Gynecomastia

What is Gynecomastia?

Gynecomastia describes the enlargement of the male breast gland. It must be distinguished from lipomastia, where only fats are stored in the man's breast. In gynecomastia, on the other hand, mammary gland tissue is formed in men, whereby this enlargement can occur on one or both sides.

Although the enlargement of the mammary glands is benign in most cases, it can also lead to breast cancer in men, especially if the breast is enlarged on one side. An ultrasound examination, in combination with mammography, should, therefore, be carried out even in cases of slight doubt.

Frequency and Degree of Breast Enlargement in Men

The pathogenesis of gynecomastia is not comprehensible in half of all those affected. While more than 90 percent of all newborns have physiological gynecomastia, this probability drops to around 50 to 70 percent at puberty, but pubertal gynecomastia does not necessarily have a pathological value. Approximately half of all men suffer from a "male breast" at some point in their lives.

To be able to classify the stages of gynecomastia, they are divided into three grades according to Deutinger:

• Grade I: A small inconspicuous male breast manifests.
• Grade II: The male breast resembles a young girl's breast.
• Grade III: The gynecomastia is developed and has a fold under the breast

Causes: What Causes the Development of Gynecomastia?

Gynecomastia can develop in a physiological and non-physiological way. The physiological male breast defines a non-pathological change.

Physiological: Gynecomastia is reasonable if it occurs in infancy, during puberty, or at an older age. Gynecomastia occurs purely on a hormonal level; it can also be observed, for example, in cases of severe overweight. In this case, however, only fatty tissue is stored so that it is not real gynecomastia and is referred to as pseudogynecomastia or lipomastia.

Non-physiological: Here, the enlargement of the male breast is caused by a pathological change caused by medication or a disturbance in the male’s hormone balance.

Medicinal Gynecomastia

Specific drugs are an essential factor in the development of gynecomastia:

• Finasteride: A prostate drug that is also used as a hair restorer
• Anabolic steroids: Drug used in bodybuilding for muscle building (bodybuilders abbreviate it as "gyno")
• Spironolactone: A diuretic drug for the kidneys
• Gastric acid tablets: Cimetidine, Omeprazole, Pantoprazole, Ranitidine
• Hormonal drugs: Estrogens and antiandrogens are increasingly used in gender reassignment surgery
• Heart disease products: rather rare, digitalis, B-blockers, calcium antagonists
• Alcohol and drug abuse can also trigger pathological gynecomastia.

Hormone Disorders as a Cause of Enlarged Male Breasts

If there is an excess of the female sex hormone estrogen or a deficiency of the male sex hormone testosterone, gynecomastia can develop. The increase in estrogen takes place in the case of tumors of the adrenal cortex or testicles.

Besides, cirrhosis of the liver can also trigger the symptom of gynecomastia. A deficiency of androgenic hormones is a result of an undescended testicle, castration, hyperthyroidism, or certain diseases such as prolactinoma or Klinefelter's syndrome, which means patients have one X chromosome too many.

How is Gynecomastia Diagnosed?

In any case, the diagnosis includes a laboratory examination of the hormones as well as the liver and thyroid gland values by a simple blood sample. A malignant breast carcinoma that is highly aggressive in men should be excluded in an appropriate mammography and ultrasound examination, especially in older patients with unilateral breast enlargement.

The more the treating physician knows about the patient's medical history and the more precise the physical examinations are, the better is the diagnosis, as this is the only way to develop an optimal treatment concept for each patient.

Gynecomastia Symptoms

Pain plays a rather subordinate role in an enlargement of the male breast. It is more the psychological dimension that causes the affected person to suffer visually and also in terms of their body awareness as a man.

Typically, the nipples and the areola also grow in the course of gynecomastia. The glandular tissue can be easily distinguished from the fatty tissue: As the tissue grows, it pushes the nipple outwards, making it appear larger.

If an extreme form of gynecomastia manifests, a fold under the breast can develop, just like in women. Particular attention should be paid to breast cancer in men: the changes can be similar to those in women, but the following symptoms usually occur on only one side:

• Bleeding around the nipple, with very rough, palpable nodules
• The skin may become absorbed or distorted
• The skin is inflamed
• In advanced breast carcinoma, the skin bulges out like an orange peel
• Tissue defects and swelling of the armpit can also occur at an advanced stage.

Gynecomastia Therapy

The treatment options can be conservative or include surgical procedures.

Gynecomastia Treatment Without Surgery

The conservative method attempts to ease the above-mentioned symptoms and eliminate possible disturbances in the hormonal balance. This requires the cooperation of various specialists. Endocrinologists, cardiologists, internists, general practitioners, and urologists usually work together. Although conservative therapy cannot reduce the enlarged male breast, it can prevent or slow down the progressive enlargement. Therefore, conservative and surgical methods are often combined.

Gynecomastia Surgery: Male Breast Reduction

The gynecomastia surgery complies with the type of breast enlargement.

Surgery for Pseudogynecomastia

If a man's breast contains fat, liposuction is indicated in most cases. In this case, it is often possible to avoid a skin incision of the areola. Instead, a small incision is made in the border area of the breast muscle; a small amount of fluid is infiltrated, which makes the fatty tissue grow larger, which can be suctioned off then.

In some cases, the male breast is developed to the extent that liposuction alone would not bring the requested results; in this case, the classic breast reduction has to be carried out in addition to liposuction.

Surgery Involving Real Gynecomastia

A glandular enlargement of the breast cannot only be compensated with liposuction, as the glandular tissue is too coarse and firm. Therefore, liposuction and removal of the male mammary gland, the so-called andromastectomy, are used. An incision is made in the nipple area, through which the excess glandular tissue can be removed.

Since gynecomastia often results in enlargement of the nipple, it can also be reduced during the surgery. At the end of each of these surgeries, drainages are placed to drain off the tissue fluid.

In the case of an extreme form of gynecomastia (grade III according to Deutinger), a breast reduction may very well be indicated, which is carried out in the same way in women: access is made, and the glandular tissue is removed via a T-incision, I-incision, or a particular incision in the areola. The breast can be tightened and stitched subsequently.

What Should Be Taken into Account after Gynecomastia?

If a breast reduction was only achieved by liposuction, outpatient treatment is also possible. However, if an andromastectomy was carried out, an inpatient stay becomes unavoidable. If a severe to moderate course of the disease is diagnosed, patients undergo surgery under general anesthesia.

As with any surgery, general risks and complications such as infections, hematomas, post-operative bleeding, or wound healing disorders may occur, although these are rather rare. Up to six weeks after the surgery, it should be abstained from doing sports. Besides, wearing a compression vest is absolutely necessary, especially in the initial phase, after the surgery, to prevent or minimize swelling, edemas, and hematomas.

Which Doctors and Clinics Are Gynecomastia Specialists?

Those affected with an enlarged male breast should initially have the cause clarified. The first contact is usually the general practitioner. If malignant breast cancer or hormonal disorder is suspected, the doctor can issue a referral to a specialist in gynecology, urology, or endocrinology. After this, the patient should contact a specialist in plastic and aesthetic surgery in case a gynecomastia surgery is considered. These physicians are specialized in male breast reduction surgery.

We will help you find an expert for your condition. All listed doctors and clinics have been checked by us for their outstanding specialization in the field of gynecomastia surgery and await your inquiry or treatment request.

Sources:

• academic.oup.com/jcem/article/100/10/3752/2835793/A-Longitudinal-Study-of-Growth-Sex-Steroids-and