Gynecomastia

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Gynecomastia

Gynecomastia is the name given to enlargement of the breast tissue in males. It is caused by a relative imbalance between androgens (“male” hormones) and oestrogens (“female” hormones).

Gynecomastia can affect one or both breasts. This condition may be seen in newborns, adolescents and elderly individuals, as a part of physiological changes. It is sometimes, but not always, painful with an associated lump behind the nipple and areola. In rare instances there may be secretion of milk from both nipples.

Generally, gynecomastia does not produce any harmful effects but it may cause undue stress and embarrassment that can impact the active sex life of the affected individual. Gynecomastia can also cause psychological damage or loss of self-esteem.

Causes of Gynecomastia

Physiological

Newborn: Due to the presence of maternal hormones (oestrogen and progesterone) circulating in blood
Adolescence: Due to hormonal changes during puberty that are temporary. Gynecomastia in adolescents usually disappears at the end of puberty.
Increased age and weight: Production of testosterone declines with age while fat cells stimulate the secretion of female hormone oestrogen.

Pathological

There are various pathological causes of gynecomastia and although they may not always be the cause, they must always be excluded before any treatment. Some of the more common conditions that cause gynaecomastia are listed below.

Increased levels of oestrogen due to various conditions such as obesity, hyperthyroidism, malnourishment, adrenal tumours and testicular tumours
Decreased or lack of testosterone production due to conditions such as Klinefelter’s syndrome, viral orchitis and renal failure
Chronic illness including, chronic liver disease, chronic renal failure, hypothyroidism, diabetes, malnutrition, HIV, obesity
Endocrine disorders: hypogonadism
Tumours of the pituitary or adrenal glands, testicle, liver, or secondary tumours.

Medications and other drugs

Certain medications and commonly used drugs cause gynaecomastia as a side effect. Some common medications that have been linked to gynaecomastia include:

Diuretics (thiazide and spironolactone)
Antipsychotics and antidepressants (e.g., diazepam, haloperidol, risperidone and tricyclic antidepressants)
Heart and blood pressure meds (e.g., digoxin, verapamil, nifedipine)
Gastric acid suppressant (e.g., omeprazole, cimetidine)
Alcohol
Opioids
Cannabis
Amphetamines
Performance enhancing drugs: Anabolic steroids hGH, estrogens, hCG, GnRH analogs and 5-α reductase inhibitors, testosterone
Chemotherapy agents
Anti-androgens used in the treatment of prostate cancer

Diagnosis – Gynecomastia

The diagnosis of gynecomastia includes a physical examination of the patient, by the physician. Typically, the breasts, abdomen and testicles are examined.

Occasionally a mammogram, ultrasound and a biopsy of the breast may be needed to confirm the diagnosis. Certain blood tests may also be conducted to evaluate the underlying cause of gynecomastia.

Treatment

Non-Surgical

The non-surgical methods employed for management of gynecomastia include:

In case of drug/medication induced gynecomastia, replacement of the offending drug with an alternative and safer medication
Medical treatment of the underlying disease conditions
Oestrogen antagonist drugs such as clomiphene and tamoxifen can achieve partial or complete reduction in size and tenderness in men with early gynecomastia symptoms

Gynecomastia Surgery

In patients not responding to non-surgical management, surgery is considered as the last option. The surgical methods for management of gynecomastia include:

Gland excision
Liposuction
Skin sculpture
Reduction mammoplasty
Combination of the surgical techniques mentioned above

Surgery is performed under general anaesthesia. Normally the operation takes about 90 minutes, and the breast tissue is removed through an incision on the edge of the areola. Most men go home the day after surgery however some can go home the same day.

The operation does not result in much pain and most patients only need simple pain relief such as paracetamol in the post operative setting.

Loss of sensation to the nipple and the skin around it is common but varies according to the amount of tissue removed.