Male Boobs: Embarrassing but harmless

Gynecomastia is defined as the growth of breast glandular tissue in males. The term gynecomastia is derived from the Greek terminology meaning female like breast. The disorder is completely benign and is frequently seen in prepubertal children and young teenagers. Another very similar condition to Gynecomastia is pseudo-gynecomastia- which looks and resembles Gynecomastia but the breast tissue is composed of fat only. Gynecomastia is a disorder which occurs in both breasts, only rarely is it seen in only one breast. Unlike Pamela Anderson, the breast enlargement is more similar to breast growth seen in pubertal and young teenage females. In almost all cases, the breast growth is symmetrical and painless. The majority of the cases of breast enlargement subside on their own which may take about 1-2 years to completely disappear. Gynecomastia by definition is enlargement of both breasts in a male. The condition is almost always bilateral but in some cases may be one sided. The condition most commonly is seen at puberty and in older age males. The majority of individuals have no symptoms, except for the obvious enlargement. The condition is linked to an imbalance between the male and female sex hormones. In other cases, gynecomastia may be caused by certain medications, alcohol, marihuana and liver failure. Surgery is only done for cosmetic reasons and only after some time period has elapsed since the condition started.

FrequencyBreast growth in males is more common than what one is led to believe. Many male children develop breast enlargement during puberty. From available data, this phenomenon is seen in about 35-60% of males and is considered physiological. The exact numbers remain unknown because not many males brag about the disorder. The condition is most commonly seen in males between the ages of 12-16. The prevalence increases again in males in the 6-7th decade of life. The condition is typically identified by the individual himself. In the majority of cases, there is no milk production from the breast and unlike the female; breast enlargement in males is not deemed erotic or sexy. Breast enlargement in the younger age group of males is almost always physiological and generally resolves with time. In males who are older, the cause may be linked to various factors (see below) and may not always resolve. Pseudo-gynecomastia is a condition which looks very similar in size and shape to Gynecomastia. However, unlike glandular tissue which is found in Gynecomastia, only fat is found in pseudo-gynecomastia. The condition is more common in obese males. Causes of GynecomastiaThere are many causes of bilateral breast enlargement. In most cases it is due to an abnormal or altered ratio between the male and female sex hormones. In simple, any one of the following changes in sex hormones can cause Gynecomastia: - Decrease in production of male sex hormone androgen - Increase in estrogen formation - Decrease in sensitivity of breast tissue to androgens Gynecomastia in infants More than 60% of infant males have Gynecomastia at birth. This physiological condition is due to the female sex hormone which has crossed from the placenta. The condition is short lived and almost all cases resolve within a few weeks. Gynecomastia during puberty Gynecomastia that occurs around the time of puberty is very common. The exact numbers are unknown as many young males are too shy to tell anyone about their condition. However, hospital data reveal that at least 40-60% of males may develop some form of Gynecomastia at around puberty. The cause of this gynecomastia is due an excess of sex hormones. The condition is also more common in tall or overweight males. The condition is completely benign and resolves in 2-3 years. Medications causing gynecomastiaA number of medications have been associated with gynecomastia and include: - There are some drugs used to treat prostate cancer and these are anti androgenic medications. By blocking the male hormones, these drugs stimulate the actions of female sex hormones. The most commonly used anti androgenic medications are flutamide and Finasteride. - There are some medications used to treat AIDS that can also cause gynecomastia. These medications are efavirenz or didanosine. Unfortunately, these medications are life saving and the individual just can’t stop them. There are some alternative HIV medications available which do not cause gynecomastia. - Anti-anxiety medications such as diazepam (Valium) also been linked to gynecomastia. However, this is not a reproducible finding in all patients who take valium. - Tricyclic antidepressants have also been associated with gynecomastia. - The most common medication known to cause gynecomastia is cimetidine. However, this is not seen in all patients. There are other anti ulcer medications which have been reported to cause gynecomastia. However, this is