What is gynecomastia?
Gynecomastia is the growth of abnormally large breasts in males. It is due to the excess growth of breast tissue. Often, excess fatty tissue accompanies gynecomastia. It is important to note that every man has breast tissue. Thus, the presence of a man having breast tissue is not abnormal or pathological. However, it is the amount of breast tissue that is considered when evaluating normal versus abnormal.
Gynecomastia is NOT cancer. Gynecomastia is the most common reason for medical evaluation of the male breast.
Medical treatment of gynecomastia that has persisted beyond a year is often ineffective and surgical removal of the excess tissue is usually required. However, medications such as aromatase inhibitors have been found to be effective in some cases. Aromatase inhibitors are more likely to prevent progression of the condition rather than cause regression.
What causes gynecomastia?
The causes of gynecomastia range from the use of certain medictions to unknown etiology. Hormones often play a role. Gynecomastia can result from an imbalance in hormone levels in which levels of estrogen (female hormones) are increased relative to levels of androgens (male hormones).
The cause of a decrease in testosterone can result from conditions that block the effects of or reduce testosterone production, or a condition that increases your estrogen level. Many things can disrupt hormone balance, including the following.
1. Natural hormone changes with aging
Testosterone and estrogen control the development and maintenance of sex characteristics in both men and women. That is, both men and women have both estrogen and testosterone. Surprised? Testosterone controls male traits, such as muscle mass and body hair. Estrogen controls female traits, including the growth of breast tissue. The concentrations of these hormones AND the ability of these hormones to act on and influence tissues varies greatly from person to person.
Most men think of estrogen as an exclusively female hormone, but men also produce it. However, estrogen in men is produced in much smaller quantities than in women. When male estrogen levels become too high or are out of balance with testosterone levels, gynecomastia can develop.
Below are some examples of hormones causing gynecomastia:
- Gynecomastia in infants. The majority of male infants are born with enlarged breasts due to the effects of their mother’s estrogen. The swollen breast tissue goes away within two to three weeks after birth as the estrogen levels dissipate.
- Gynecomastia during puberty. Puberty incites a tornado of hormonal changes. Gynecomastia caused by these fluctuations during puberty is actually very common. In the majority of cases, the enlarged breast tissue will subside without treatment within six months to two years.
- Gynecomastia in men. After infancy and puberty, the next biggest spike in gynecomastia can be found in adults between the ages of 50 and 80. A whopping 25 percent of men in this group are affected. Again, hormonal changes are likely the culprit in this population. However, there are other factors that can play a role.
2. About 10–25% of cases are estimated to result from the use of medications. This is known as non-physiologic gynecomastia.
The list of medications that can cause gynecomastia is large and they 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. (This is paradoxical, isn’t it? Well, the byproducts of testosterone can result in estrogen elevations.)
- Chemotherapy, many harsh, toxic chemicals are used to kill cancer cells. These drugs may also imbalance the levels of sex hormones in the body, which can cause abnormal breast growth in men.
- AIDS medications. Gynecomastia can develop in HIV-positive men who are receiving highly active antiretroviral therapy (HAART). The medication Efavirenz (Sustiva) is more commonly associated with gynecomastia than are other HIV medications.
- Anti-anxiety medications, such as diazepam (Valium).
- Tricyclic antidepressants, which are older antidepressants that are only infrequently prescribed now that selective serotonin reuptake inhibitors are available, also increase the risk of gynecomastia.
- Ulcer medications, such as cimetidine (Tagamet).
- Heart medications. Several drugs prescribed to treat high blood pressure and heart conditions carry the risk of increased breast tissue growth. The ACE inhibitor drugs, such as lisinopril, ramparil and enalapril, that treat high blood pressure and congestive heart failure may disrupt sex hormones and cause gynecomastia. Calcium channel blocking drugs, such as verapamil, also carry a high risk of abnormal breast enlargement in men, as well as digitalis, also called digoxin, and amiodarones.
- Street drugs and alcohol
3. Substances that may cause gynecomastia include:
4. Health conditions
Several health conditions can cause gynecomastia by in different ways affecting the normal balance of testosterone and estrogen.
- Hypogonadism. Primary hypogonadism (in which there is an intrinsic problem with the testes in males) leads to decreased testosterone synthesis and increased conversion of testosterone to estradiol (a form of estrogen). This can potentially lead to a gynecomastic. Klinefelter syndrome is a notable example of a disorder that causes hypogonadism, and subsequently gynecomastia. While gynecomastia alone does not predispose one to male breast cancer, Klinefelter syndrome is one condition that DOES portend a higher risk of breast cancer in males (10-20 times higher than males without the disorder).
- Pituitary disorders too, 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. 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. A failing liver will result in higher conversion to estrogen hormones.
- 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.
5. 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 they induce when absorbed into the body.
All individuals, whether male or female, possess both female hormones (estrogens) and male hormones (androgens). During puberty, levels of these hormones may fluctuate and rise at different levels, resulting in a temporary state in which estrogen concentration is relatively high. Studies regarding the prevalence of gynecomastia in normal adolescents have yielded widely varying results, with prevalence estimates as low as 4% and as high as 69% of adolescent boys. These differences probably result from variations in what is perceived to be normal and the different ages of boys examined in the studies.
