What is gynecomastia?

In the vast majority of cases, gynecomastia is not a serious problem. However, it may be psychologically difficult to cope with. Apart from affecting self-confidence and causing embarrassment, some men and boys may also experience pain in their breasts.

A study carried out at Boston Children’s Hospital and reported in the journal Plastic and Reconstructive Surgery found that gynecomastia negatively affects self-esteem as well as other areas of emotional health in adolescent boys.

Team leader, Dr. Brian I. Labow wrote “Merely having gynecomastia was sufficient to cause significant deficits in general health, social functioning,mental health, self-esteem, and eating behaviors and attitudes compared with controls.”

An adolescent male with gynecomastia
corrected by surgery

The picture on the right is an example of adolescent gynecomastia that was corrected by surgery protocol, devised and performed by Dr. Mordcai Blau, Chief Emeritus of Plastic Surgery in the Westchester Ambulatory Surgical Center, White Plains, New York.

Most males who develop gynecomastia find that it goes away on its own. A study published in the journal Pediatrics reported that in over 75% of cases of pubertal gynecomastia, signs and symptoms resolve within one year¹.

If gynecomastia persists, there are treatments available.

Gynecomastia is not caused by extra fat from being overweight. It is caused by extra breast tissue. So, doing exercise or losing weight will not get rid of it. There are other conditions, such as pseudogynecomastia, in which fat builds up in the breasts, and are sometimes associated with being overweight or obese.

What are the signs and symptoms of gynecomastia?

Signs and symptoms may occur in one or both breasts.

• The breast gland tissue swells.
• The breast becomes tender.
• The diameter of the areola increases, or the chest tissue becomes asymmetrical. The areola is the ring of pigmented skin surrounding the nipple.

You should see the doctor if there is unusual and persistent swelling, tenderness, pain, and/or nipple discharge.

What are the causes of gynecomastia?

Gynecomastia may have several causes.

• A Hormone imbalance between the sex hormones testosterone and estrogen. Estrogen, the “female” hormone, makes breast tissue grow, while testosterone, the “male” hormone, has inhibitory effects at the breast tissue level (it stops estrogen from making breast tissue grow).As mentioned above, gynecomastia is caused by extra breast tissue, not fat accumulation.

  Over 50% of newborn males are born with enlarged breasts. This is because they have high levels of estrogen, which came from the mother. As the estrogen levels return to normal, the swelling goes away, usually within a few weeks.

  Swollen breasts become more common among males as they get reach middle and old age. This is because older men produce less testosterone. Older males are usually fatter than young men, which results in more estrogen being produced. A study carried out at the New Jersey Medical School and published in the Journal of Clinical Endocrinology and Metabolism² showed that overweight men produce more estrogen.

• Kidney failure

• Alcohol abuse – most medical and family practice websites mention that alcohol abuse raises the risk of enlarged male breasts.

• Liver disease

• Radiation treatmen of the testicles

• Klinefelter’s syndrome

• Cannabis/marijuana and other illegal drugs – several studies have looked into whether there might be a link between cannabis use and gynecomastia. Some have found an association while others have not detected a significant link. The majority of medical and health websites mention a link. The Mayo Clinic³ says there is a link between marijuana, amphetamines, methadone, heroin and gynecomastia risk.

• Infections or lumps in the testicles

• Some thyroid disorders

• Medications – several medications can cause the breasts in men to enlarge, including:- some antibiotics
  – some ulcer medications
  – chemotherapy
  – tea tree oil and lavender products, according to patient.co.uk⁴
  – tricyclic antidepressants
  – diazepam (Valium) and some other drugs for treating anxiety
  – some HIV medications, including efavirenz (Sustiva)
  – anabolic steroids
  – anti-androgens, commonly prescribed for patients with cancer or prostate enlargement
  – some heart drugs, including calcium channel blockers and digoxin (Lanoxin)

An article published in the journal Expert Opinion on Drug Safety⁵ reported on a study that examined all the scientific reviews on cases of possible/probable drug-induced gynecomastia since 1940 and concluded “Most of the reported drug-gynecomastia associations were based on poor quality evidence. The drugs definitely associated with the onset of gynecomastia are spironolactone, cimetidine, ketoconazole, hGH, estrogens, hCG, anti-androgens, GnRH analogs and 5-α reductase inhibitors. Medications probably associated with gynecomastia include risperidone, verapamil, nifedipine, omeprazole, alkylating agents, HIV medications (efavirenz), anabolic steroids, alcohol and opioids.”

Diagnosing gynecomastia

The doctor will ask the patient questions regarding symptoms, his medical and drug history, and possibly family history.

The physician will examine the breast tissue, as well as the genitals and abdomen.

If the doctor determines that it is caused by a hormone imbalance, as may be the case during puberty, and the gynecomastia appears typical for a teenage boy, the patient will be told not to worry and that it will all go away within about a year.

