Gynecomastia

Article Author:
Heather Vandeven
Article Editor:
Jay Pensler
Updated:
5/14/2019 12:55:15 PM
PubMed Link:
Gynecomastia

Introduction

Gynecomastia relates to any condition in which the male breast volume is enlarged due to an increase in ductal tissue, stroma, or fat. Gynecomastia is derived from the Greek terms gyne and masto, gyne meaning feminine and masto meaning breasts. This condition most often occurs during times of hormonal change such as birth, adolescence and old age. There are many etiologies for this condition which include morbid obesity, steroid use, pharmacologic agents, medical conditions including hypogonadism, liver, and kidney failure. However, the majority of patients present with idiopathic gynecomastia. The treatment of this condition consists of treating the underlying condition, lab work, imaging, and surgical intervention, when necessary.[1][2]

Etiology

The cause of most cases of gynecomastia is idiopathic. However, it has been proven to be associated with imbalances in the hormones estrogen and testosterone.[3][4]

This condition can appear transient at birth; this is thought to be due to an increased level of circulating maternal estrogens. Adolescent boys may also suffer from this condition due to an imbalance of estradiol and testosterone. In men older than 65 years, hypertrophy is thought to be due to a decline in testosterone levels and a shift in the ratio of testosterone to estrogen.

Underlying medical conditions such as breast cancer, obesity, hypogonadism, adrenal disease, thyroid disease, cirrhosis, renal failure, and malnutrition may contribute to this condition. Tumors of the adrenal glands, pituitary, lungs, and testes can impact hormonal changes resulting in imbalances and ultimately gynecomastia. Medications that have been shown to contribute to this condition include digoxin, thiazides, estrogens, phenothiazines, and theophylline. Use of certain recreational drugs including marijuana has also been associated with this disease.

Epidemiology

Gynecomastia appears more within certain age groups of the male population. Newborns can suffer from this condition until their hormonal imbalances normalize. 

Adolescence hypertrophy occurs in boys beginning around age 13 and can last into early adulthood. The incidence of this condition again increases in men 65 years of age and older.

Pathophysiology

Gynecomastia is a result of enlargement of glandular breast tissue and adipose tissue. The hormone estrogen is responsible for the growth of glandular tissue, as well as the suppression of testosterone secretion. Estrogen suppresses luteinizing hormone, the hormone that is responsible for testicular secretion of testosterone. This process of hormonal imbalance leads to gynecomastia.

Pubertal gynecomastia is thought to be caused by a faster rise in estradiol than the rise of testosterone, causing an imbalance that normally regresses with time as testosterone increases.  

Medical conditions such as tumors of the adrenal, pituitary, and testes can cause increases in estrogen and decrease testosterone. These imbalances lead to hormonal imbalances resulting in gynecomastia in some males.[5][6][7]

Diseases of the liver, adrenal, thyroid, and testes can produce imbalances, along with the above-listed medications.  

Three types of gynecomastia, florid, fibrous and intermediate, have been identified. The type seen is usually related to the length of the condition. Florid gynecomastia is usually seen in early stages of the condition, four months or less. This type is characterized by an increase in ductal tissue and vascularity. Fibrous gynecomastia is seen after a year duration and is noted to have more stromal fibrosis and few ducts. After one year, intermediate gynecomastia is present which is thought to be a progression from florid to fibrous.

History and Physical

Important factors in the history from the patient include onset and duration of gynecomastia, associated symptoms, problems with certain organ systems such as liver, renal, adrenal, prostate, pulmonary, testicular or thyroid. A careful review of family history, genetic history, medications, and recreational drug use should also be taken into consideration. A complete and thorough physical exam should be done. The head and neck exam should evaluate for any abnormal masses or thyroid abnormalities. Assess breasts for the nature of the tissue, masses, skin changes, nipple discharge, asymmetries, and tenderness, along with an axillary examination. The testes should be examined to look for asymmetry, masses, enlargement, or atrophy. Those males with feminizing characteristics should have endocrine testing and genetic testing. Any other positive findings on physical examination should be treated in an appropriate manner.

