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Gynecomastia is a condition in which there is enlargement of the male breasts. It is not just deposition of fat tissue but proliferation of the breast tissue leading to enlargement of male breasts.Enlarged male breasts can be on one side or on both sides.

Gynecomastia- male breasts

The enlargement may sometimes be larger on one side compared with the other. Though enlarged male breasts can cause psychological problems, the more serious issues include the fear of breast cancer and sometimes the underlying hormonal problem or systemic diseases which lead to enlarged male breasts. Most often no specific treatment is necessary. In those who are to be treated, the solution for gynecomastia depends on treating the underlying cause. 

Though enlarged male breasts are abnormal, there are three situations where enlarged male breasts can be considered a normal physiological phenomenon. These include:

  • Transient gynecomastia of the newborn ( due to hormones that has crossed over from mother to the fetus across the placenta)
  • Pubertal gynecomastia
  • Gynecomastia in older adult men ( due to changes in sex hormone metabolism)

About 30-65% of men have some degree of gynecomastia. About 50-70% of boys have enlarged breasts during puberty. This is a transient phenomenon which may persist for a few months. Some degree of gynecomastia is seen in more than 50% of hospitalized men. Sometimes deposition of fat tissue may mimic enlarged male breast. This condition is called lipomastia or pseudogynecomastia. These two mimicking conditions can be differentiated by physical examination or by mammography.

Causes of enlarged male breasts

The various causes of enlarged male breasts are:

  1. Absolute excess of estrogen ( the female sex hormone) – This could occur due to excess production as in certain testicular and adrenal tumors or due to excess estrogen that is administered as in the treatment of prostate cancer.
  2. Absolute deficiency of androgen (the make sex hormone) – This could occur when the production is deficient as in primary or secondary hypogonadism or when the secreted androgen is ineffective in its action. Klinefelter syndrome is one of the conditions in which there is absolute deficiency of androgen.
  3. When there is relative excess of estrogen – This could be due to
  • Pubertal gynecomastia
  • Gynecomastia of aging
  • Renal failure and hemodialysis
  • Cirrhosis of liver
  • Hyperthyroidism
  • Gynecomastia in men with prostate cancer
  • Gynecomastia in HIV positive men
  • Diabetes
  • Drugs

The various medications which can cause gynecomastia are:

  • Estrogen
  • Alcohol
  • Chemotherapeutic agents like alkylating agents, vincristine, methotrexate, nitrosoureas, cisplatin, imatinib
  • Ketaconazole
  • Spironolactone
  • Finasteride and dutasteride
  • Flutamide
  • Cimetidine
  • Isoniazid
  • Digoxin
  • Medications used to treat HIV

Evaluation of enlarged male breasts

Not all with gynecomastia need to be evaluated. As mentioned earlier it can be physiological also. The neonatal gynecomastia and pubertal gynecomastia are transient and will subside on its own in a couple of months. Moreover, as more than 50% of those who get hospitalized develop some degree of gynecomastia, it is not necessary to evaluate the cause in all individuals with gynecomastia. Evaluation of enlarged male breasts is required in the following individuals:

  • In those who are lean
  • In those who had a recent onset of gynecomastia
  • In those in whom the growth is rapid
  • In those in whom it is tender
  • In those in whom the breast tissue is large

The evaluation includes a detailed history including that of intake of any medication, examination of the testes, assessment of the development of secondary sexual characteristics and assessment of liver function. As mentioned earlier lipomastia should be excluded by mammogram in all who undergo evaluation for gynecomastia. The laboratory tests that are to be done includes:

  • Liver function test
  • Serum testosterone
  • Androstenedione
  • Estradiol
  • Luteinizing hormone
  • hCG
  • Thyroid function test
  • Tumor markers for germ cell  tumors
  • Genetic analysis if the testes are small

Enlarged male breast and breast cancer

Not all cases of enlarged male breasts are associated with increased risk of breast cancer. But however there is an increased risk of developing breast cancer especially in individuals with gynecomastia who are diagnosed to have Klinefelter syndrome. Obesity increases the risk of breast cancer in those with gynecomastia.

Solution for gynecomastia

The following are some of the solutions for gynecomastia:

General measures

  • If the person with gynecomastia does not have any symptoms and has been having enlarged breasts for a long time, there is no need for any specific treatment.
  • If enlarged male breasts are due to any medication, recreational drug, then the offending drug should be withdrawn. Once the individual stops taking it, the gynecomastia improves over a period of few weeks. But if there is no improvement in spite of stopping the offending medication and enlarged breasts continue to persist for months even after that or if it is unable to stop certain medications for various reasons, then medical therapy should be attempted to treat gynecomastia.

Medical therapy for enlarged male breasts

Since enlarged male breast are due to increased effects of estrogen or decreased effect of androgen, medical therapy is used to address these issues.

  • Medications that block estrogen effect – These include tamoxifen, raloxifene and clomiphene
  • Medications that decrease estrogen production – These include aromatase inhibitors like testolactone and anastrazole
  • Androgens to counteract the effects of estrogens.

Surgical treatment

Though treating the underlying cause and medical therapy are the common solutions for gynecomastia, they are sometimes ineffective especially in longstanding cases of gynecomastia. This is because   the breast tissue gets replaced by scar tissue in longstanding cases of gynecomastia and it is not amenable to medical treatment. In these individuals surgery is done to treat gynecomastia. Surgery is also done in those in whom there is failure of medical treatment, in those who do not tolerate medical therapy and also for cosmetic reasons. Incision is made around the areola and the excess breast tissue is removed surgically.

Radiation therapy

Though radiation therapy is not a common solution for enlarged male breasts, it is sometimes indicated. The indications include:

  • Men with prostate cancer
  • Gynecomastia associated with antiandrogen therapy

  • Gynecomastia - Endocrinology and Metabolism Clinics - Volume 36, Issue 2 (June 2007
  • Rakel: Textbook of Family Medicine, 7th edition
  • Kronenberg: Williams Textbook of Endocrinology, 11th edition