Male breasts; called Gynecomastia, is a condition that affects men. It commonly occurs during adolescence due to hormonal changes during this age.
Although a physical condition, it can have damaging effects emotionally and be a cause of embarrassment.
During adolescence, the enlarged breasts reduce in size within a few years, generally requiring no treatment.
However, if it occurs in adult life, it mostly becomes permanent and can lead to extremely low self-esteem and a lack of confidence.
Surgery then becomes the last, if not the only option, to solve the problem.
What is Gynecomastia?
Gynecomastia is a condition that results in excessive growth and enlargement of breast tissue in men.
The male breast consists of both ductal and stromal tissue, commonly known as fatty tissue. The excessive growth of glandular tissue results in overgrown breasts in males. Patients with severe gynecomastia may have excess skin leading to drooping of the breast.
Signs and Symptoms of Gynecomastia
Although not a severe condition, Gynecomastia is challenging to deal with. The primary symptom of gynecomastia is swelling of the male breast tissue. The proliferation of the glandular tissue occurs rather than the fat tissue. The breasts might have a firm or rubbery texture.
Gynecomastia commonly occurs bilaterally, but in some cases, can also be unilateral. Even if it occurs bilaterally, one side is generally heavier. If pain occurs, it is mostly not very severe, and only tenderness and sensitivity may be present.
It is, however, essential to differentiate Gynecomastia from male breast cancer. Cancer generally involves one side. It is not necessarily centered surrounding the nipple and can be associated with inversion and discharge from the nipple.
What Causes Gynecomastia?
Gynecomastia is caused by a greater reduction in the effects of testosterone, the male hormone, as compared to estrogen. This occurs due to decreased testosterone levels, or an increase in estrogen level.
Conditions that can disturb the hormone balance include:
Characteristics in men and women are controlled by hormones such as testosterone and estrogen.
Testosterone is primarily the male sex hormone, whereas estrogen is regarded as the female hormone. Testosterone imparts male attributes, e.g., body hair, muscle mass.
Meanwhile, estrogen is responsible for female characteristics, including greater breast size.
Estrogen and testosterone are exclusively female and male hormones. Both women and men produce them in their bodies. However, estrogen is more in quantity in females and vise versa for males.
When the hormonal balance fluctuates, and higher levels of estrogen are present, the result will be conditions such as gynecomastia and prostate cancer.
- 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)
- Steroids and androgens
- Antiretroviral therapy. Medications 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)
Certain substances that affect the brain, such as narcotics, can also lead to enlarged breasts in men. These include
- Amphetamines – for the treatment of attention-deficit or hyperactivity disorder
- Methadone, e.g., Methadose, Dolophine
Physiological or Non-Physiological Ailments
Conditions that disturb the normal balance of hormones can also cause gynecomastia. These are as follows.
- Hypogonadism: Normal testosterone production is disturbed, e.g., Klinefelter syndrome, pituitary insufficiency.
- Aging: Aging involves hormonal changes that can cause gynecomastia, particularly in overweight men.
- Tumors: Tumor glands that are involved in hormone production such as of the testes, adrenal glands or pituitary gland can alter the hormone balance. Diet, e.g., dairy products, also has a role to play in the increase in the growth of breast cancer cells.
- Hyperthyroidism: high levels of the hormone thyroxine.
- Kidney failure: Also associated with Gynecomastia due to disturbed hormones.
- Liver failure: Medications for liver problems and cirrhosis can produce hormonal imbalance causing Gynecomastia.
- Malnutrition: Gynecomastia can occur due to a drop in testosterone when your body is not getting enough nutrition.
How is Gynecomastia Diagnosed?
Palpation shows a tender, firm, mobile mass that is a disc-like stack of tissues. This mass is less hard than in breast cancer and is positioned centrally under the nipple-areola complex.
Breast cancer should be suspected when the palpable mass is:
- Peripheral to the nipple
- Coupled with nipple discharge, lymphadenopathy or changes in the skin
In such a case, a thorough evaluation is recommended. Gynecomastia is the presence of true glandular tissue in male breasts around the nipple. If there’s excess fat tissue deposition, it is called “pseudo- (false) gynecomastia.”
Your doctor might undertake some or all of the following steps to confirm a diagnosis of true gynecomastia.
- A detailed medical history including the use of alcohol, medications and other conditions.
- A careful physical examination.
- According to research, mammography can distinguish between true gynecomastia. It is found to be reasonably accurate in differentiating malignant and benign male breast conditions, considerably decreasing the need for biopsies.