Gynecomastia caused by transient changes in hormone levels with growth usually disappears on its own within six months to two years. Occasionally, gynecomastia that develops in puberty persists beyond two years and is referred to as persistent pubertal gynecomastia.
What are the classifications of gynecomastia?
Several classification systems have been adopted to describe the degree of gynecomastia. All of them focus on skin and the subcutaneous tissue (fat and breast tissue below the skin).
- Grade I: Minor enlargement, no skin excess
- Grade II: Moderate enlargement, no skin excess
- Grade III: Moderate enlargement, skin excess
- Grade IV: Marked enlargement, skin excess
The classification system is often utilized to guide treatments. As a rule, the higher the grade, the bigger the surgery when diet and exercise or medications doesn’t work.
What are the treatments of gynecomastia?
In mild cases of gynecomastia, diet, exercise, and observation are often employed first. While medications are available, they are rarely used. Their benefit is traditionally minimal. Selective estrogen receptor modulators such as tamoxifen may be beneficial in the treatment of gynecomastia but are not approved by the Food and Drug Administration for use in gynecomastia.Aromatase inhibitors such as testolactone have been approved for the treatment of gynecomastia in children and adolescents. Tamoxifen may be used for painful gynecomastia in adults.
Often, surgery is necessary to correct the gynecomastia. Depending on the degree of development and skin excess, surgery may involve any combination of liposuction, breast excision, and skin excision.
Most cases of gynecomastia are managed with aggressive liposuction in combination with glandular excision. Rarely is it necessary to excise skin. In the cases where skin is excised, it is often in the background of massive weight loss. In this particular population, the gynecomastia is mainly a skin issue, not true breast development. That is, there is a large discrepancy between skin and breast.
In patients with very good elasticity (generally, the younger the patient the more elasticity), even cases with skin redundancy may be able to avoid skin excision (which requires more incisions and larger scars). The skin in men with good elasticity have the propensity to contract and tighten over the course of weeks to months.
The goal for liposuction in gynecomastia is to remove the fat in the breast and blend that contour into the chest to provide a natural, smooth looking result. This requires generally 1 to 2 small incisions for the liposuction cannula. The incisions are placed in areas that are well hidden, such as in the armpit.
Liposuciton does NOT remove breast tissue. This is important to understand. If there is true breast enlargement and not just fat, glandular excision is required in addition to the liposuction. In MOST cases, this is the rule. Men who have large breasts are usually the result of fat AND breast tissue. This is in contrast to the massive weight loss person who has mainly a skin issue.
Where are the incisions in gynecomastia surgery?
The liposuction incisions which are about 1 cm are hidden under the arm and/or breast fold. The most common incision to excise breast tissue is the 3 to 9 o’clock incision around the areola (green). Here, the incision is camouflaged well between the border of lighter skin and areaola.
In cases where skin needs to be excised, incisions may need to be placed totally around the areola and/or fold of the breast (white and red, respectively). There generally is no need ever to have a vertical scar on the male chest (as opposed to the incision pattern we see for female breast reduction). The vertical scar in women is a result of excising skin to project the breast. In men, naturally, we want to reduce breast projection.
What is the downtime of gynecomastia?
Gynecomastia surgery is a surface operation. All of the surgery is focused above the muscles and bones. Thus, downtime is minimal. For at least one week, one should take it easy. While one can go about their daily activities such as walking, and driving (once off narcotics), there is still room for complications. If heart rate or blood pressure goes up from strenuous exercise, bleeding can develop. Not life threatening bleeding, but enough that requires aspiration in the office or operating room. More common than bleeding is seroma and scar tethering where the areola sticks down onto the muscle.
What are the complations of gynecomastia surgery?
Seroma is the accumulation of fluid under the skin. Often, seromas will reabsorb. But when they don’t, aspiration is generally performed in the office with a needle. Under local anesthesia, a small needle is placed under the skin and into the pocket of fluid and sucked out. This is why drains are usually placed during surgery. Drains collect the fluid that would normally accumulate. The drains that are placed are usually removed in the office within a week following surgery. This is an easy, painless process that takes a minute.
Scar tethering is when the areola tissue heals down onto the muscle and creates a slight depression. This is generally not obvious and often gets better with time. To improve or correct this if it is visible, steroid injections or fat grafting in the office can be performed.
The complete healing process for gynecomastia surgery is weeks to months. A tight vest will be worn for 4 weeks. This allows the tissues to heal and contract uniformly and help prevent seroma. It may take 6 weeks or more for the skin to tighten. If skin fails to tighten , small skin excision can be performed in the office under local anesthesia. However, this is rare.
Does insurance cover gynecomastia surgery?
Because gynecomastia surgery is not a physical harm to the body, health insurance will not cover the surgery. While there is no doubt gynecomastia is psychologically harmful, unfortunately, insurance providers don’t care. If the gynecomastia is so large, or if it is one of excessive skin causing rashes, then insurance MAY cover the surgery. However, covering the surgery often translates into “paying for some but not all”. Most offices will not try to obtain authorization for the surgery because authorization doesn’t mean “reimbursable”.