not a universal finding. - Cancer drugs are also known to cause gynecomastia. - Heart medications such as digitalis and spironolactone are also known to cause gynecomastia. Illicit drugs and alcoholIllicit drug use and alcohol appear to be a common cause of gynecomastia among the adolescents and older individuals. The majority of these individuals develop gynecomastia after prolonged use of these agents. Other illicit drugs that have also been known to cause this disorder are heroin and use of anabolic steroids. Alcohol is postulated to cause gynecomastia after the liver is destroyed. A cirrhotic liver is no longer able to breakdown the normal circulating female sex hormone- and this eventually accumulates and causes gynecomastia. Steroids and other excess androgens are sometimes converted by the body into estrogens and consequently cause gynecomastia. Medical conditions which have been associated with Gynecomastia include: - In children the most common condition known to cause gynecomastia is kleinfelter’s. This is a genetically acquired condition which is diagnosed in early childhood. The breast enlargement unfortunately is persistent and does not always resolve. - Pituitary failure. In some cases, the pituitary gland may fail and there is failure to make hormones. This leads to a lack of the male hormones. The condition is rare but can be treated with hormonal supplements - Obesity- in obese individual there is a lot of excess fat. The excess fat contains a lot of cholesterol which is a precursor chemical for the female sex hormones- and it is for this reason that many obese individuals develop female characteristics - Some cancers are known to generate precursors for the synthesis of the female sex hormones. These cancers are generally lung, testes and adrenal. - Liver and Kidney Failure- when the liver fails, there is an accumulation of the female sex hormone. This is due to the liver’s inability to breakdown this hormone. So the excess hormone is known to cause Gynecomastia - In some individuals, an excess of the thyroid hormone may be responsible for the condition - Starvation is a common cause of gynecomastia in children. This condition is typically seen in Africa where poverty is endemic. ComplicationsGynecomastia has no medical or physiological consequences. The major problem is cosmetic and may create emotional stress due to embarrassment. Despite claims by some that gynecomastia is a risk factor for breast cancer, there is no scientific data to prove such a claim. In fact, if this was true, there would be thousands of cases of male breast cancer each year, and this is not true. Male breast cancer is a rare condition. Could the breast lump be cancer?When both breasts are enlarged in a young male, the chances of breast cancer are almost nil. Breast cancer does occur in males. When it does occur, it occurs in one breast and the cancer is seen in older males. In the majority of cases of gynecomastia, there is no cancer associated. However, any male over the age of 50 with a sudden increase in a single breast, should definitely be seen by a doctor for further work up. Breast cancer in males presents just like in females. A mass is identified in a single breast but there is generally no pain or nipple discharge but the mass may be hard to touch. The only way to tell if it is a cancer, is by a biopsy. SymptomsThe male individual generally present with an increase in breast tissue which he has identified himself. Most of the individuals present late to the doctor, mainly due to embarrassment. The diagnosis of gynecomastia is in most cases made on physical examination. The breasts are enlarged on both sides. In most cases, the breast enlargement is mild to modest. There is no “Pamela Anderson –like Breast growth”- in males the breast enlargement is more a source of embarrassment-unlike a female who tends to have a sex appeal and infact is willing to show off her boobs. In the majority of cases, the enlargement is bilateral and in about 10-20%, only one breast is enlarged. The breasts are soft and the nipples and the areola area also well developed. A few males, especially, the younger ones will also complain of nipple sensitiveness. There is no real pain but an odd ache is a typical complaint. The breast enlargement is symmetrical in most cases. Nipple discharge is almost never seen. There is nothing specific about the breast examination. There are several classifications of gynecomastia based on either size or the tissue component found in the breast. In simple, if the breasts are large, surgery may require not only removal of the breast tissue but also the excess redundant skin left over. DiagnosisIn the majority of cases, the diagnosis of gynecomastia is made by the physician by just simple observation and the presenting history. The breast is always palpated (felt with hands) to ensure there are no hard masses present. Infection of the