- Laboratory tests to determine the cause of Gynecomastia. These include blood tests to check the function of the kidney, liver, and thyroid.
- Hormonal testing measures the levels of bioavailable testosterone, estradiol, luteinizing hormone, prolactin, and hCG.
Risk Factors for Gynecomastia
Risk factors for gynecomastia are:
- Older age
- Anabolic steroids or androgens used to enhance physical performance.
- Health conditions like liver disorder, kidney disease, thyroid disease, tumors with overactive hormone and Klinefelter syndrome.
- Treatment of breast cancer – Elevated ambient temperature, exhaust emissions, radiation on the chest as well as liver injury are also risk factors for male breast cancer.
Although Gynecomastia does not have any long-term complications, it can inflict emotional damage. Unfavorable appearance leads to a low sense of self-worth.
How is Gynecomastia Managed?
Gynecomastia is not always permanent. It typically advances through numerous phases and then resolves.
In the inflammatory phase, most people feel some breast tenderness. The inflammation then settles after approximately 6 to 12 months, and the scar tissues are left behind. Most cases require no or little treatment.
However, specific treatment will be required if Gynecomastia has occurred due to a pre-existing medical condition like pituitary gland disorder or liver disease (cirrhosis).
If any medications are causing you Gynecomastia, your physician might suggest switching or stopping them altogether.
Pharmacological therapy is possibly helpful if executed early before the glandular tissue is replaced by fibrous tissue.
Medical treatment is given if Gynecomastia.
- Is severe
- Does not resolve one its own
- Has an onset of fewer than 6 months
- Does not have an underlying cause that needs treatment
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, you should discuss it with your doctor.
Despite the medical treatment, if the enlarged breasts remain persistent and also involve pain or discomfort, surgery might be the option.
At present, a multifaceted surgical approach is utilized for gynecomastia correction. Your doctor will determine whether you need intravenous sedation or general anesthesia.
Liposuction is used to remove the fatty component, whereas direct resection is done for the glandular tissue. The skin is repositioned on the underlying structures or otherwise resected.
Your plastic surgeon will determine the correct treatment plan. Choose a board-certified plastic surgeon who is a member of the American Society of Plastic Surgeons (ASPS).
Surgical intervention will be needed in the following conditions.
- If you have long-lasting gynecomastia that does not resolve by medications.
- If Gynecomastia disturbs patient’s daily life activities.
- If breast cancer is suspected.
Subcutaneous Mastectomy is done as the most common procedure. The surgical procedure for male breast reduction includes resection of glandular tissue. It can also be done together with liposuction if there’s a need.
If breast enlargement is primarily because of excess fatty tissue, liposuction may be enough. Skin resection is required for more complex cases.
A minimally invasive surgical approach is available. This is associated with fewer complications and timely recovery.
Generally, less invasive surgical treatment requires a small incision and produces less scarring. Your doctor will conduct a detailed histological examination.
Reduction mammoplasty also called breast reduction surgery is used for
- Severe cases of gynecomastia.
- Long-term gynecomastia.
- Cases in which medicinal therapies have not been successful.
Follow the postoperative instructions as laid down by your doctor. These may include most or all of the following.
- Application of compression garments for at least 4 weeks.
- Resume physical activities within a few days.
- Resume exercise after the first or second after the surgery and increase it gradually over time.
- Return to work 1-2 weeks after the surgery.
A little amount of blood, injection fluid and liquefied fat may leak at the incision sites for about 24 hours. Your surgeon may or may not use drains depending on his experience and your case.
How to Prevent Gynecomastia
Gynecomastia is not entirely preventable. Gynecomastia, due to medical conditions, can only be prevented if the underlying health conditions are avoided.
Gynecomastia caused by hormonal disturbances that occur during puberty aging can typically not be prevented. However, controlling a few factors may decrease their risk. These factors include
- Avoiding the use of certain drugs. For example, androgens, amphetamines, heroin, marijuana, etc.
- Avoiding alcohol. Either drink alcohol in moderation or avoid it altogether.
- Evaluating your medications. If you’re using medicines that cause gynecomastia, consult your doctor if there are alternate options.
Succeeding imaging and laboratory investigation help rule out possible neoplasms and endocrinopathies. The characteristic of gynecomastia is generally benign.
If you are a healthy, adult man with enlarged breasts that have remained persistent and are causing embarrassment, shame, and a poor sense of self-confidence, you are the ideal candidate for breast reduction therapy.
If you are considering breast reduction surgery, take a practical approach, and research the potential side effects. Book an appointment with your healthcare practitioner for a bit of more precise and accurate advice.