Gynecomastia is triggered by a decrease in the amount of the hormone testosterone compared with estrogen. The cause of this decrease can be conditions that block the effects of or reduce testosterone or by a condition that increases your estrogen level. Several things can upset the hormone balance, including:
Natural hormone changes (The testosterone-estrogen balance)
– The hormones testosterone and estrogen control the development and maintenance of sex characteristics in both men and women. Testosterone controls male traits such as muscle mass and body hair; estrogen controls female traits including the growth of breasts.
– Most people think of estrogen as an exclusively female hormone, but men also produce it — though normally in small quantities. Estrogen helps regulate bone density, sperm production and mood. But male estrogen levels that are too high or are out of balance with testosterone levels can cause gynecomastia.
Gynecomastia in infants
– More than half of male infants are born with enlarged breasts due to the effects of their mother’s estrogen. Generally the swollen breast tissue goes away within two to three weeks after birth.
Gynecomastia during puberty
– Gynecomastia caused by hormone changes during puberty is common. In most cases, the swollen breast tissue will go away without treatment within six months to two or three years.
Gynecomastia in men
– The prevalence of gynecomastia peaks again between the ages of 50 and 80. At least one-quarter of men are affected during this time.
A number of medications can cause gynecomastia. These include certain:
– Anti-androgens used to treat prostate enlargement or cancer and some other conditions. Examples include cyproterone, flutamide, finasteride and spironolactone.
– AIDS medications. Gynecomastia can develop in HIV-positive men who are receiving a treatment regimen called highly active antiretroviral therapy (HAART). Efavirenz is more commonly associated with gynecomastia than are other HIV medications.
– Anti-anxiety medications, such as diazepam (Valium).
– Tricyclic antidepressants.
– Ulcer medications, such as cimetidine.
– Cancer treatment (chemotherapy).
– Heart medications, such as digitalis and calcium channel blockers.
– Street drugs and alcohol
Substances that can cause gynecomastia include: – Anabolic steroids and androgens
Certain health conditions
Several health conditions can cause gynecomastia by affecting the normal balance of hormones. These include:
– Hypogonadism. Any of the conditions that interfere with normal testosterone production, such as >Klinefelter syndrome or pituitary insufficiency, can be associated with gynecomastia. Aging. Hormone changes that occur with normal aging can cause gynecomastia, especially in men who are overweight.
– Tumors. Some tumors, such as those involving the testes, adrenal glands or pituitary gland, can produce hormones that alter the male-female hormone balance.
– Hyperthyroidism. In this condition, the thyroid gland produces too much of the hormone thyroxine.
– Kidney failure.
– Liver failure and cirrhosis
– Malnutrition and starvation.
– Herbal products Plant oils, such as tea tree or lavender, used in shampoos, soaps or lotions, have been associated with gynecomastia. This is probably due to their weak estrogenic activity.
In about 25 percent of cases, the cause of gynecomastia is never found.
What are the Symptoms
Signs and symptoms of gynecomastia include:
– Swollen breast gland tissue – Breast tenderness Prognosis
Gynecomastia is not physically harmful, but in some cases can be an indicator of other more serious underlying conditions. Growing glandular tissue, typically from some form of hormonal stimulation, is often tender or painful. Furthermore, it can frequently present social and psychological difficulties for the sufferer. Weight loss can alter the condition in cases where it is triggered by obesity, but losing weight will not reduce the glandular component and patients cannot target areas for weight loss.
Massive weight loss can result in sagging tissues about the chest, chest ptosis. The size and geometry of the fibro-glandular tissue present is unique to each patient. This results in a range of physically apparent aesthetic deformities, for which, classification systems have been devised
There are multiple manifestations of gynecomastia. The following types have the same basic features of gynecomastia in common, namely, hypertrophy of the male breast glandular tissue, but vary in size, shape, and the extent to which they are intermixed with adipose and fibrous tissue.
Puffy Nipples is among the most common forms of gynecomastia. This glandular tissue accumulation is concentrated under and typically confined to the areola, or can be slightly extended outside the areola forming a dome shaped appearance to the areola.
In bodybuilders this may be a result of the use of anabolic steroids. Due to their low level of body fat, bodybuilders and other athletes are sometimes afflicted with gynecomastia in its purest form. Gynecomastia in lean men is usually only a breast tissue gland with little to no adipose tissue. Proper treatment of pure gynecomastia can be done only by excision of the breast tissue, which in the case of bodybuilders is by itself sufficient to achieve a flat nipple-areola complex. Liposuction is only rarely necessary.
