Gynecomastia

Fabian Dupont is a freelance writer in the medical department. The human medicine specialist is already doing scientific work in Belgium, Spain, Rwanda, the USA, Great Britain, South Africa, New Zealand and Switzerland, among others. The focus of his doctoral thesis was tropical neurology, but his special interest is international public health and the comprehensible communication of medical facts.

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Gynecomastia is a benign growth of the mammary gland in men. It can occur on one side or on both sides. Gynecomastia must be differentiated from so-called pseudogyecomastia (lipomastia), which is caused solely by the increased formation of fatty tissue in the breast area if you are very overweight. Gynecomastia is not always pathological, but can also occur naturally in certain phases of life in boys or men. Here you can find out everything you need to know about it.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. N62

Gynecomastia: description

A female breast growth in men is called gynecomastia. In the process, the glandular tissue grows, which, similar to puberty, goes through different stages in girls. Doctors differentiate between different forms of gynecomastia based on their causes. Depending on whether it is a natural (physiological) or a pathological (pathological) process, the doctor knows whether and how the gynecomastia needs to be treated.

Gynecomastia: symptoms

Gynecomastia (men with breast growth) can occur either on one side or on both sides of the chest area. Gynecomastia is actually a symptom, not a disease in itself. The trigger has to be found in order to develop a suitable therapy.

Other symptoms can occur depending on the cause of the gynecomastia. Gynecomastia can lead to subjective complaints, for example a feeling of tightness in the breasts, restricted mobility or a particular sensitivity to touch of the nipples.

However, it can also appear exclusively through the increase in size of one or both mammary glands, without causing any other symptoms. The so-called puberty gynecomastia can put a lot of psychological stress on adolescents and lead to swimming pools, changing rooms or sports being avoided for fear of ridicule.

Gynecomastia: causes and risk factors

In most cases, the underlying disease, a normal (physiological) body process, medication or drugs influence the hormone ratio of testosterone and estrogen: The normal testosterone level in adult young men is around six nanograms per milliliter of blood (ng / ml), the normal estrogen level around 20 to 40 picograms (pg / ml). This results in a testosterone / estrogen quotient of around 200-300.

The mammary gland tissue reacts very sensitively to fluctuations in the male hormone balance, so that if the balance is disturbed, breast growth can occur. All things that interfere with this balance therefore play a role as risk factors for the development of gynecomastia.

It is important to differentiate gynecomastia from so-called pseudogynecomastia (lipomastia), because with this disorder only fat is stored in the breast. Pseudogynecomastia usually arises in connection with being overweight.

The most important forms and causes of gynecomastia at a glance:

Physiological gynecomastia

Physiological gynecomastia is caused by an altered balance between female sex hormones (estrogens) and male sex hormones (testosterone).The proportion of the female messenger substance, which is always circulating in the body in small quantities in men, increases. The mammary gland tissue is very sensitive to such changes. However, these do not always arise from pathological processes, but can also occur naturally in certain phases of life:

Neonatal gynecomastia: Around 60 percent of all male newborns have a small breast in the first few weeks. However, this occurs only temporarily and disappears again after a few weeks or months. Male babies come into contact with their mother's female hormones during pregnancy and in the first few weeks of their lives. Estrogen is passed on to the child through the placenta and breast milk. The child's liver cannot break down this hormone as efficiently in the first few weeks of life, so that initially the estrogen has a greater influence on the child's development and breast formation can occur more easily.

Puberty gynecomastia: During puberty, some boys develop breast growth, known as puberty gynecomastia. Here, too, a changed balance of sex hormones is responsible. In the course of the serious changes in the hormone balance, it happens that more and more female sex hormones are formed. Puberty gynecomastia usually resolves by the age of 20. If it persists, the glandular tissue can be surgically removed. Many young people find puberty gynecomastia embarrassing and their self-confidence suffers. Because adipose tissue plays a role in the conversion of the male sex hormone testosterone to female estrogen, puberty gynecomastia is more common in overweight adolescents.

Geriatric gynecomastia: With age, the body's percentage of adipose tissue increases and the production of testosterone decreases. The enzyme aromatase, which is particularly abundant in adipose tissue, converts testosterone to estrogen. Both effects together can cause the mammary gland tissue to begin to grow. This form of breast growth is also often favored by being overweight.

Pathological gynecomastia

Breast growth in men can also be an indication of a pathological process in the body that disturbs the hormonal balance or that takes place directly in the breast itself.

Hereditary Gynecomastia: Some men have a problem with the production or processing of hormones. For example, enzymes cannot form certain precursors of the male hormone, or both testes - the main producers of testosterone - are missing. The doctor gets the first indications of this form of gynecomastia in the patient consultation, because "men with breasts" are often already known in the family.
Sometimes parts of the genetic material DNA are missing, or the (female) X chromosome X is present twice (Klinefelter syndrome). Despite the fact that the sex characteristics are actually male, it can happen that the female breast, pelvis and bottom are feminine. Such errors in the genetic material usually arise during the production of the sperm or egg cell or during their fusion (fertilization).

