Gynecomastia

Gynecomastia is a condition that refers to the enlargement of the breast tissues (glandular proliferation) in males. Only accumulation of fatty tissue is not regarded as gynecomastia. One or both breasts may be affected either symmetrically or unevenly. Gynecomastia can affect males during any age group, infancy, puberty, and middle-aged to older men. Often the mothers’ estrogen hormone can cross the placenta and lead to the enlargement of the male babies' breasts, but that condition resolves on its own within 2-3 weeks.

About 1 in 4 men are affected by gynecomastia between the ages of 50 and 69. The condition itself is not usually harmful or serious, but it can lead to low self-esteem and psychological problems in males. In some cases, it is accompanied by pain or soreness, swelling, and nipple discharge. Immediate medical care is required if one experiences any of these symptoms. 

Gynecomastia is caused by an imbalance in the sex hormones, which are estrogen and testosterone. These hormones usually determine the sexual characteristics of males and females. In males, testosterone is in greater amount than estrogen and is responsible for muscle mass, distribution, and quality of body hair, sex drive, and mood. Any condition that can alter this balance of hormones can lead to gynecomastia. It can either be caused by natural hormone alterations during puberty or due to some pathological conditions or adverse effects of some medicines.

Disorders that can result in gynecomastia include;

• Tumors of the testes, adrenal gland, or pituitary gland
• Kidney failure
• Malnutrition or starvation,
• Liver failure, or cirrhosis,
• Hyperthyroidism

Medications that may result in the development of gynecomastia include;

• Illicit drugs; amphetamines, heroin, marijuana, methadone
• Cancer and chemotherapy drugs
• Antiandrogens; flutamide, finasteride
• Antibiotics such as metronidazole, isoniazid
• Cimetidine
• Heart medications; digoxin, Calcium channel blocker.
• A tricyclic antidepressant; amitriptyline, antianxiety medication; diazepam 

You may have increased chances of getting gynecomastia if you have one of the following;

• Age groups; infancy, puberty, older age
• Use of steroids for increasing muscle mass
• Thyroid disorders
• Using some medications discussed above
• Advanced liver disease
• Renal disease
• Klinefelter syndrome
• Familial
• Lung carcinoma

The condition can be classified as functional gynecomastia, in which no pathological cause is present, and it occurs due to normal imbalance at different age peaks like infancy, puberty, and very old age.

The other type is pathological, in which the gynecomastia is due to some abnormal condition or disease. 

Gynecomastia is quite a common condition. Temporary gynecomastia affects around 60 – 90% of infants due to the high estrogen state of pregnancy. The second peak of functional gynecomastia occurs during puberty and affects approximately 4-69% of boys about the age of 12 years. The third peak affects 24-65% of older men. 25% of people are diagnosed with persistent pubertal gynecomastia. In 8%, the condition is due to cirrhosis or malnutrition, 3% are due to testicular tumors, while no abnormality is detected in 25% of the patients. 

The condition may not result in any particular symptoms except for the enlargement of the breast. Other symptoms may include;

• Breast tenderness or pain
• Swollen breast gland tissue
• Discharge from the nipples 

If you have bothersome symptoms or notice any change in the size, shape, or pain of the breasts, consult your doctor. Diagnosis is made based on the following;

• A careful medical history, including drug use, past, and current medical conditions, and family history, may be necessary.
• A thorough physical examination, including assessing the breast tissue, abdomen, and genitalia.
• Blood tests to evaluate levels of Free or total testosterone, estradiol, luteinizing hormone (LH), Dehydroepiandrosterone (DHEA) sulfate levels, and parameters to evaluate the liver, kidney, and thyroid function.
• If cancer is suspected, a mammogram may be ordered by the doctor.
• Further testing may be required depending on the initial test result, such as CT scan, MRI scan, tissue biopsy, testicular ultrasound.

Several conditions may need to be excluded to make efficient progress towards treating the disorder like;

• Hypogonadism
• Idiopathic gynecomastia
• Hyperprolactinemia
• Chronic liver disease
• Drug-induced gynecomastia
• Obesity (pseudo gynecomastia )
• Breast cancer
• Lymphangioma
• Dermoid cyst
• Breast mouse

In most cases, especially in pubertal males, the condition resolves over time with no treatment. If the patient's condition is caused by an underlying medical condition such as malnutrition or cirrhosis, those conditions may need treatment. The doctor may ask to stop or change medication in cases where it is caused by the adverse effects of a medicine. Breast cancer medication such as aromatase inhibitors (Arimidex) Tamoxifen (Soltamox ) may be helpful for some, but these medications are approved by the FDA to treat breast cancer, not gynecomastia.

If significant breast enlargement still exists after initial treatment, the doctor may suggest surgery. Liposuction or mastectomy are two gynecomastia surgical options. The liposuction procedure involves removing the breast fats and not the breast gland tissue. In a mastectomy, the breast gland tissue is removed.

One may go for counseling and support to cope, talk to friends and family, or connect with people with the condition.

Following medication are used for gynecomastia ; 

• Tamoxifen (estrogen agonist)
• Raloxifene
• Testosterone replacement therapy 

Gynecomastia is a benign condition. It is not known to cause long-term complications. Pubertal gynecomastia resolves spontaneously within months or years. In other cases, the only treatment is removing breast tissue which requires surgery. Gynecomastia is sometimes associated with breast cancer which needs to be treated accordingly. 

Besides medicines, some modifications of the habits can be made to cope with the condition;

• Firstly, consult a doctor for any underlying cause and its treatment
• Perform some chest exercises to reduce the associated fatty tissue and improve muscle mass.
• Make dietary modifications with minimum fat inclusion and increased fruits and vegetables.
• There is no shame in consulting a psychotherapist to treat associated depression, anxiety, low self-esteem, etc.
• Join support groups or connect with people with a similar issue.