What is Gynecomastia?
Gynecomastia is the atypical breast enlargement of one or both breasts in men. The process usually begins with a small lump underneath the nipple which causes uneven swelling. Enlarged breasts in men are not uncommon, especially as a newborn or during puberty. In newborns, the gynecomastia may include minor lactation or milk flow (also referred to as galactorrhea) and often disappears within a couple of weeks. During puberty, the condition usually lasts for just a couple months.
Gynecomastia can be one of the most upsetting symptoms of andropause. Low self-esteem, libido and mood are just some of the consequences of this symptom of male menopause.
Male breasts enlargement and andropause
Andropause gynecomastia is usually caused with hormonal imbalances. This explains why the condition occurs in newborns: in newborns gynecomastia is a temporary consequence of the high estrogen levels transmitted to the infant's system from the mother in the womb. Usually the infant's hormones balance themselves without treatment shortly after birth and the enlarged male breasts diminish.
Andropause gynecomastia is another matter. Andropause causes testosterone levels to fall. With less testosterone to regulate and balance estrogen, estrogen levels tend to rise.
Estrogen is mainly considered a female hormone, but every man needs low levels of estrogen to regulate various metabolic processes such as bone density, sperm production, and mood.
Enlarged male breasts are more common in overweight men. Weight gain is also a symptom of andropause, so it is not unusual for men to experience both gynecomastia and weight gain at the same time.
Enlarged breasts during andropause occur when testosterone and male estrogen are drastically out of balance. Proper hormone balance is central to all approaches to treating gynecomastia.
Other causes of Gynecomsatia
Besides the natural aging process in men, and hormonal imbalance, associated with that, a number of various medical conditions may also result in gynecomastia:
- Malnutrition and re-feeding (recovery from malnutrition) have both been shown to create a hormonal environment that may lead to gynecomastia. Similarly, cirrhosis of the liver alters normal hormone metabolism and may lead to gynecomastia.
- Disorders of the male sex organs (testes) can result in decreased testosterone production and relatively high estrogen levels, leading to gynecomastia. These disorders may be genetic, such as Klinefelter's syndrome, or acquired due to trauma, infection, or reduced blood flow. Testicular cancers may also secrete hormones that cause gynecomastia.
- Other conditions that are associated with an altered hormonal environment in the body and may be associated with gynecomastia are chronic renal failure and hyperthyroidism. Rarely, cancers other than testicular tumors may produce hormones that can cause gynecomastia.
Gynecomastia can also be a side effect of a number of medications. Examples of drugs that can be associated with gynecomastia are listed below:
- spironolactone (Aldactone), a diuretic that has anti-androgenic activity;
- Calcium channel blockers used to treat hypertension [such as nifedipine (Procardia and others)];
- ACE inhibitor drugs for hypertension [captopril (Capoten), enalapril (Vasotec)];
- some antibiotics [for example, isoniazid, ketoconazole (Nizoral, Extina, Xolegel, Kuric), and metronidazole (Flagyl)];
- anti-ulcer drugs [such as ranitidine (Zantac), cimetidine (Tagamet), and omeprazole (Prilosec)];
- anti-androgen or estrogen therapies for prostate cancer;
- methyldopa (Aldomet);
- highly active anti-retroviral therapy (HAART) for HIV disease, which may cause fat redistribution leading to pseudogynecomastia or, in some cases, true gynecomastia;
- diazepam (Valium);
- drugs of abuse (for example, alcohol, marijuana, heroin); and
- lavender oil and tea tree oil, when used in skin-care products, have been associated with gynecomastia.
The definition of gynecomastia is the presence of breast tissue greater than 0.5 cm in diameter in a male. As previously discussed, gynecomastia is the presence of true breast (glandular) tissue, generally located around the nipple. Fat deposition is not considered to be true gynecomastia. Therefore, gynecomastia should not be confused with pseudogynecomastia, which occurs in overweight men whose breasts enlarge because of fat deposits.
If you are a man with enlarged or tender breasts, your healthcare provider will perform an examination to determine whether the tissue in your breasts is fatty or glandular. Glandular tissue is designed to secrete substances, such as milk or hormones, and usually has a network of ducts that can be felt.
If the provider has difficulty determining whether you have gynecomastia, he or she may recommend that you have a mammogram, a specialized x-ray of the breast.