Chronic illnesses: The finely balanced hormonal balance of the body can be disturbed by illnesses.
- The liver plays a particularly important role because it is responsible for breaking down hormones, especially estrogen. In liver diseases such as cirrhosis of the liver, an excess of female hormones can develop, and consequently gynecomastia. The kidney can also cause gynecomastia. In the event of a functional disorder (kidney failure), the hormonal balance is also influenced by the changed filter function.
- In the case of severe malnutrition, such as that caused by anorexia, the testosterone level drops drastically and the liver no longer works at full strength. If you switch to a normal diet after such a hunger phase, the hormone levels are still disturbed for a certain time and gynecomastia can develop. However, this usually regresses within one to two years.
- The loss of one or both testicles can also change the testosterone / estrogen ratio in such a way that the clinical picture of a “man with breasts” appears.

Cancer diseases and gynecomastia: Tumors are groups of cells that have lost their normal function. Your metabolism growth is no longer subject to natural limits and regulatory mechanisms. Some tumors produce effective amounts of hormones themselves, so that an excess of these messenger substances circulates in the body. Sometimes these are sex hormones or substances that actually only occur in the body during pregnancy. This can stimulate breast growth and lead to gynecomastia. In this case one speaks of “paraneoplastic symptoms” (neoplasia = new tissue formation).
However, excessive hormone production with gynecomastia does not always indicate a tumor. There are also many other, less serious diseases that change the hormonal balance, such as the relatively common overactive thyroid (hyperthyroidism).
Breast cancer can also occur in men. This is much rarer than in women and is therefore often only recognized late. Typical of tumor-related gynecomastia (breast cancer) are its acute, one-sided appearance, pain and a feeling of tension.

Gynecomastia due to medication, drugs or care products: A very common cause of gynecomastia is the external intake of hormones or substances that influence the hormonal balance. Some heart drugs, antibiotics or antidepressants also change the hormone metabolism. If a doctor examines a man with a “female” breast, he must also ask in detail about any drug consumption (marijuana, heroin), because prolonged abuse of both substances can lead to gynecomastia, among other things. Heavy, long-term alcohol consumption can also be the cause of a hormone disorder with gynecomastia.
Some skin and hair care products contain small amounts of man-made female hormones that enter the bloodstream through the skin or scalp. The doctor may therefore ask about the hair gel or shampoo as well.

Pseudogynecomastia (lipomastia)

It is important to distinguish gynecomastia from lipomastia. In pseudogynecomastia, the glandular tissue does not multiply, but fat is stored in the breast. Pseudogynecomastia occurs mainly in people who are very overweight and obese. Using the BMI (Body Mass Index) you can estimate the excess weight yourself.

Gynecomastia: examinations and diagnosis

The most important tool of the doctor in gynecomastia is the patient consultation (anamnesis). Often gynecomastia occurs due to the use of medication or drugs, or it is a natural growth process during puberty, the so-called puberty gynecomastia. For this reason, boys under the age of 15 usually do not need any further diagnostics.

Based on the shape and size of the nipple, the growth of the breast can be divided into stages and observed and compared over a longer period of time.

In the case of gynecomastia, the doctor must particularly differentiate between pseudogynecomastia (lipomastia) and real gynecomastia. Therefore, palpation is a very important step in making a diagnosis. In this way, the doctor can quickly distinguish glandular tissue from simple fatty tissue and assess whether there is any abnormal growth of the mammary gland tissue. Some doctors prefer to use an ultrasound machine to determine this difference.

In addition, the doctor determines in particular the liver and kidney values as well as the hormone levels of estrogen and testosterone and their breakdown products in the blood.

An ultrasound examination of the testicles and the abdomen is important in order to assess where the hormones are produced. During this process, the testicles are also palpated, in this way, for example, structural changes or nodules can be felt. In adolescents, the development of the penis and body structure are assessed at the same time - they allow conclusions to be drawn about physical development and the stage of puberty. An X-ray or a CT (computer tomography) of the chest can also be important in certain forms of gynecomastia or if tumors are suspected.

Unilateral gynecomastia with hard tissue (lumps) can raise suspicion of breast cancer. In this case, a mammogram is also done in men to rule out breast cancer.

If no cause for the gynecomastia can be found or if it has existed since birth or puberty, a chromosome analysis can provide clues to a possibly existing genetic disorder. For cost reasons, this examination will only be carried out if there are further indications of a genetic disease.

Gynecomastia: treatment

For gynecomastia, treatment is determined based on the cause of the disease. Often times, like puberty gynecomastia, the problem is only temporary and no treatment is needed. If the cause is known and treatable, the treatment approaches aim to correct the hormonal balance again. If this does not succeed with simple means such as a change in diet or the renunciation of hidden external sources of estrogen, one can intervene in the hormonal balance with medication. Either by giving testosterone directly or by blocking the conversion, production and action of the female hormone estrogen. Such drug therapy is controversial, however, and it is assumed that this will only have an effect in the first few months after the start of breast growth.

Gynecomastia: OP

If medication does not help, surgical breast removal may be considered. Read everything about this in the article on gynecomastia surgery.

Gynecomastia: disease course and prognosis

In the case of physiological gynecomasite, treatment is only necessary if the changes are stressful for the patient. In addition, it is often only a temporary appearance, which disappears by itself after a while. If, on the other hand, it is a pathological gynecomastia, various examinations help to identify possible underlying diseases and hormonal disorders.

In addition, in men with breasts who see a doctor, the doctor must always try to distinguish true gynecomastia from pseudogynecomastia. Pseudogynecomastia can be cosmetically stressful for the patient, but has no disease value. Often there are also mixed forms, because fatty tissue plays an important role in the hormonal balance of men and therefore also in gynecomastia.

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