  • Anabolic steroids or androgens used to enhance physical performance
  • Health conditions like liver disorders, kidney disease, thyroid disease, tumors with overactive hormones and genetic diseases such as Klinefelter syndrome

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

  • Is severe
  • Does not resolve on its own
  • Has an onset of fewer than 6 months
  • Does not have an underlying cause that needs treatment first

There are 3 categories of medical treatment for gynecomastia:

  • Administration of androgens (testosterone, dihydrotestosterone, danazol)
  • Estrogen-blocking agents (clomiphene citrate, tamoxifen)
  • Aromatase Inhibitors e.g. letrozole and anastrozole.

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

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:

  • You have long-lasting gynecomastia that does not resolve with medications
  • Gynecomastia prevents you from doing what you enjoy
  • Breast cancer is suspected

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.

Prevention

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:
  • Avoiding the use of certain drugs. Such as anabolic steroids, certain heart or stomach medications, and several antidepressant medications. Ask your physician for alternatives if one of your medications has a gynecomastia causing side effect.
  • Avoiding alcohol. Excessive alcohol intake can lead to estrogen excess and gynecomastia.
  • Treat underlying medical conditions. If particular medical conditions that lead to gynecomastia are treated early, then the risk of gynecomastia decreases.

Conclusion

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.