An Overview of Gynecomastia

Enlarged male breasts are usually the result of a hormone imbalance

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22 year old patient before and after gynecomastia surgery (frontal view). The excision of the gland and the liposuction were both done through one small incision only in the bottom of each areola(as opposed to around the entire areola).This resulted in a smaller areola with a tiny incision. This patient was featured on The Learning Channel
JMZ1122 Dr. Mordcai Blau www.gynecomastia-md.com/Wikimedia Commons/CC-BY-SA-3.0

Gynecomastia is the enlargement of the glandular tissue in one or both of a boy's or man's breasts, usually due to hormone imbalance though other causes exist. The condition is benign (noncancerous) and very common: Up to 70 percent of boys adolescent boys experience gynecomastia, and according to one study, up to 65 percent of men over 50 have some degree of it. Gynecomastia (aka "man boobs") is often embarrassing for males and can take a toll on their self-confidence and body image. The condition often resolves on its own as hormone levels normalize, but treatments—including medication and surgery—are available if it persists.

The first recorded breast surgery was done on a man with gynecomastia in 625 A.D., according to breast surgeon Susan Love, M.D. Breast surgery was not performed on a woman until over a thousand years later, in 1897.

Symptoms

The main symptom of gynecomastia is enlarged breasts. It often begins as a slight bump or lump behind the nipple. This enlargement is usually painless, but about a third of men experience tenderness. One breast may be larger than the other.

Causes

There are two types of gynecomastia: physiologic and nonphysiologic.

Physiologic gynecomastia results from an increase in the ratio of estrogen (female hormone) to testosterone (male hormone) that occurs naturally at birth, puberty, or as part of aging. Eventually, the exposure to this hormone imbalance can stimulate the growth of glandular tissue.

Birth

Up to 90 percent of newborn boys have enlarged breasts as a result of the estrogen that's transferred from their mother in the womb. Newborn gynecomastia usually resolves spontaneously after about a month.

Puberty

Half of adolescent boys will experience gynecomastia, usually around 13 or 14 years old. It often goes away on its own within six months to two years, but the condition persists into adulthood up to 20 percent of the time.

Older Adults

Decreasing levels of the hormone testosterone may contribute to the final peak in gynecomastia incidence in men older than 50.

Nonphysiologic gynecomastia may be caused by chronic conditions, such as cirrhosis of the liver, hypogonadism (aka testosterone deficiency), hyperthyroidism, poor kidney function; use of medications like spironolactone (heart medication), ketoconazole (anti-fungal), heartburn and ulcer medications, supplements, or illicit drugs (marijuana, heroin, amphetamines); and, rarely, tumors (testicular, adrenal). Anabolic steroid use often causes irreversible gynecomastia as well, according to one report. The injection of external testosterone inhibits the natural production of testosterone, which cannot recover rapidly enough between steroid-injecting cycles to prevent estrogen predominance, the authors explain.

Gynecomastia is also a symptom of Klinefelter's syndrome, a condition in which a male has an extra X chromosome. Males usually have one X and one Y chromosome. Some of the other clinical findings associated with Klinefelter's are hypothyroidism, infertility, and testicular cancer. Klinefelter's syndrome is associated with an increased risk of developing male breast cancer. But if you have gynecomastia, the condition alone does not increase your risk of breast cancer.

Gynecomastia in children has been associated with regular use of skin care products (lotions, soaps, and shampoos) containing tea tree oil and lavender oil, according to one study. These oils contain plant estrogens that can affect the body's hormone balance. Gynecomastia usually resolves completely after stopping the products.

Although breast cancer is rare in men, representing less than one percent of all cases of the disease, those with gynecomastia often become anxious and seek medical attention, according to one report. Only one percent of mammograms in men reveal breast cancer.

Diagnosis

To diagnose gynecomastia, a doctor will perform a physical exam of the genitals, liver, lymph nodes, thyroid, as well as the breasts. It's important to be sure that a male's large breasts are due to excess growth of glandular tissue, which has a network of ducts that can be felt, and not excess fat tissue. Known as "pseudogynecomastia," this occurs when the breasts of overweight boys and men enlarge due to increased fat and not true breast tissue. Unlike males with true gynecomastia, pseudogynecomastia will not usually go away on its own unless the person loses weight.

If your "man boobs" are due to too much body fat, a combination of diet and exercise can help reduce your total body fat percentage and, likely, your chest size.

Blood tests to check hormone levels may also be performed. Sometimes imaging tests like a mammogram or ultrasound may also be needed to confirm the diagnosis.

Treatment

When gynecomastia is the result of an underlying health problem or use of medication that may cause breast growth, treating that problem or discontinuing the medication usually improves the condition.

Home care

Pain is more common in patients with gynecomastia that recently developed or has progressed rapidly. If breasts are tender, cold compresses may be applied. Analgesics (pain relievers) may also be used.

Medication

Treatment of gynecomastia depends on a number of factors, including age. Because breast growth in newborns and adolescents often goes away on its own, no treatment may be needed. In cases where the condition is persistent or causing substantial discomfort or mental anguish, a doctor may prescribe a brief (three-to-six-month) course of an estrogen-blocking drug called tamoxifen or raloxifene.

Adult men may also be prescribed a short course of tamoxifen or raloxifene, however, the drug is only effective in men whose breast tissue is tender and who have had the condition for less than a year. Tamoxifen or radiation therapy is often prescribed to men with prostate cancer to prevent treatment-induced gynecomastia. These patients often develop gynecomastia as a result of their treatment, which blocks male hormones.

Medications are more effective if used as early as possible after symptoms are first noted, according to one report.

Breast Reduction Surgery 

Surgery is a common treatment for gynecomastia. In 2016, it was the second most common plastic surgery procedure performed on men. Surgery is generally not recommended for adolescents until puberty is completed to be sure the breast tissue has stopped growing.

There are a number of surgical techniques used to reduce breast tissue. Often men are treated with a combination of an excision technique to remove glandular tissue and/or excess skin and possibly reduce the areola or reposition the nipple and liposuction to remove excess fat.

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