Gynecomastia

Gynecomastia (also spelled gynaecomastia) is the non-cancerous enlargement of one or both breasts in men due to the growth of breast tissue as a result of a hormone imbalance between estrogens and androgens. Physically speaking, gynecomastia is completely benign, but it is associated with significant psychological distress, social stigma, and dysphoria. Gynecomastia can be normal in newborn male babies due to exposure to estrogen from the mother, in adolescent boys going through puberty, in older men over the age of 50, and in obese men. Most occurrences of gynecomastia do not require diagnostic tests. Abnormal hormone changes that cause gynecomastia may be caused by any condition that leads to an increase in the ratio of estrogens/androgens such as liver disease, kidney failure, thyroid disease and some non-breast tumors. Alcohol and some drugs can also cause breast enlargement. Other causes may include Klinefelter syndrome, metabolic dysfunction, or a natural decline in testosterone production. This may occur even if the levels of estrogens and androgens are both appropriate, but the ratio is altered. Gynecomastia is the most common benign disorder of the male breast tissue and affects 35% of men, being most prevalent between the ages of 50 and 69. It is normal for up to 70% of adolescent boys to develop gynecomastia to some degree. Of these, 75% resolve within two years of onset without treatment. If the condition does not resolve within 2 years, or if it causes embarrassment, pain or tenderness, treatment is warranted. Medical treatment of gynecomastia that has persisted beyond two years is often ineffective. Gynecomastia is different from "pseudogynecomastia", which is commonly present in men with obesity. Medications such as aromatase inhibitors are effective, even in rare cases of gynecomastia from disorders such as aromatase excess syndrome or Peutz–Jeghers syndrome, but surgical removal of the excess tissue can be needed to correct the condition. In 2019, 24,123 male patients underwent the procedure in the United States, accounting for a 19% increase since 2000.

Definition Gynecomastia is the abnormal non-cancerous enlargement of one or both breasts in men due to the growth of breast tissue as a result of a hormone imbalance between estrogen and androgen. Gynecomastia is different from "pseudogynecomastia", which is defined as an excess of skin and/or adipose tissue in the male breasts without the growth of true glandular breast tissue; this is commonly associated with obesity and can be ruled out by physical exam.

Signs and symptoms In gynecomastia, there is always enlargement of one or both breasts, symmetrically or asymmetrically, in a man. A soft, compressible, and mobile mass of breast tissue is felt under the nipple and its surrounding skin in contrast to softer fatty tissue, which is not associated with a mass. It may also be accompanied by breast tenderness or nipple sensitivity, which is commonly associated with gynecomastia observed in adolescents, typically early in development. Gynecomastia that is painful, bothersome, rapidly-growing, associated with masses in other areas of the body, or persistent should be evaluated by a clinician for potential causes. Dimpling of the skin, nipple discharge, and nipple retraction are not typical features of gynecomastia and may be associated with other disorders. Milky discharge from the nipple is not a typical finding, but may be seen in a gynecomastic individual with a prolactin secreting tumor. An increase in the diameter of the areola and asymmetry of the chest are other possible signs of gynecomastia. Much of the research on gynecomastia has focused on its causes and treatment, but little has explored its effects on mental health and overall quality of life. Gynecomastia has psychosocial implications that may be particularly challenging for adolescents who are experiencing physical maturation and self-identity formation, which includes body image disturbances, negative attitudes towards eating, self-esteem problems, social withdrawal, anxiety, and shame. Men with gynecomastia may appear anxious or stressed due to concerns about its appearance and the possibility of having breast cancer. Particular studies suggest that gynecomastia can lead to various psychological and social challenges, such as depression, anxiety and disordered eating.

Causes Gynecomastia is thought to be caused by an altered ratio of estrogens to androgens mediated by an increase in estrogen action, a decrease in androgen action, or a combination of these two factors. Estrogen and androgens have opposing actions on breast tissue: estrogens stimulate proliferation while androgens inhibit proliferation. The cause of gynecomastia is unknown in around 25% of cases. Known causes can be physiologic (occurring normally) or non-physiologic due to underlying pathologies such as drug use, chronic disease, tumors, or malnutrition.

Physiologic Physiologic or normal gynecomastia can occur at three timepoints in life: shortly after birth in both female and male infants, during puberty in adolescent males, and in older adults over the age of 60.

Newborns 60–90% of male and female newborns may show breast development at birth or in the first weeks of life. During pregnancy, the placenta converts the androgenic hormones dehydroepiandrosterone (DHEA) and DHEA sulfate to the estrogenic hormones estrone and estradiol, respectively; after the placenta produces these estrogens, they are transferred into the baby's circulation, thereby leading to temporary gynecomastia in the baby. In some infants, neonatal milk (also known as "witch's milk") can leak from the nipples. The temporary gynecomastia seen in newborn babies usually resolves after two or three weeks.

Adolescents

Hormonal imbalance (elevated ratio of estrogen to androgen) during early puberty, either due to decreased androgen production from the adrenals and/or increased conversion of androgens to estrogens, leads to transient gynecomastia in adolescent males. It can occur in up to 65% of adolescents as early as age 10 and peaks at ages 13 and 14. It is self-limited in 75–90% of adolescents. Usually, it resolves spontaneously within 1 to 3 years as pubertal progression increases testosterone levels and causes regression of breast tissue. By age 17, only 10% of adolescent males have persistent gynecomastia.

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