Gynecomastia is the benign enlargement of glandular breast tissue in men. It is defined by the presence of greater than 0.5 cm of palpable, firm gland beneath the areola (the pigmented skin around the nipple), in addition to ductal breast tissue.
At least 30% of men worldwide are affected by gynecomastia at some point in their life and the condition may affect males of all ages.
When breast enlargement is due to increased fat deposition without glandular proliferation, the condition is called lipomastia and is most commonly seen in obese people.
Gynecomastia is triggered by the imbalance between estrogen and androgen on breast tissue, which respectively have a stimulatory and an inhibitory effect. This can result from an increased estrogen synthesis, a reduced androgen production, or a combination of both.
There are both physiological and nonphysiological factors that may cause gynecomastia.
There are 3 main phases of physiological gynecomastia, which correspond to the times of hormonal changes:
Certain pathologies and drugs may increase the chances of developing gynecomastia.
Klinefelter Syndrome: a genetic disorder caused by an extra X chromosome.
Kallmann Syndrome: a form of hypogonadism.
Congenital anorchia: a XY disorder of sex development. Individuals affected have both testes absent at birth.
Cirrhosis: poor functioning of the liver.
Kidney failure: end-stage renal disease may lead to reduced testosterone and elevated gonadotropin values.
Inhibitors of androgen synthesis: e.g. cyproterone acetate, flutamide, spironolactone.
Chemotherapeutic drugs: e.g. alkylating agents, methotrexate, imatinib.
Cardiac medications: e.g. calcium channel blockers, digoxin, alpha-blockers, amiodarone, nitrates.
Hormones: e.g. androgens, anabolic steroids, estrogens, growth hormones.
Psychoactive drugs: e.g. haloperidol, diazepam, tricyclic antidepressants.
Drugs for infectious diseases: e.g. antiretroviral therapy medications.
Drug abuse of alcohol, amphetamines, heroin or methadone.
Although divided into groups, not all medications within the same category cause gynecomastia to the same extent.
Treatments for gynecomastia include pharmacological treatment and surgical treatment. While most cases of gynecomastia regress over time without treatment, medications or surgery may be a viable option for persistent gynecomastia.
If gynecomastia is caused by specific medications (such as the ones listed above), it may be advisable to stop taking or substituting them with other medications. This option should be duly discussed with a doctor.
Medications used to treat gynecomastia include tamoxifen, raloxifene, danazol, and aromatase inhibitors. The main goal of these medications is to correct the estrogen-androgen imbalance by either blocking the effects of estrogens on breasts, increasing the amount of androgens, or inhibiting estrogen production.
Pharmacological treatment is most successful when used during the early stages of gynecomastia. If the condition has not been treated at its onset, medications may not be as effective. A doctor will be able to assess which solution best suits each individual’s needs.
Gynecomastia surgery (or male breast reduction) can be an effective solution to treat long-term and severe gynecomastia, or in cases where drug therapies did not work.
Gynecomastia surgery involves removing the excess glandular tissue in the breast. If there is also excess fatty tissue, liposuction may be performed in conjunction. The surgeon makes a small incision on each side of the chest, either along the edge of the areola or within the armpit, and removes excess fat and glandular tissue. In severe cases where patients have excess or sagging skin, a greater amount of glandular tissue may have to be removed, in which case the surgeon will make an incision either along the edge of the areola or within the natural creases of the chest.
The duration of gynecomastia surgery depends on the amount of fatty and glandular tissue, as liposuction may also be required. Generally speaking, the procedure can last 1 to 2.5 hours and is performed as an outpatient procedure.
Recovery time is different for each individual. Typically, a gynecomastia surgery patient is off work for about a week and can resume physical activities 2-3 weeks after surgery. Overall improvement may take from 3 to 6 months.
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