GYNECOMASTIA

• Gynecomastia is enlargement of the glandular tissue of the male breast.
• Gynecomastia may occur during infancy and puberty in normally-developing boys.
• Gynecomastia results from an imbalance in the hormonal environment in the body, with a relative excess of estrogens (female hormones) when compared to androgens (male hormones).
• Gynecomastia can result as a side effect of numerous medications and drugs of abuse.
• Gynecomastia is associated with certain medical conditions including hyperthyroidism, chronic kidney failure, and cirrhosis of the liver.
• Medications and surgical treatments can be used to treat gynecomastia.

Gynecomastia results from an imbalance in hormone levels in which levels of estrogen (female hormones) are increased relative to levels of androgens (male hormones). Gynecomastia that occurs in normally-growing infant and pubertal boys that resolves on its own with time is known as physiologic gynecomastia.

All individuals, whether male or female, possess both female hormones (estrogens) and male hormones (androgens). During puberty, levels of these hormones may fluctuate and rise at different levels, resulting in a temporary state in which estrogen concentration is relatively high. Studies regarding the prevalence of gynecomastia in normal adolescents have yielded widely varying results, with prevalence estimates as low as 4% and as high as 69% of adolescent boys. These differences probably result from variations in what is perceived to be normal and the different ages of boys examined in the studies.

Gynecomastia caused by transient changes in hormone levels with growth usually disappears on its own within six months to two years. Occasionally, gynecomastia that develops in puberty persists beyond two years and is referred to as persistent pubertal gynecomastia.

A number of medical conditions may also result in gynecomastia:

• Malnutrition and re-feeding (recovery from malnutrition) have both been shown to create a hormonal environment that may lead to gynecomastia. Similarly, cirrhosis of the liver alters normal hormone metabolism and may lead to gynecomastia.
• Disorders of the male sex organs (testes) can result in decreased testosterone production and relatively high estrogen levels, leading to gynecomastia. These disorders may be genetic, such as Klinefelter’s syndrome, or acquired due to trauma, infection, reduced blood flow, or aging. Testicular cancers may also secrete hormones that cause gynecomastia.
• Other conditions that are associated with an altered hormonal environment in the body and may be associated with gynecomastia are chronic renal failure and hyperthyroidism. Rarely, cancers other than testicular tumors may produce hormones that can cause gynecomastia.

Gynecomastia can also be a side effect of a number of medications. Examples of drugs that can be associated with gynecomastia are listed below:

• spironolactone (Aldactone), a diuretic that has anti-androgenic activity;
• Calcium channel blockers used to treat hypertension (such as nifedipine [Procardia and others]);
• ACE inhibitor drugs for hypertension (captopril [Capoten], enalapril [Vasotec]);
• some antibiotics (for example, isoniazid, ketoconazole [Nizoral, Extina, Xolegel, Kuric], and metronidazole [Flagyl]);
• anti-ulcer drugs (such as ranitidine [Zantac], cimetidine [Tagamet], and omeprazole [Prilosec]);
• anti-androgen or estrogen therapies for prostate cancer;
• methyldopa (Aldomet);
• highly active anti-retroviral therapy (HAART) for HIV disease, which may cause fat redistribution leading to pseudogynecomastia or, in some cases, true gynecomastia;
• digitoxin;
• diazepam (Valium);
• drugs of abuse (for example, alcohol, marijuana, heroin); and

Normally-developing pubertal males may be at risk for gynecomastia that is part of the normal developmental process. Normal male infants also may have gynecomastia. Other risk factors include aging, since aging may promote decreases in testosterone production that can cause gynecomastia. The risk factors for developing gynecomastia related to specific diseases and conditions (such as cirrhosis of the liver) are the same risk factors that predispose to those conditions. Taking certain medications (see above) may increase the risk of developing gynecomastia.

What are the symptoms of gynecomastia?

The primary symptom of gynecomastia is enlargement of the male breasts. As mentioned before, gynecomastia is the enlargement of glandular tissue rather than fatty tissue. It is typically symmetrical in location with regard to the nipple and may have a rubbery or firm feel. Gynecomastia usually occurs on both sides but can be unilateral in some cases. The enlargement may be greater on one side even if both sides are involved. Tenderness and sensitivity may be present, although there is typically no severe pain.

The most important distinction with gynecomastia is differentiation from male breast cancer, which accounts for about 1% of overall cases of breast cancer. Cancer is usually confined to one side, is not necessarily centered around the nipple, feels hard or firm, and can be associated with dimpling of the skin, retraction of the nipple, nipple discharge, and enlargement of the underarm (axillary) lymph nodes.

It is appropriate to consult a health care practitioner if a male develops gynecomastia in order to determine its cause. The health care practitioner can order tests if necessary to rule out any serious medical conditions that may be the cause of gynecomastia.

How is gynecomastia diagnosed?

The definition of gynecomastia is the presence of breast tissue greater than 0.5 cm in diameter in a male. As previously discussed, gynecomastia is the presence of true breast (glandular) tissue, generally located around the nipple. Fat deposition is not considered to be true gynecomastia.

In most cases, gynecomastia can be diagnosed by a physical examination. A careful medical history is also important, including medication and drug use. If there is a suspicion of cancer, a mammogram may be ordered by a health care practitioner. Further tests may be recommended to help establish the cause of gynecomastia in certain cases. These can include blood tests to examine liver, kidney, and thyroid function. Measurement of hormone levels in the bloodstream may also be recommended in some cases.

Reduction mammoplasty (breast reduction surgery) has been used for decades as the definitive treatment of gynecomastia, or in cases in which drug therapies have not been effective. Dr. Ishoo has extensive experience in surgical treatment of gynecomastia and has developed ChestSculpt, a highly effective minimally invasive surgical treatment of gynecomastia with a highly masculine appearance.

Although pubertal gynecomastia typically regresses on its own, in rare cases it may persist, requiring treatment. Gynecomastia that is present over the long term (12 months or more) may undergo scarring (medically termed fibrosis), making treatment with medications much more difficult if not impossible to achieve a response.

Psychological consequences can occur if the breast enlargement is pronounced or is a source of embarrassment.

Can gynecomastia be prevented?

Gynecomastia that occurs because of hormonal fluctuations with growth or aging cannot be prevented. Gynecomastia related to medical conditions can only be prevented to the extent that the underlying or responsible condition can be prevented.

What is the prognosis for gynecomastia?

True gynecomastia does not generally resolve without treatment, and medical treatment is not effective in resolving it in many cases. For cases in which the breast tissue has become persistently enlarged or fibrotic, surgical techniques can help restore normal appearance. However, the standard procedures may result in significant deformity and require prolonged recovery. Dr. Ishoo’s ChestSculpt innovation, results in dramatic contouring and sculpting of breast fat and gland tissue to create the most natural and masculine chest.

It is important that you entrust your Male Chest Reduction to an experienced surgeon performing this procedure. Dr. Edwin Ishoo has extensive experience with using the VASER™ and the microdebrider in body sculpting. Please contact Dr. Ishoo for a confidential, complimentary consultation to see if ChestSculpt procedure is right for you. Please visit our photo gallery to see our before and after photos.