male breast is almost unheard of, except in those males who pierce their nipples. However, the physical examination should also be done to ensure that the scrotum does not have any abnormal mass that may be responsible for the gynecomastia. There are a few testicular cancers that can make female sex hormones and Gynecomastia may be initial presenting feature. In some cases, there is no real breast tissue and the breast is infiltrated with a fatty tissue. In these cases a diagnosis of pseudo-gynecomastia is made. This is a common finding in obese individuals. Breast cancer in males does occur but is seen in the older males and typically presents as a hard mass in a single breast. Both breasts having a cancer is very unusual. The majority of the younger individual do not require any tests, either radiological or blood tests. Mammogram has no role in the evaluation of breast mass in males. Unless the male has undergone a sex change and undergone a size 44 C breast enlargement, it is impossible to place a male breast on a mammogram machine. A mammogram requires fairly decent sized breasts to be placed between two metal plates. A chest x ray of an ultrasound of the scrotum may be obtained in the rare individual with Gynecomastia. Biopsy of the breast is very unusual and is only done if there is a great suspicion of a breast cancer, or if the physician is clueless Treatment of Gynecomastia In the child or young adolescent, the treatment of Gynecomastia is relatively simple. Patience and observation will do it. If there is no visible cause for the gynecomastia then it is considered physiological and will spontaneously resolve over time. The need for surgery is absolutely cosmetic and surgery should be done after the breasts have stopped growing. There is no need to rush for surgery and later find out that the breasts are still growing. There must be a period of time; at least 1-2 years after the breast have stopped growing. This is to give the breast every chance to resolve on their own. All gynecomastia seen in the pubertal stage of male life will spontaneously resolve. It is criminal negligence for any physician to perform surgery in these individuals. If it is pubertal, watchful waiting is in order, since in most patients the condition will resolve spontaneously. The physician generally follows up on the breast growth every 3-6 months. In more than 90% of young males, the condition will spontaneously resolve over 2-4 years. For those in whom the Gynecomastia is related to a medication, cessation of that medication will help resolve the breast enlargement. Alcohol and all illicit medications should also be stopped to help decrease the breast enlargement. If gynecomastia is caused by liver or renal failure or a cancer, the breast enlargement may not always resolve even if the predisposing conditions have been treated. In such cases, surgery may be an option at a much later time. Medical therapyMedical therapy for gynecomastia is only for those few case where there is a true testosterone deficiency, as in kleinfelter’s syndrome. In a few individuals who have had testicular infections or the failure of the testes to secrete the male hormone, testosterone therapy may help. One has to be careful with testosterone therapy because all the extra testosterone in the body is also converted to estrogen, the female sex hormone. Therefore, the therapy designed to correct the problem, can sometimes, even worsen it. Other drug therapies that have been used to treat gynecomastia include the anti estrogen medications Tamoxifen and clomiphene. These drugs inhibit the stimulation of female sex hormones. However, these drugs are only temporary therapy and there is no evidence to prove their effectiveness. The long term side effects of these drugs also remain unknown. All the data reported about their use in Gynecomastia remain anecdotal. Radiation There have been studies which show that in patients with prostate cancer, prophylactic irradiation decreases the breast enlargement that normally occurs after administration of anti- androgen therapy. This is all well and good in patients with prostate cancer but it is completely unethical and immoral to administer radiation to normal individuals with physiological gynecomastia. Radiation therapy offered to normal healthy individuals is considered criminal and one wonders if there are any individuals who may want to undergo such therapy, for a benign disorder. Any individual offered such therapy should immediately seek another opinion. Surgical therapy Many unscrupulous surgeons perform unnecessary surgery in some male individuals with Gynecomastia. These physicians usually use scare tactics making the individual think he has cancer or some bogus nonsense. Surgery for Gynecomastia is a last resort treatment and only done for cosmesis. Surgery is typically reserved for diagnostic purposes or for those patients who want some