In certain situations, blood tests may be ordered to measure the level of hormones. Blood tests are not usually needed if the cause of the gynecomastia (eg, puberty, drugs) is known.
The best treatment for gynecomastia depends upon its cause, duration, and severity and whether it causes pain or discomfort.
Adolescents — Because pubertal gynecomastia usually goes away on its own, treatment is not usually recommended initially. Instead, the provider will keep close tabs on the condition for several months. In most cases, pubertal gynecomastia resolves during that time.
For boys with severe gynecomastia that is causing substantial tenderness or embarrassment, a short course of a drug called tamoxifen (Nolvadex®) or raloxifene (Evista®) may be recommended. These drugs block the effects of estrogen in the body, and can reduce the size of the breasts somewhat. However, neither of these drugs is approved in the United States for the treatment of gynecomastia. Drugs may be prescribed without FDA approval, although the risks and benefits have not been studied completely.
Adult men — Treatment is also usually delayed in adult men whose gynecomastia is likely to be caused by an underlying health problem or by drugs. In these men, treating the underlying condition or suspending the problematic drug usually allows the gynecomastia to resolve.
Medications that have been used to treat gynecomastia include:
- Testosterone replacement has been effective in older men with low levels of testosterone, but it is not effective for me who have normal levels of the male hormone.
- The selective estrogen receptor modulators (SERMs) tamoxifen (Nolvadex) and raloxifene (Evista) have been shown to reduce breast volume in gynecomastia, although they are not able to entirely eliminate all the breast tissue. This type of therapy is most often used for severe or painful gynecomastia.
- Aromatase inhibitors [such as anastrozole (Arimidex)] are a class of medication that interferes with the synthesis of estrogen. While these drugs theoretically should be able to reduce breast mass in gynecomastia, studies have failed to show a significant benefit in treating gynecomastia.
Prostate cancer patients — Gynecomastia is a known complication of a treatment for prostate cancer (called antiandrogen monotherapy). Approximately 75 percent of men who use this treatment develop gynecomastia. However, there are several treatment options available to prevent the development of gynecomastia, including tamoxifen and radiation therapy.
Tamoxifen — Tamoxifen can be taken along with the anti-cancer (antiandrogen) treatment. Tamoxifen must be taken every day for the duration of antiandrogen treatment. In one study, only 8 percent of men who took tamoxifen plus an antiandrogen developed gynecomastia (compared to 68 percent of men who took the antiandrogen alone).
Tamoxifen may also be given to men who develop gynecomastia while taking antiandrogens.
Radiation therapy — Treating the breasts with radiation before antiandrogen treatment begins can prevent gynecomastia. Radiation treatment (RT) is usually delivered in one to three sessions (similar to having an x-ray). In the study above, 34 percent of men who had RT before antiandrogen therapy developed gynecomastia.
Gynecomastia that has already developed can be treated with higher radiation doses and may improve pain. However, when given after breasts have already developed, radiation is not very effective at reducing breast size.
Radiation therapy versus tamoxifen — Although tamoxifen may be more effective than radiation for men who take antiandrogen monotherapy, tamoxifen needs to be taken for the duration of antiandrogen therapy. For some men, taking another medication every day is less convenient than to have three sessions of radiation therapy.
Surgery — Although tamoxifen and raloxifene are effective for men who have had enlarged breasts for a few months, the drug is not effective in men who have had the condition for one to two years or more. For these men, surgery is an option to reduce the size of the breasts.
Two types of surgery are used to treat gynecomastia:
- Liposuction. This surgery removes breast fat, but not the breast gland tissue itself.
- Mastectomy. This type of surgery removes the breast gland tissue. The surgery is often done on an endoscopic basis, meaning only small incisions are used. This less invasive type of surgery involves less recovery time.
The extent of surgery depends upon the severity of the breast enlargement and whether there is also excess fatty tissue. Many men are treated with a combination of surgical removal of the glandular tissue and liposuction. More extensive cosmetic surgery, including partial surgical removal of the breast skin, is required for men with more severe breast enlargement or those who have excessive sagging of the breast tissue, which may occur after weight loss.
Sources and Additional Information:http://www.cnn.com/HEALTH/library/gynecomastia/DS00850.html