Gynecomastia

Gynecomastia is the benign and abnormal development of the male mammary gland resulting in breast enlargement. Initially thought to be a rare condition, more recent studies have reported an overall incidence of 40% and over 60% in adolescent boys. The condition can occur physiologically in neonates due to female hormones from the mother, in adolescence and the elderly due to a low or diminished testosterone level, and as an adult due to disease or metabolic disorders.

Gynecomastia is defined clinically by the presence of a firm, rubbery often painful 0.5 cm mass extending concentrically from the nipple-aerolar complex forming a dome shaped appearance to the aerola. In many cases, there is a fatty component that enlarges the entire breast (lipomastia).

The causes of common gynecomastia remain unclear, although it has generally been attributed to an imbalance of sex hormones estrogen and testosterone. Testosterone controls male traits such as muscle mass and body hair while estrogen controls female traits including the development and growth of breasts. Recent studies have demonstrated pathophysiologic mechanisms to involve either a relative excess of estrogens, a decrease in testosterone or a defect in its receptors. Approximately 4-10% of cases are due to prescribed drugs such as Proscar, Aldactone, digoxin, cimetidine, HIV retrovirals, or illegal drug use such as anabolic steroids, marijuana, heroin, and methadone. Several health conditions can cause gynecomastia by affecting the normal balance of hormones. These include:

• Hypogonadism – any condition that interferes with normal testosterone production, such as klinefelter syndrome or pituitary insufficiency.
• Aging – decreasing levels of testosterone during the normal aging process can cause gynecomastia especially in men who are overweight (body mass index > 25).
• Tumors – testicular, adrenal, or pituitary tumors can produce hormones that alter the male-female hormonal balance.
• Hyperthyroidism – increased levels of the thyroid hormone thyroxine have been linked to gynecomastia.
• Kidney disease – 50% of renal dialysis patients have gynecomastia due to hormonal imbalance.
• Cirrhosis and liver failure – hormonal fluctuations related to liver disease from hepatitis or alcoholism as well as medications administered for cirrhosis are associated with gynecomastia.
• Malnutrition and starvation – levels of testosterone decrease while estrogen levels remain constant resulting in a hormonal imbalance.

In most instances, no etiology is discovered and the exact cause is unknown (25%).

Clinical examination is mandatory to correctly diagnose true gynecomastia from pseudogynecomastia (lipomastia) or male breast cancer. The physical examination should involve assessment for glandular or fat predominance, degree of glandular ptosis (skin excess), nodules or masses, and nipple abnormalities or discharge. The history should include age, duration and onset of breast enlargement, symptoms of pain or tenderness, medications and recreational drug use, and the psychological and social effects.

It cannot be underestimated the torment that men with this condition have endured from the inability to exercise to recreational activities shirtless. No laboratory or imaging studies are necessary unless a pathologic cause is identified.

Generally, no treatment is required for physiologic gynecomastia. However, if gynecomastia is caused by an underlying condition, such as malnutrition, kidney disease, cirrhosis, this must be treated prior to the decision to treat gynecomastia. In adolescents with no apparent etiology, observation every three to six months to see if the conditions improves or resolves spontaneously is recommended.

Gynecomastia usually goes away in less than two years. That being said, if the condition does not improve, or causes pain and/or embarrassment, surgery is required. Although medications have been prescribed and attempted, such as clomiphene, tamoxfen, danazol, and testlactone, these have not been approved by the FDA specifically for the treatment of gynecomastia and have had limited success. In fact, if the breast enlargement has been present for more than two years, the current standard of care is surgery.