Male Gynaecomastia

The Condition

Description

Gynaecomastia is a condition in which there is enlargement of the breast tissue in men. One or both breasts can be affected and is usually not a serious problem.

Anatomy

Breast tissues are made up of glandular and fat tissue. Muscles underline the breasts and help in the movement of the arms and breathing. The anatomy of the breast tissue differentiates in boys and girls during puberty. While female hormones in girls increase the fat content in the breasts and encourage its development, male hormones in boys prevent them from growing too much; however, in gynaecomastia there is an increase in the amount of female hormone (oestrogen) relative to the male hormone (androgen), which causes the breasts to increase in size.

Causes

The common causes of gynaecomastia include:

  • Effect of the mother's oestrogen that passes through the placenta and also during breastfeeding. This is a temporary condition that will resolve on its own.
  • Obesity, which can cause increased oestrogen levels and hence swelling of the breasts
  • Hormone imbalance due to an unknown cause, resulting in relatively decreased levels of testosterone compared to oestrogen
  • Hormonal changes during puberty, which can cause temporary gynaecomastia
  • Old age, due to diminished levels of testosterone

Rare causes of gynaecomastia include:

  • Side effects of anti-ulcer or heart disease medications
  • Anabolic steroids
  • Cannabis
  • Alcoholism
  • Kidney failure or liver disease
  • Infection or lumps in the testicles
  • Hypogonadism
  • Genetic disorder (Klinefelter's syndrome)

Impact

Gynaecomastia can cause emotional and psychological distress. Many may feel embarrassed and withdraw from social interaction. The condition however rarely produces any serious complications.

Symptoms

Symptoms may be limited to the increase in size of one or both breasts, but can sometimes be associated with pain and nipple discharge.

Stages

Gynaecomastia is seen in 3 developmental stages:

  • Infancy: This is due to the effect of the mother's hormones on the child, and is commonly seen during breastfeeding.
  • Adolescence: The onset of puberty triggers hormonal changes, which may cause gynaecomastia. Most cases of the condition occur at this stage and usually regress by age 18.
  • Old age: This occurs due to decrease in the level of the male hormone testosterone and elasticity of the skin with advancing age.

Diagnosis

Diagnosis usually begins with a comprehensive medical history and drug history, as well as a family medical history. This is followed by a physical examination of the breasts, abdomen and genitalia. Your doctor may further order blood tests, mammogram, tissue biopsy, ultrasound of the testicles, magnetic resonance imaging and computerised tomography. These tests are performed to ensure that the signs and symptoms are not due to breast cancer, breast abscess (mastitis) or just fatty breast tissue (false gynaecomastia).

Untreated

Gynaecomastia is generally a benign condition and there is little chance of any complication other than the embarrassment and stress caused due to your physical appearance.

Treatments

Gynaecomastia occurring during infancy and puberty are usually self-limiting conditions and do not require any treatment. If it is associated with a condition such as hypogonadism, cirrhosis or malnutrition, treating the underlying condition will lead to improved appearance. Your doctor may substitute or stop medications that cause gynaecomastia. If there is significant pain or grossly abnormal appearance of the breast, your surgeon will suggest surgery.

Approach

Surgery may include liposuction or mastectomy.

Liposuction: This involves the removal of excess fat from the breasts. Liposuction is performed under intravenous sedation and general anaesthesia. You will lie on your back. Markings are made on the breasts. A cannula, a narrow long tube, is inserted into the breast tissue through various incisions. It is moved back and forth to loosen the fat, which is removed by vacuum suction.

Mastectomy: This involves the removal of excess glandular tissue. Mastectomy is performed under intravenous sedation and general anaesthesia. You will lie on your back. Markings are made on the breasts. An incision is made on the breasts and the glandular tissue is removed.

Two-stage breast reduction: Sometimes, liposuction and mastectomy are combined. This is performed in two stages. In the first stage, fat, glandular tissue and fibrous tissue are removed. Four to six months later, the breast tissue may be reconstructed to avoid sagging of the breasts through a process called mastopexy.

Once the size and shape of your breasts are corrected, the incision(s) is closed, bandages applied or a support garment used to support your new chest contour and reduce swelling. A narrow tube may be left in place for drainage of extra fluid and blood.

Preparation

Before surgery, you will be advised to:

  • Avoid aspirin, other blood thinners, anti-inflammatory medication and herbal supplements
  • Continue or adjust the current medication
  • Stop smoking

Post-op

Following gynaecomastia surgery, you will be prescribed medication to aid in healing and avoid infection. You will be given specific instructions that will help your breast tissue to heal well. You will have to wear compression garments for about 4 weeks. It may take a few days before you can resume your regular activities.

Outcome

Following surgery, the size of your breasts are reduced to near-normal size with the right contour and lift needed for male breasts. You will also experience pain relief from breast distension. Surgical scars will lighten with time.

As with all surgeries, male gynaecomastia surgery may be associated with certain risks and complications such as infection, persistent pain, bleeding, blood clots, poor wound healing, unfavourable scars, damage to adjacent blood vessels, nerves, muscle or lungs, and dissatisfactory results in breast symmetry, contour and shape. Some of these complications are temporary, while others may require re-surgery to correct.

Downtime

You will be able to return to work after one or two days, but will not be able to see the final results for about a year.

Prognosis

In certain cases, gynaecomastia can cause boys to have a poor self-image and make it difficult to participate in certain sports such as swimming and boxing. However, if the underlying cause is treated you can expect to make a full recovery. Regression in medication-induced gynaecomastia is seen in 60% of patients. You may need to be off these medications, steroids and have a healthy weight to maintain the results. Surgical prognosis is very good when performed by a skilled surgeon.

Research

Extensive research is being done in treatment of gynaecomastia and includes:

  • Luh JY, Harmon MW. Radiation Therapy for Gynecomastia. Mayo Clin Proc. 2010 Apr;85(4):398–399.
  • Carlson HE. Approach to the patient with gynecomastia. J Clin Endocrinol Metab. 2011 Jan;96(1):15-21.