Congenital or Hereditary Gynecomastia is typically evident by the ages of 9 to 14 in boys. Thirty percent to sixty percent of young boys suffer from large male breasts. As many as thirty percent may live with enlarged male breasts for the rest of their lives, but in other cases the gynecomastia will recede with age. However, severe forms of adolescent gynecomastia may require an intervention, in consultation with the patient, the parents, and child development professionals.
The most common form of gynecomastia. Gynecomastia in most adults is composed of glandular tissue but may contain varying quantities of adipose and fibrous tissue.
Pseudogynecomastia is composed not of glandular tissue, but of adipose tissue. It looks much like real gynecomastia but requires different treatment. Exercise and diet may be effective in combating pseudogynecomastia. Only if this regimen is unsuccessful should surgery be considered. This is generally the only type of gynecomastia which can be improved with liposuction, but excision may be indicated in some cases. This is also known as “false Gynecomastia” and is often attributed by obesity whereby insulin interacts with an excess of sugars or certain carbohydrates, namely those of which that have been processed.
Severe gynecomastia is characterized by excess and/or saggy skin and severely enlarged breasts. This is itself determined in part by age, as older persons suffering from gynecomastia tend to have less skin elasticity and thus will have a greater abundance of excess skin related to gynecomastia. Experienced cosmetic surgeons will perform as much of the surgical treatment of severe gynecomastia as possible through an aereolar incision so as to avoid extensive scarring. However, some scarring may be unavoidable when treating extreme cases of gynecomastia.
What are tests for Gynecomastia?
Your doctor will ask you questions about your medical history, what medications you’re taking and what health conditions run in your family. The doctor will also do a physical examination that may include careful evaluation of your breast tissue, abdomen and genitals.
Your doctor will want to be sure your breast swelling is actually gynecomastia and not another condition. Other conditions that can cause similar symptoms include:
– Breast cancer. This is uncommon in men, but can occur. Enlargement of one breast or the presence of a firm nodule raises the concern for male breast cancer.
– A breast abscess (mastitis).
Initial tests to determine the cause of your gynecomastia may include:
– Blood tests – Mammograms
You may need further testing depending on your initial test results, including:
– Chest X-rays
– Computerized tomography (CT) scans
– Magnetic resonance imaging (MRI) scans
– Testicular ultrasounds
– Tissue biopsies
Coping and Support/Psychological Issues
Gynecomastia can be emotionally devastating. Feelings of shame, embarrassment and humiliation are common. One does not feel masculine in a society where masculinity is exalted. Self-hate threads itself through all aspects of the individual’s life, creating an insidious web of powerlessness. A man or boy with gynecomastia struggles with anxiety over such simple acts as taking off his shirt at the beach.
For many men, the best solution is surgery. That accomplishes step one of the healing. Step two is psychological redress. From childhood taunting to a lifetime of hating his chest, the hurt feelings will not go away with the fact of breast reduction alone.
Men who have developed gynecomastia later in life from steroid abuse or some other cause may have little to no psychological distress. However, for some in this situation, it can leave them feeling out of control of their body or emasculated in some matter. Hopefully, corrective surgery will resolve these feelings, for some it will not and therapy will needed to relieve the distress.
It is important to recognize the scars on the inside. This is difficult work because it means coming to terms with one’s body and past. Acknowledging the pain, moving into a new relationship with one’;s body and changing how he thinks the world sees him is the key to healing and freedom.
Men often have a very difficult time talking about their breasts to anyone, but it is the first step toward relief. Realizing that they are not alone is a powerful antidote for the shame and a beginning toward healing.
For a man, enlarged breasts can be stressful and embarrassing. Gynecomastia can be difficult to hide and a challenge to romantic relationships. During puberty, gynecomastia can make boys a target for teasing from peers. It can make activities like swimming or changing for gym class traumatic. Whatever your age, you may feel like your body has betrayed you and you may feel unhappy with yourself. These feelings are normal, but there are a few things you can do to help you cope:
Get counseling.Talk therapy can help you avoid anxiety and depression caused by gynecomastia. It can also help you communicate with your partner or family members so that they understand what you’re going through.
Reach out to your family and friends.You may feel embarrassed to talk about gynecomastia with the people you care about. But explaining your situation and asking for help will likely strengthen your relationships and reduce stress.
Connect with others who have gynecomastia.Talking with men who have had a similar experience can help you cope. Web sites such as Gynecomastia.org provide a forum for connecting with others who have the condition.