Evaluation

The history and physical will guide the remainder of the workup. Healthy males with no associated symptoms or physical abnormalities other than long-standing gynecomastia (more than 12 months) need no further workup. However, if symptoms are present, or if there are positive physical exam findings, these should be investigated first.

  • Testicular masses require the following: testicular ultrasound, serum testosterone, luteinizing hormone (LH), estradiol, and DHEAS. If a thyroid mass is present the following are required: thyroid function tests, thyroid ultrasound (US), and endocrine evaluation.
  • If a breast mass is palpated, the patient needs the following: mammography or US, biopsy, and possible surgical consultation.
  • If hypogonadism is present, order the following: serum LH/follicle stimulating hormone (FSH), estradiol, testosterone, DHEAS + karyotype +/- adrenal scan with the endocrine consult.
  • If abdominal masses or hepatomegaly are present order the following: liver function tests, serum LH/FSH, estradiol, testosterone, DHEAS +/- abdominal CT, and an endocrine consultation.

Treatment / Management

Gynecomastia is classified into three grades depending on the amount of breast enlargement, skin excess, and ptosis. The treatment for each Grade differs depending on the amount of skin excess and ptosis.

  • Grade I: Small enlargement, no skin excess
  • Grade II: Moderate enlargement, no skin excess
  • Grade IIb: Moderate enlargement with extra skin
  • Grade III: Marked enlargement with extra skin

Treatment of this condition consists first of treating any underlying condition if this is contributing to the condition. If the condition has been present less than one year, and the history and physical are within normal limits, observation can be done with close follow-up. If an underlying medication is noted within the history, this should be discontinued. If anything abnormal is found on physical exam, treatment depends on this finding.  If the underlying condition is treated, and the condition persists longer than a year, surgical treatment is suggested.[8][9][10]

Patients with grade I or grade IIa can be treated with liposuction and surgical excision.

If the patient presents with grade IIb gynecomastia, open surgical excision with possible skin resection is indicated if a large amount of ptosis is present.[11]

Enhancing Healthcare Team Outcomes

Gynecomastia is best managed by a multidisciplinary team that includes the pharmacist and nurse practitioner. The key is to determine if there is a reversible cause and discontinue it (eg medications). Secondly, gynecomastia is not a surgical emergency and watch observation is recommended because some cases may resolve spontaneously. Those cases that persist should be referred to a plastic surgeon. Because of fibrosis in chronic cases, liposuction may not always work and an open procedure may be required.

The outcomes for males with gynecomastia are fair; the condition can lead to embarrassment and isolation.[12]


References

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[3] Jin Y,Fan M, Treatment of gynecomastia with prednisone: case report and literature review. The Journal of international medical research. 2019 Apr 8;     [PubMed PMID: 30958070]
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[6] Baumann K, Gynecomastia - Conservative and Surgical Management. Breast care (Basel, Switzerland). 2018 Dec;     [PubMed PMID: 30800036]
[7] Oana Cristina V,Monica Mihaela C,Daniel I,Maria S,Adrian Vasile D,Oana Mari P,Dan-Corneliu J,Adriana Elena N, Histology of Male Breast Lesions. Series of Cases and Literature Review. Maedica. 2018 Sep;     [PubMed PMID: 30568739]
[8] Reisenbichler E,Hanley KZ, Developmental disorders and malformations of the breast. Seminars in diagnostic pathology. 2019 Jan;     [PubMed PMID: 30503250]
[9] Sollie M, Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. Gland surgery. 2018 Aug;     [PubMed PMID: 30175067]
[10] Chesebro AL,Rives AF,Shaffer K, Male Breast Disease: What the Radiologist Needs to Know. Current problems in diagnostic radiology. 2018 Jul 29;     [PubMed PMID: 30122313]
[11] Malhotra AK,Amed S,Bucevska M,Bush KL,Arneja JS, Do Adolescents with Gynecomastia Require Routine Evaluation by Endocrinology? Plastic and reconstructive surgery. 2018 Jul;     [PubMed PMID: 29952889]
[12] Soliman AT,De Sanctis V,Yassin M, Management of Adolescent Gynecomastia: An Update. Acta bio-medica : Atenei Parmensis. 2017 Aug 23;     [PubMed PMID: 28845839]