The Diagnosis, Causes And Treatment Of “Gynecomastia” In Men

Gynecomastia is the development of female-like breast tissue and enlargement of the chest/breasts of a male. Both men and women are born with breast tissue, but this tissue stays very rudimentary and minimal in the male chest. The nipple/areola complex probably represents the most significant”reminder” of these tissues in the male that we normally recognize. More than 50% of newborn males have a feminine, plump look to their breasts which is a temporary form of gynecomastia (due to the effects of maternal estrogens) but this condition essentially disappears within 2 – 3 weeks of birth. However, several years later, the breast tissue in many young men will seem to suddenly develop and enlarge.This soon creates a mass-like effect in the breast which is then further accentuated by an increase in fat deposition. The fat which accumulates is actually a unique type of fat – it is distinctively thick, fibrous and dense.It is not like the normal, softer fat which is elsewhere on the body. The combination of this increased fibrous fat and increased breast tissue starts to make each breast look larger, fuller and more prominent. The breast can become so large that it even begins to droop a bit, just like a woman’s would. The nipple/areola can also grow and become wide, large, “puffy” and projecting. A hard lump of breast tissue, sometimes as large as a golf ball, can often be felt behind the nipple/areola. The breast or nipple area can become very painful and tender, not unlike what many women experience during their menstrual cycle.

On rare occasions, a milky like secretion might even be expressible from the nipple. Gynecomastia is a physically and psychologically extremely disturbing condition which is diagnosed in thousands of young men each year. Young men who are increasingly embarrassed to ever be seen without a shirt on; some of whom can’t even wear an ordinary t-shirt without feeling incredibly self-conscious or humiliated. They skip pool parties, avoid the gym, and pass on the beach trip. They can become overly quiet, isolated, withdrawn; even anti-social. In fact, there is recent research evidence revealing that many of these young men will develop features of mental illness requiring psychiatric evaluation and treatment. It makes sense – their lives are literally thwarted; hijacked by a physical condition that only gets worse with time, that they cannot fix by “working out” more or by dieting, and which undermines their confidence, identity issues and sense of masculinity.And this is all ongoing at the very same time – during adolescence – that these issues are already in turmoil! Gynecomastia typically first appears during adolescence but it often also affects older men. Yet,despite all the negatives, the treatment is often simple, results in a “cure”, and these men, young or more mature, can then go on to lead normal, healthy happy lives just like all the other guys!

What causes gynecomastia in so many young men is not quite clear but we do know that it regularly occurs in some 50 – 60% of all adolescent males! Most experts feel it is related in some way to the tremendous surges in circulating hormones, possibly an “imbalance”, or perhaps hormones are somehow “mis-processed” for a time. Fortunately, in most (about 75%) of these affected teenage boys, the gynecomastia will actually resolve without any treatment, on its own, within 1 – 2 years. However, for many the psychological and emotional toll is too high and simply demands intervention sooner. Parents are often unaware that any of this is occurring and might not understand where the sudden terrible change in behavior and attitude has come from in their teenage son. After treatment, the change for the positive is typically just as dramatic. For about one in four boys affected by gynecomastia, the condition does not spontaneously resolve and persists. Then it gradually gets just a little worse, year after year. This is because a repeating vicious cycle of recurrent inflammation, tissue stimulation and increased fibrous fat and breast gland growth occurs, becoming almost self-perpetuating, even in the absence of adolescent hormonal level swings.

Many commonly prescribed medications have been linked to gynecomastia: Anti-ulcer/reflux medications (e.g. Pepcid, Prilosec, Zantac, Tagamet), ACE inhibitors for hypertension (e.g. Capoten, Vasotec), Calcium Channel Blockers (e.g. Procardia), and Diuretics (e.g. Lasix, Aldactone). Valium, Proscar, Effexor, Motrin, Pepcid, and Digoxin are other common medication examples as well. Some chemotherapy agents may also cause gynecomastia, and the “HAART” therapy used for AIDS patients has also been determined to be a cause. Many medical conditions (e.g. hyperthyroidism, liver failure/cirrhosis, pituitary insufficiency, or kidney failure requiring hemodialysis) and even some tumors (e.g. testicular, adrenal and pituitary) all of which may affect circulating male hormone levels and which can also cause gynecomastia should be considered. Interestingly, malnutrition and starvation can also cause gynecomastia – circulating testosterone levels drop off rapidly, leaving unopposed estrogen effects on the body under such conditions. Self administered and abused anabolic steroids and testosterone supplementation are, unfortunately, probably the most common cause of gynecomastia today- special enzymes in the male system convert a good amount of the “extra” hormones floating around into estrogens which then directly stimulate the growth of the breast tissue and the development of gynecomastia. Unfortunately, once this process starts, even when the steroids are discontinued, the gynecomastia remains or can worsen as the vicious cycle described above begins and allows the gynecomastia to persist and progress. Alcohol, amphetamines, marijuana, heroin and methadone use are also recognized as causes of gynecomastia. Plant oils, such as Lavender oil and tea tree oil as often found in soap, skin lotions, and shampoo, have weak estrogen-like activity and have been implicated in cases of gynecomastia. Similarly, soy beans, soy containing foods and soy based protein supplements as well as sweet potatoes in the diet have all been identified as potential links in the development of gynecomastia thought secondary to the effects of the estrogen-like compounds associated with these foods.

