What is gynecomastia

Gynecomastia (sometimes referred to as “man boobs”) is a common condition that causes boys’ and men’s breasts to swell and become larger than normal. Gynecomastia is the benign development of the glandular and ductal tissue in the male breast beneath the nipple (subareolar region) ¹⁾. Gynecomastia may occur in one or both breasts. It begins as a small lump beneath the nipple, which may be tender. One breast may be larger than the other. Gynecomastia in males are usually harmless, but may cause embarrassment for some men.

Gynecomastia is typically caused by an imbalance of the action of estrogens (female hormones) and testosterone (male hormones) on the breast tissue. 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 a condition that increases your estrogen level. Several things can upset the hormone balance, including the following. A variety of medications, medical conditions and age-related factors can cause or contribute to this condition. Several medical conditions are associated with gynecomastia such as primary or secondary gonadal failure, androgen resistance syndromes, hyperthyroidism, chronic liver disease, use of some medications such as spironolactone, digoxin, bicalutamide, cimetidine and drugs of abuse such as alcohol and marijuana ²⁾.

True gynecomastia is typically a rubbery or firm mound of tissue that is concentric with the nipple-areolar complex. This is to be distinguished from pseudogynecomastia, which lacks such a disk of tissue, as it is an increase in subareolar fat without enlargement of the breast glandular component. In about half of the cases, the process is clinically bilateral. Gynecomastia is not related to breast cancer, but if you’re worried about breast swelling, see a doctor.

Gynecomastia is most common in teenage boys and older men. Male breast development usually starts in early teenage years as hormones change. Gynecomastia is usually a hard, tender lump just behind the nipples, usually on both sides. It usually disappears during puberty but not always.

Prevalence of asymptomatic gynecomastia is 60%–90% in neonates, 50%–60% in adolescents, and up to 70% in men age 50–69 years ³⁾. Trimodal distribution for asymptomatic gynecomastia is noted (neonatal, pubertal, and in elderly males). Prevalence of symptomatic gynecomastia is markedly lower.

How to know if you have gynecomastia

Signs vary from a small amount of extra tissue around the nipples to more prominent breasts. Gynecomastia can affect one or both breasts.

Sometimes, the breast tissue can be tender or painful, but this isn’t always the case.

If you’re worried about breast tissue growth, see your doctor.

Figure 1. Male gynecomastia – tissue inside the breast glands grows. This can cause female-appearing breasts.

Gynecomastia causes

Gynecomastia can have several causes.

Hormone imbalance

Gynecomastia can be caused by an imbalance between the sex hormones testosterone and estrogen. Estrogen causes breast tissue to grow. While all men produce some estrogen, they usually have much higher levels of testosterone, which stops the estrogen from causing breast tissue to grow.

If the balance of hormones in the body changes, this can cause a man’s breasts to grow. Sometimes, the cause of this imbalance is unknown.

Natural hormone changes

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. However, 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 relatively common. In most cases, the swollen breast tissue will go away without treatment within six months to two years.
• Gynecomastia in men. The prevalence of gynecomastia peaks again between the ages of 50 and 69. At least 1 in 4 men in this age group are affected.

Obesity

Some growth in breast tissue is not due to extra body fat from being overweight, so losing weight or doing more exercise may not improve the condition. However, a common reason for gynecomastia is that being very overweight (obese) can increase levels of estrogen, which can cause breast tissue to grow.

Newborn baby boys

Gynecomastia can affect newborn baby boys, because estrogen passes through the placenta from the mother to the baby. This is temporary and will disappear a few weeks after the baby is born.

Puberty

During puberty, boys’ hormone levels vary. If the level of testosterone drops, estrogen can cause breast tissue to grow. Many teenage boys have some degree of breast enlargement. Gynecomastia at puberty usually clears up as boys get older and their hormone levels become more stable.

Older age

As men get older, they produce less testosterone. Older men also tend to have more body fat, and this can cause more estrogen to be produced. These changes in hormone levels can lead to excess breast tissue growth.

Medications

A number of medications can cause gynecomastia. These include:

• Anti-androgens used to treat prostate enlargement, prostate cancer and some other conditions. Examples include flutamide, finasteride (Proscar, Propecia) and spironolactone (Aldactone).
• Anabolic steroids and androgens.
• AIDS medications. Gynecomastia can develop in HIV-positive men who are receiving a treatment regimen called highly active antiretroviral therapy (HAART). Efavirenz (Sustiva) is more commonly associated with gynecomastia than are other HIV medications.
• Anti-anxiety medications, such as diazepam (Valium).
• Tricyclic antidepressants.
• Antibiotics.
• Ulcer medications, such as cimetidine (Tagamet HB).
• Cancer treatment (chemotherapy).
• Heart medications, such as digoxin (Lanoxin) and calcium channel blockers.
• Gastric motility medications, such as metoclopramide (Reglan).

Street drugs and alcohol

Substances that can cause gynecomastia include:

• Alcohol
• Amphetamines
• Marijuana or cannabis
• Heroin
• Methadone
• Anabolic steroids

Health conditions

Several health conditions can cause gynecomastia by affecting the normal balance of hormones. These include:

• Kidney failure. About half the people being treated with regular hemodialysis experience gynecomastia due to hormonal changes.
• Liver failure and cirrhosis. Hormonal fluctuations related to liver problems as well as medications taken for cirrhosis are associated with gynecomastia.
• Malnutrition and starvation. When your body is deprived of adequate nutrition, testosterone levels drop, but estrogen levels remain constant, causing a hormonal imbalance. Gynecomastia can also occur once normal nutrition resumes.
• Klinefelter’s syndrome (a rare genetic disorder)
• Lumps or infection in the testicles
• Hypogonadism. Any of the conditions that interfere with normal testosterone production, such as Klinefelter’s 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.