There are a few factors you can control that may reduce the risk of gynecomastia, including:
– Don’t use illicit drugs. Examples include steroids and androgens, amphetamines, heroin, and marijuana.
– Avoid alcohol. Don’t drink, or drink very little.
– Review your medications. If you’;re taking medication known to cause gynecomastia, ask your doctor if there are other choices.
Treatments and Drugs for Gynecomastia
Most cases of gynecomastia regress over time without treatment. However, if gynecomastia is caused by an underlying condition, such as hypogonadism, malnutrition or cirrhosis, that condition may need treatment. If you’re taking medications that can cause gynecomastia, your doctor may recommend stopping them or substituting another medication.
In adolescents with no apparent cause of gynecomastia, the doctor may recommend periodic re-evaluations every three to six months to see if the condition improves on its own. Gynecomastia often goes away without treatment in less than three years. However, treatment may be necessary if gynecomastia doesn’t improve on its own, or if it causes significant pain, tenderness or embarrassment.
Medications used to treat breast cancer and other conditions, such as tamoxifen and raloxifene, may be helpful for some men with gynecomastia. Although these medications are approved by the Food and Drug Administration, they have not been approved specifically for this use.
Surgery to remove excess breast tissue
If you still have significant bothersome breast enlargement despite initial treatment or observation, your doctor may advise surgery. Two types of surgery are used to treat gynecomastia:
– Liposuction. This surgery removes breast fat, but not the breast gland tissue itself.
– Mastectomy. This type of surgery removes the breast gland tissue. The surgery is done on an endoscopic basis, meaning only small incisions are used. This less invasive type of surgery involves less recovery time.
In cases of obesity, weight loss can alter the gynecomastic condition, but for many it will not eliminate it. For all other causes, surgery is the only known physical remedy. Once the physical encumbrance is lifted, psychological scars still need to be addressed. One must come to terms with one’s body, accept it, and heal the wounds from the past.
Treating the underlying cause of the gynecomastia may lead to improvement in the condition. Patients should talk with their doctor about revising any medications, such as risperdal, that are found to be causing gynecomastia; often, an alternative medication can be found that avoids gynecomastia side-effects, while still treating the primary condition for which the original medication was found not to be suitable due to causing gynecomastia side-effects (e.g., in place of taking spironolactone the alternative eplerenone can be used). Selective estrogen receptor modulator medications, such as tamoxifen and clomiphene, or androgens (typically testosterone) or aromatase inhibitors such as Letrozole are medical treatment options, although they are not universally approved for the treatment of gynecomastia.
Endocrinological attention may help during the first 2–3 years. After that window, however, the breast tissue tends to remain and harden, leaving surgery (either liposuction, gland excision, skin sculpture, reduction mammoplasty, or a combination of these surgical techniques) the only treatment option.
Many American insurance companies deny coverage for surgery for gynecomastia treatment on the grounds that it is a cosmetic procedure. Radiation therapy is sometimes used to prevent gynecomastia in patients with prostate cancer prior to estrogen therapy. Compression garments can camouflage chest deformity and stabilize bouncing tissue bringing emotional relief to some. There are also those who choose to live with the condition.
The following procedures should be discussed with an experienced Board Certified Plastic Surgeon who will help you choose the technique best suited for each individual.
– For pseudogynecomastia: Men Liposuction or lipo sculpture of the of the pseudogynecomastia is used to remove the fatty tissue by suction using a negative pressure source (pump or syringe). Usually performed with tumescent method to decrease bleeding.
– For true Gynecomastia: Excision of the male breast tissue. This real gynecomastia tissue cannot be suctioned and has to be removed by surgical excision – male breast reduction. Usually performed through the lower part of the aerola (between the pigmented part and the skin). When done properly, this usually leaves inconspicuous scars (athletes and body builders cannot afford prominent scars).
– For a combined pseudogynecomastia (fatty tissue) and true gynecomastia (breast tissue) The treatment of choice is a combination of surgical excision and liposuction for men (for better breast contour).
For treatment of severe Gynecomastia. For easy understanding, we will compare the male breast size to the female breast size (A, B, C, D, DD, etc.) and as such, there are a few modalities of treatment available:
– Periaureolar (incision around the nipple aureola complex) male breast reduction: this procedure is meant for mild to moderate reductions. This can be compared to size A and B in women. – Classical breast reduction with superior or inferior flaps: this is for larger breasts (C, D) and leaves an inverted xTx incision and periaurieolar incision. It is used very rarely.
– Vertical incision breast reduction that results in a vertical subareolar scar (not horizontal scar) in large breasts: this is new and exciting alternative.