Although rare, breast cancer can occur in the male breast and should be especially considered in the case of an enlargement and solid mass effect on just one side or for the older male with one or both breasts enlarged and where no other reasonable medical explanation exists.

“Pseudogynecomastia” is not a true gynecomastia since it is not characterized by actual excessive breast tissue development but simply significant fat deposition in the chest and breasts, usually in association with similar deposits elsewhere, such as the sides of the chest ( along/near the “lats”) or the abdomen and hips ( or “love handles”). This is really a localized fat deposition problem affecting the chest and, as is the case with troublesome fat found on the body anywhere, may be “cured” by diet, exercise, or liposuction.

A majority of the time, liposuction will be the foundation of any treatment plan for eliminating gynecomastia. In fact, in most cases, the only treatment which may be needed will be liposuction! Tiny armpit area nicks are used to liposculpt the chest – removing the fibro-fatty deposits while reshaping the entire breast to be more masculine. The goals are to get the breast and the nipple/areola to lay as flat as possible against the chest while simultaneously, the pectoral muscles are somewhat accentuated in the upper chest. Most men will only need a day or two off to recover. A couple of weeks for everything to “stick down” and taking it easy with chest muscle use is about it. The nick sites will usually heal to be very inconspicuous, nearly invisible. Liposuction of the outer chest and sides (out toward the “lats”) is often incorporated to further accentuate the overall flattening effect on the chest.

It is typically best to have this type of liposuction performed using either ultrasonic (e.g. Vaser) or laser-assisted (e.g. SmartLipo) techniques. These methods allow for a “melting” of the fat that makes it easier to extract. In addition, the ultrasonic or laser energy can be used to “break up” the dense breast tissue, allowing it to compress, collapse and flatten as is aesthetically desired. Lastly, a better tightening and “snap-back” effect on the skin is also created by these technologies as they heat and “shrink wrap” the collagen on the inside surface, inducing it to retract properly. This is a significant benefit because over time gynecomastia typically causes the overlying skin of the breasts to stretch out, eventually leaving the skin lax and inelastic. Without the use of special technology, this pre-existing limited skin tone would then render the skin only even more loose once the fat is removed. The dense nature of the fibrous fat found in gynecomastia makes it much more difficult to remove by simple mechanical style liposuction than would be the case for “normal”, soft fat. More difficult means more traumatic (i.e. hurts more, bruises more and swells more post-op), more likely to risk contour deformities (i.e. too much out here, not enough out there), more likely to result in asymmetry between the sides, more numbness (because the nerves get more beat up, too!) and more expense (i.e. takes longer). Moreover, traditional mechanical liposuction is virtually useless for making any headway in the contouring of the breast tissue itself and it will have very limited effect (if any) on fighting the tendency of the skin to be loose or hanging. This creates a greater chance that the surgeon will have to resort to more invasive and aggressive methods such as actual mass excision or even skin removal and a male-type breast reduction. Very often, these aggressive procedures can be obviated by the proper use of ultrasonic or laser-assisted liposuction.

Nevertheless, many cases of gynecomastia are associated with a hard lump of gristle-like breast tissue that will not flatten or come out unless it is “cut out”. Sometimes this is predictable by examination pre-op, but sometimes the breast is overall so hard and dense that the lump cannot be detected until significant liposuction has been performed and the lump has been “revealed”. Excision of the lump behind the nipple requires an incision. Some cosmetic surgeons prefer an incision placed in the perimeter of the areola, others will try to hide the incision as a slightly larger version of the liposuction armpit “nick” access. Needing a mass excision adds a bit to the recovery and adds more risk for potential complications (such as fluid accumulation, numbness and long-term contour deformities) post-op. A drain may need to be used and removed in a day or two. The recovery restrictions and time-off are correspondingly more strict.

In more severe cases of breast enlargement and skin tissue laxity, a male-style breast reduction may have to be considered. If the surgeon believes that there is just too much loose skin and that the risk for having wrinkled, hanging, drooping chest skin post-op is too high, this will be recommended. This requires much more extensive incisions, more risk, more scars, more expense, a longer procedure and more of a recovery. Breast tissue removal and lax skin removal are designed so as to create a proper, flat shape. Drains are commonly used and will have to be removed at some point as will be the non-dissolvable sutures needed for this more involved and complex surgery. The discomfort and recovery for a male-style breast reduction is more significant than is the case for the other methods, but if it is needed, it is very worthwhile.

Once healing and recovery are complete, all normal activities can be resumed. Weight lifting, exercise, and sports are all a go. Hopefully, so will be the locker room, the pool, the beach and the confidence level! It may take several months for any small areas of unevenness, numbness or stiffness to finally sort out but usually it is without any interventions needed. However, even the immediate “early” results of treatment are typically quite gratifying. Gynecomastia, once definitively treated as described here, should be “cured” and should never return. However, if circumstances, medical conditions, medications, etc. which may have caused the condition in the first place persist or recur, the process may be re-initiated as well.

Source by Lyle M. Back, MD

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