If the breast lump is abnormally large, tender, one-sided, or fixed and hard, further investigation will probably be required, including a biopsy. If the man has an unusual lump in one breast only, the doctor needs to know whether there is a family history of breast cancer.

The doctor will try to rule out other causes of male breast enlargement, such as:

• A cyst
• Lipoma (benign tumor composed of body fat)
• Mastitis – inflammation of breast tissue
• Breast cancer
• Pseudogynecomastia – this is caused by fat, while gynecomastia is caused by breast tissue
• Hematoma – a solid swelling of clotted blood
• Metastasis – cancer that originated elsewhere in the body and has spread to the breast
• Fat necrosis – a lump that forms as a result of damage to fatty breast tissue
• Hamartoma – a benign tumor-like growth

The doctor may order some blood tests and a mammogram. Depending on the results, further tests may be ordered, including:

• X-rays of the chest
• CT (computerized tomography) scan
• MRI (magnetic resonance imaging scan)
• Ultrasound scan of the testicles
• Tissue biopsy – a sample of cells or tissue is removed from the target area and is examined under a microscope by a pathologist

What are the treatment options for gynecomastia?

If the doctor finds an underlying condition that is causing the gynecomastia, it needs to be treated.

If the gynecomastia appears to be caused by a medication, the doctor may recommend switching to a different drug, discontinuing it, or carrying on. If the course of medication is not long-term, the condition will be temporary.

In the majority of cases, gynecomastia resolves on its own without any treatment. It is important that the doctor explains this to the patient.

Teenagers with no apparent cause of the condition will be advised to come back periodically to see whether it improves on its own – it usually does.

If the condition does not resolve on its own within a couple of years, causes embarrassment, pain and/or tenderness, treatment may be necessary.

Treatment for gynecomastia is rare, and may include medications such as hormone therapy to block the effects of estrogens, or breast reduction surgery.

Medications for the treatment gynecomastia

• Tamoxifen – a drug that blocks the action of the female hormone estrogen in the body. It is used for treating and preventing breast cancer, but is also effective in reducing the symptoms of breast pain and breast enlargement in men.Researchers at the university of California at Irvine carried out a study comparing tamoxifen with placebo for men with gynecomastia. They reported in the journal Metabolism⁶ that the majority of the participants (70%) on Tamoxifen experienced significant decrease in the size of their gynecomastia. All the patients with painful gynecomastia experienced symptomatic relief.

  The study authors concluded “…antiestrogenic treatment with tamoxifen may represent a safe and effective mode of treatment for selected cases of cosmetically disturbing or painful gynecomastia.”

• Aromatase inhibitors – a class of drugs used for treating breast cancer and ovarian cancer in post-menopausal women. These medications may also be used off-label to prevent or treat gynecomastia in males.A small study published in Hormone Research in Paediatrics⁷ on adolescent boys found that most of them experienced decreased breast size after receiving the selective aromatase inhibitor anastrozole. Since the aim of the treatment was the total disappearance of excess breast tissue, the researchers explained that anastrozole was of limited effect. Anastrozole may be of benefit for the treatment of tenderness, and also for those in whom surgery is particularly risky.

  The study authors added “However, as spontaneous disappearance of pubertal gynecomastia is common, further double-blinded, placebo-controlled trials are necessary before a definite conclusion can be drawn about the effectiveness and the side effects of this therapy.”

• Testosterone replacement is sometimes used for the treatment of gynecomastia in elderly men whose testosterone levels are low. This treatment does not work if the patient’s testosterone level is normal.

Surgery for gynecomastia

The breast consists of two main components:

• Glandular tissue – which is firm and dense.
• Fatty tissue – which is soft.

The ratio of glandular to fatty tissue varies from patient to patient. In individuals with gynecomastia there may be too much of both types of tissue.

22-year-old patient with gynecomastia,
before and after surgery

Liposuction – if there is too much fatty tissue, liposuction can be used to suck it out. A 3-4mm incision is made, through which a small tube is inserted.

Excision – this means cutting out tissue with a scalpel. If the breast enlargement is caused by excess glandular tissue, it will need to be excised. This procedure will leave a scar, typically around the edge of the nipple. If a major reduction in tissue and skin is required, the surgeon will need to make a larger incision, resulting in a bigger scar.

The surgeon may recommend both – excision in conjunction with liposuction.

According to The British Association of Aesthetic Plastic Surgeons⁸ (BAAPS), most gynecomastia operations last about 90 minutes and are performed under general anesthesia – in some cases local anesthesia with sedation is administered.

After surgery the chest will be bruised and swollen, making it hard to determine how effective the operation has been. The doctor will probably instruct the patient to wear an elastic pressure garment continuously for a couple of weeks to help reduce swelling.

According to BAAPS, it takes typically about six weeks before the patient is able to return to completely normal activities.

Complications from surgery are rare, and may include not enough removal of breast tissue, the chest having an uneven contour, or reduced sensation of the nipple(s). Surgery involving excision, rather than liposuction, carries the risk of a blood clot forming, which may need to be drained.

Written by Christian Nordqvist