Enlargement of a male breast (gynecomastia) is not uncommon. Normally, I receive my share of referrals for this condition – approximately two to three cases a year.
Recently, in one month, I saw three patients with gynecomastia. One in early teens, one in late teens and one in his fifties. So I thought it is a good time to review the literature and refresh my knowledge.
Gynecomastia is due to formation of firm tender tissue directly under the nipple. It may affect one breast or both breasts. In pseudo-gynecomastia, enlargement of the male breast occurs due to collection of excessive non-tender fatty tissue. Differentiation is important for investigation and management.
Could it be cancer? Yes, one per cent of all breast cancers are in men.
Gynecomastia can occur temporarily in 60 to 90 per cent of the newborns because of the passage of estrogen (female sex hormone) through the placenta.
Gynecomastia can occur during puberty. This can be anywhere from the age of 10 and peaking between the ages of 13 and 14. Then it declines during the late teenage years.
Gynecomastia can occur in the adult population as well. This occurs usually between the ages of 50 to 80.
At birth, the breast tissues of both sexes appear identical. The tissues remain dormant during childhood. At the time of puberty, the male and female breast tissues start showing features of different development.
In the majority of males, breast changes occur during rapid sexual maturation at the time of puberty. This is followed by reversal of changes and atrophy of breast tissues. But in females, the breast tissues continue to enlarge and develop glands for future production of milk.
Estrogen stimulates breast tissue while androgens (male sex hormones) counteract the effects of estrogen. Gynecomastia is caused by relative imbalance between these two types of hormones.
Sometimes it is difficult to know the exact reason for gynecomastia. It may be associated with other medical conditions. Here is the list:
-25 per cent of gynecomstias are idiopathic (unknown cause)
-25 per cent are due to puberty
-10 to 20 per cent due to drugs (prescription drugs, over-the-counter medicines, illegal drugs)
-8 per cent due to cirrhosis of liver or malnutrition
-3 per cent due to testicular tumors
-2 per cent due to poor testicular function
-1.5 per cent due to over active thyroid
-One per cent due to kidney disease
Breast cancer is very rare in males. It is usually hard, non-tender and can be anywhere in the breast. There may be bloody nipple discharge. There may be dimpling of the skin.
How should we investigate?
All patients need full history (including previous medical problems and use or abuse of medications) and full physical examination (especially examinations of the testicles to see if there is a tumor).
If there is nothing significant to find then most teens do not require extensive blood work because most gynecomastia are part of growing up. A periodic follow-up may be advised. In 90 per cent of teenage boys, gynecomastia goes away in less than 3 years.
Gynecomastia can be due to increased production or decreased breakdown of estrogen, which may indicate a hormonal or liver function work-up (blood tests).
In adults, sometimes the problem can be solved by stopping the medications. Rarely, surgery may be necessary to remove the extra breast tissue.
If a breast enlargement is one sided, hard, and nodular, it is very important to perform a biopsy and mammogram to rule out breast cancer.
If gynecomastia is due to disease or tumor then further treatment is required.
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