Gynecomastia

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Men can have breasts too! I don’t mean pecs, but feminine looking breasts. Some want them, while many men do not, especially when they might be sagging, tender, lop sided, or cone shaped. There are three possible causes for enlargement of the male breasts: 1. gynecomastia, which is a proliferation of glandular tissue of the breast; 2. pseudogynecomastia, which is an accumulation of fatty tissue surrounding the male breast; or, in rare cases, due to 3. breast cancer. The American Cancer Society estimates nearly 2000 men will be diagnosed with breast cancer in the U.S. in 2008 resulting in about 450 deaths.
 
In patients with true gynecomastia, a rubbery or firm and often painful mass may be felt in the area directly surrounding the nipple, whereas in pseudogynecomastia the increase of the smooth, soft underlying fat tissue may result in the look of enlarged breasts. Breast cancer is usually felt as a hard or firm painless mass most often further away from the nipple area and on one side of the chest. Breast tumors may be associated with dimpling of the skin, changes in the appearance of the nipple, crusting or discharge of the nipple and swollen lymph nodes under the arms. Although sometimes seen only in one breast, gynecomastia and pseudogynecomastia are generally present in both breasts
 
Gynecomastia is the result of an imbalance of female (estrogen) to male (androgen) sex hormones at the level of breast tissue. When the scale is tipped in favor of estrogen, there is a stimulating effect on breast tissue. Gynecomastia is common during adolescence due to hormonal fluctuations, and the majority of these cases resolve without treatment. In adulthood, 30% to 50% of males between the ages of 40 and 70 can present with gynecomastia, thought to be due to a combination of genetics, gradual decrease in testosterone level, and excess fatty tissue producing greater estrogens.  Furthermore, certain drugs are implicated in causing gynecomastia; the most common include anabolic steroids (used for bodybuilding or the treatment of medical conditions), HIV  protease inhibitors, Propecia, certain cardiovascular and antihypertensive medications and some classes of antidepressants or psychoactive drugs, alcohol, marijuana, amphetamines or opioids, and even too much soy (phytoestrogens). Although less common, testicular or adrenal tumors, thyroid, liver or kidney disease, and others may cause gynecomastia.  For this reason, it is recommended that all cases of gynecomastia or pseudogynecomastia should be evaluated by a medical provider to rule out the possibility of a serious underlying illness and to determine the appropriate course of treatment.  Although the likelihood of finding a pathologic abnormality is low among patients with long-standing, asymptomatic gynecomastia, a detailed medical history, complete physical examination and lab tests to measure hormone levels and kidney, liver and thyroid functions are prudent.  In cases where breast enlargement is not typical of gynecomastia, a mammogram or fine-needle biopsy may be ordered to rule out breast cancer. 
 
If a specific cause of gynecomastia can be identified and treated early in the course of the condition, there may be some spontaneous decrease in the breast enlargement.  For example, if gynecomastia is drug-induced, there will generally be decreased tenderness and softening of the glandular tissue within a month after discontinuation of the drug. However, gynecomastia which has been present for more than one year is less likely to resolve spontaneously or with medical therapy due to the development of surrounding fibrous tissue.  In these cases, surgical removal of the tissue or liposuction is often needed to reduce the size of the breast. Good cosmetic outcomes have been demonstrated with liposuction of the male breast. These procedures can be safely and comfortably performed under local anesthesia along with oral sedation and pain medication, thereby minimizing the risks associated with general anesthesia. Furthermore, tamoxifen (an estrogen blocker) has had some success in reversing gynecomastia.
 
While the majority of cases of male breast enlargement are benign, the condition can cause embarrassment and significantly impact a patient’s lifestyle and self-image. Many young boys with gynecomastia are shy to remove their shirts in sports. This can cause depression and isolation. It is important to seek treatment in a supportive and reassuring setting and remember to be sensitive to friends or loved-ones who may be dealing with this condition.
 
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Chicago Dermatologic Surgeon