treatment. The surgery is almost never indicated in young males and it is recommended that the individual wait to see if the breast enlargement resolves spontaneously. For that who have had gynecomastia and which fails to resolve, there is no medical treatment, except for plastic surgery. It is essential that all individuals wait out the maximum time period of at least 2 years to ensure there is no more growth. It would be a very painful experience to have to re undergo surgery twice. The principles of surgery are (1) to restore the normal male breast shape and size and (2) to correct deformity of the breast, nipple, or areola. There are two surgical options for the individual with Gynecomastia: simple mastectomy or liposuction-assisted mastectomy. Subcutaneous mastectomy Preoperatively, the surgeon always mark his incision outline and has a rough idea how much tissue he will remove. In most cases, a small incision is made and the excess breast tissue is removed. There are numerous skin incisions devised for the best cosmetic result and they all serve the same purpose. When excess skin is present, it is also removed. The most common approach to the male breast is a skin incision just below the areola, and the length of the incision is dependent on the amount of breast tissue that needs to be excised. After the excess breast tissue is removed, the nipple is repositioned back into its place. In most cases, the cosmetic result is excellent Liposuction-assisted mastectomyLiposuction has become a surgical tool to treat gynecomastia. The technique avoids large incisions and advances in techniques have helped reduce the complications of surgery. Liposuction is a surgical procedure intended to remove fat deposits and shape the body. Fat is removed from under the skin with the use of a vacuum-suction cannula (a hollow pen-like instrument) or using an ultrasonic probe that emulfsies (breaks up into small pieces) the fat, which is then removed using suction. Unlike the open procedure, liposuction has less blood loss, there is less anatomic deformity of the nipple and skin sloughing is less. Potential complications of mastectomy: - hematoma (collection of blood) - Breast asymmetry - Nipple or areola necrosis - Nipple or areola inversion - Infection - Numbness around nipple - Painful skin incision - Obvious surgical scar/keloid - Skin redundancy Postoperative resultsAfter surgery, the pressure dressing are left for about 2 weeks. Most individuals have minimal pain. Some individuals may have a serous discharge from the incision site- the majority which resolve in a few days. All individuals are able to resume their normal activities in a few days. The patients are seen in a follow up clinic in 2-3 weeks. The majority of individuals have an excellent result which is most conspicuous 6 months after surgery. PrognosisIn the majority of cases of gynecomastia, the prognosis is excellent without any treatment. The majority of cases in pubertal teens and adolescents resolve on their own within 2-3 years. There are individuals who may have developed gynecomastia from use of certain medications and in these cases, stopping the medication will help resolve the gynecomastia over 3-6 months. There are a few individuals whocalso develop gynecomastia from liver failure or alcohol, and in these cases, the regression is only partial. In those with long standing gynecomastia of many years the chances of resolution are almost nil. Daily living with gynecomastiaAny male with enlarged breasts is unlikely to brag about it and will become socially isolated and remain shy. He will most likely not participate in any activities that require removal of his clothes. This can lead to difficulty in relationships and even a romantic relationship with the opposite sex can be full of anxiety. A number of boys in school report being teased from their peers during gym. And the majority go on to lead a solitary lifestyle, because the condition is not understood. The above feelings are normal and because our society is based on outward cosmetic appearances, it does lead to a great deal of difficulty for a number of individuals. Not everyone is born with the perfect figure. The best advice is to seek help and counseling. PreventionUnfortunately, gynecomastia can not be prevented at least in the young children and adolescents. The condition is physiological. However, in the elderly, medications that cause gynecomastia should be avoided and one should refrain from alcohol. - one should try and exercise , walking is the best remedy not only to prevent Gynecomastia but for a general active health style - one should keep away from steroids, illicit drugs like amphetamines and marijuana- all of which have been linked to breast enlargement - avoid alcohol or drink only socially - Review one’s medications with the doctor and today, the internet a great source to discover the potential side effects of drugs.