Gynecomastia, Male Breast Enlargement: Why Would a Man Be Uncomfortable Removing His Shirt?
Men that are uncomfortable in the locker room or at the beach may be those whose chest appears more like an adolescent female than a male. Male breast enlargement, called GYNECOMASTIA, is common and can be a source of embarrassment.
Recently a 16-year-old boy came in with his parents to talk about his gynecomastia. Brian had become increasingly unhappy at school. He socialized less comfortably than he had as a little boy and he refused to participate in sports. He spent more time alone playing computer games and had put on a lot of weight. At 5'8" he was 225 lbs. He had trouble losing the weight because he was humiliated to take his shirt off in front of others and did not want to participate in sports. Teenage boys at school targeted him as the brunt of their jokes.
Brian had a very extreme case of male breast growth that was made worse by his weight gain. His embarrassment was understandable. He had been evaluated at the Children's Hospital endocrinology clinic and no cause had been found for the breast enlargement. He and his parents wanted to remove the stigma as soon as possible.
Brian's surgery incorporated a variety of surgical techniques. LIPOSUCTION of the chest wall helped to smooth the contour with removal of the extra fatty component. The dense glandular tissue was removed through a small incision camouflaged at the junction of normal skin and the brown areola, a variation on a SUBCUTANEOUS MASTECTOMY. The TUBULAR BREAST shape was corrected by a PERIAREOLAR MASTOPEXY, which means that extra skin was removed and constricting fibrous bands were removed to reshape his chest.
Brian had an enormous sense of relief immediately after his procedure. He is more confident and outgoing and relieved of the sense of shame he felt about his chest. He is hoping to tackle his weight issue next.
What Causes GYNECOMASTIA?
Male breast enlargement happens commonly at two times in a man's life. At mid to late puberty there can be an excess of free ESTROGEN before adult levels of TESTOTERONE have been produced. Breast enlargement at this phase goes away within a year 95% of the time. If it lasts longer, it is likely to persist unchanged. The second time that breast enlargement is common is in late life as testosterone level is falling. 50% of men have decreased free testosterone by age 70.
The vast majority of the time no cause can be found for gynecomastia. Rarely there may be tumors of the testes or adrenal that produce feminizing hormones. Failure of the testes to produce testosterone can also result in breast growth. Obesity can be a cause of gynecomastia as increasing BMI results in converting adrenal hormones into estradiol, which stimulates glandular growth.
Men with severe liver failure, kidney failure, and hyperthyroidism can all be associated with benign growth of the male breast.
There are a number of medications that have been known to stimulate breast growth, including certain diuretics and anabolic steroids.
There is not complete agreement on whether or not biochemical studies should be ordered for the evaluation of gynecomastia, because the tests have a low yield. The cause is usually found with a careful history and physical exam. Medications including estrogen inhibitors have been largely unhelpful. If the gynecomastia has lasted for more than a year, then surgical removal of gland and fat improves their appearance.
Reference: New England Journal of Medicine 357;12, p.1229.