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.

Risk factors for gynecomastia

Risk factors for gynecomastia include:

• Adolescence
• Older age
• Use of anabolic steroids or androgens to enhance athletic performance
• Certain health conditions, including liver and kidney disease, thyroid disease, hormonally active tumors, and Klinefelter’s syndrome

Gynecomastia prevention

There are a few factors you can control that may reduce the risk of gynecomastia:

• Don’t use illegal drugs. Examples include steroids and androgens, amphetamines, heroin, and marijuana.
• Avoid alcohol. Don’t drink alcohol, or drink in moderation.
• Review your medications. If you’re taking medication known to cause gynecomastia, ask your doctor if there are other choices.

Gynecomastia symptoms

Signs and symptoms of gynecomastia include:

• Swollen breast gland tissue
• Breast tenderness

Conditions that cause similar symptoms

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:

• Fatty breast tissue. Some men and boys have chest fat that resembles gynecomastia. This is called false gynecomastia (pseudogynecomastia), and it isn’t the same as gynecomastia.
• 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). This is an infection of the breast tissue.

Gynecomastia diagnosis

Your doctor will ask you questions about your medical and drug history 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.

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:

• Computerized tomography (CT) scans
• Magnetic resonance imaging (MRI) scans
• Testicular ultrasounds
• Tissue biopsies

Gynecomastia treatment

Gynecomastia is a benign condition and 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 two years. However, treatment may be necessary if gynecomastia doesn’t improve on its own or if it causes significant pain, tenderness or embarrassment.

If your doctor thinks treatment is needed, there are two types of treatment for gynecomastia:

• surgery to remove the excess breast tissue
• medication to adjust a hormone imbalance

Your doctor can discuss the treatment options with you.

Procedures such as breast reduction surgery are not usually available unless there is a clear medical need for them. For example, if you have had gynecomastia for a long time, it has not responded to other treatments and it is causing you a lot of distress or pain, your doctor may refer you to a plastic surgeon to discuss the possibility of surgery.

Always see your doctor if the area is very painful or there is an obvious lump. Sometimes, the lump may need to be removed.

Gynecomastia medication

Medications used to treat breast cancer and other conditions, such as tamoxifen (Soltamox), raloxifene (Evista) and aromatase inhibitors (Arimidex), 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.

Gynecomastia surgery

If you still have significant bothersome breast enlargement despite initial treatment or observation, your doctor may advise surgery.

However, it is not suitable for men whose large breasts are simply excess fat from being overweight.

Breast reduction surgery is usually carried out under general anesthetic.

Two gynecomastia surgery options are:

• 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 often done endoscopically, meaning only small incisions are used. This less invasive type of surgery involves less recovery time.

There are several techniques the surgeon could use, but generally the operation involves:

• making a cut (incision) around the nipple
• using liposuction to suck out excess fatty tissue
• extending the cuts and repositioning the nipples if there is a lot of tissue to remove

The operation takes about 90 minutes. You usually need to stay in hospital overnight.

Recovery

It can take a few weeks to fully recover from breast reduction surgery. You may need to take a few days off work. It can take up to six months to see the full results.

You will need to wear an elastic garment day and night for a few weeks after the operation.

The length of time you need to keep the dressings on depends on how quickly your wounds heal. After one or two weeks, your stitches will either dissolve or be removed at an outpatient clinic.

You should avoid stretching, strenuous exercise and heavy lifting for up to six weeks after the operation. You can drive again when it’s no longer painful to wear a seatbelt, which may be several weeks.

Side effects to expect

It’s typical after breast reduction surgery to have:

• sore breasts for a few weeks
• scars – these may take several months to fade

Most men are just left with a scar around the nipple. But a large breast reduction operation may also result in a scar that runs down vertically and horizontally across the breast crease.

What could go wrong

Breast reduction surgery can occasionally result in problems, including:

• thick, obvious scarring
• unevenly shaped breasts or nipples
• wound healing problems
• loss of nipple sensation
• bleeding inside the breast tissue (hematoma) – this generally occurs within the first 24 hours after the operation
• developing lumps, bruising or swelling

Also, any type of operation carries a small risk of:

• excessive bleeding
• infection
• an allergic reaction to the anesthetic
• a blood clot forming in the deep veins

The surgeon should explain how likely these risks and complications are, and how they would be treated if they occurred.

What to do if you have problems

Cosmetic surgery can sometimes go wrong, and the results may not be what you expected.

You should contact the clinic where the operation was carried out as soon as possible if you have severe pain or any unexpected symptoms, such as redness of your breast skin, a burning sensation or unusual swelling.

If you have breast reduction surgery and are not happy with the results or think the procedure wasn’t carried out properly, you should take up the matter with your surgeon through the hospital or clinic where you were treated.

Coping and support

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 such as swimming or changing in the locker room 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 to help you cope you can:

• 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 support 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. Websites such as Gynecomastia.org provide a forum for connecting with others who have the condition.