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Gynecomastia

The development of gynecomastia is usually associated with benign pubertal changes; in adolescent boys, the condition is often a source of psychological distress. However, 75% of pubertal gynecomastia cases resolve within two years of onset without treatment. In rare cases, gynecomastia has been known to occur in association with certain disease states. Gynecomastia may be seen in individuals with Klinefelter syndrome or certain cancers, with disorders involving the endocrine system or metabolic dysfunction, with the use of certain medications, or in older males due to a natural decline in testosterone production.

Disturbances in the endocrine system that lead to an increase in the ratio of estrogens/androgens are thought to be responsible for the development of gynecomastia. This may occur even if the levels of estrogens and androgens are both appropriate but the ratio is altered.  The disorder is usually diagnosed by a physician after a detailed history and physical examination. Conservative management of gynecomastia is often appropriate as the condition commonly resolves on its own. Medical treatment of gynecomastia that has persisted beyond two years is often ineffective. Medications such as aromatase inhibitors have been found to be effective in rare cases of gynecomastia from disorders such as aromatase excess syndrome or Peutz–Jeghers syndrome, but surgical removal of the excess tissue is usually required

Signs and symptoms

The classic feature of gynecomastia is male breast enlargement with rubbery or firm glandular subcutaneous chest tissue palpated under the areola of the nipple in contrast to softer fatty tissue. This enlargement may occur on one side or both. Milky discharge from the nipple is not a typical finding, but may be seen in a gynecomastic individual with a prolactin secreting tumor.  Males with gynecomastia may appear anxious or stressed due to concerns about the possibility of having breast cancer.  An increase in the diameter of the areola and asymmetry of chest tissue are other possible signs of gynecomastia

Gynecomastia is thought to be caused by an altered ratio of estrogens to androgens mediated by an increase in estrogen production, a decrease in androgen production, or a combination of these two factors. Estrogen acts as a growth hormone to increase the size of male breast tissue. The cause of gynecomastia is unknown in around 25% of cases

To diagnose gynecomastia, a thorough history and physical examination are obtained by a physician. Important aspects of the physical examination include evaluation of the male breast tissue with palpation to evaluate for breast cancer and pseudogynecomastia (male breast tissue enlargement solely due to excess fatty tissue), evaluation of penile size and development, evaluation of testicular development and an assessment for masses that raise suspicion for testicular cancer, and proper development of secondary sexual characteristics such as the amount and distribution of pubic and underarm hair. Other causes of male breast enlargement such as mastitis, breast cancer, pseudogynecomastia, lipoma, sebaceous cyst, dermoid cyst, hematoma, metastasis, ductal ectasia, fat necrosis, or a hamartoma are typically excluded before making the diagnosis. Another condition that may be confused with gynecomastia is enlargement of the pectoralis muscles. Gynecomastia usually presents with bilateral involvement of the breast tissue but may occur unilaterally as well.

Mammography is the method of choice for radiologic examination of male breast tissue in the diagnosis of gynecomastia when breast cancer is suspected. However, since breast cancer is a rare cause of breast tissue enlargement in men, mammography is rarely needed. If a tumor of the adrenal glands or the testes is thought to be responsible for the gynecomastia, ultrasound examination of these structures may be performed. A review of the medications or illegal substances an individual takes may reveal the cause of gynecomastia. Recommended laboratory investigations to find the underlying cause of gynecomastia include tests for aspartate transaminase and alanine transaminase to rule out liver disease, serum creatinine to determine if kidney damage is present, and thyroid-stimulating hormone levels to evaluate for hyperthyroidism. Additional tests that may be considered are markers of testicular, adrenal, or other tumors such as urinary 17-ketosteroid, serum beta human chorionic gonadotropin, or serum dehydroepiandrosterone. Serum testosterone levels (free and total), estradiol, luteinizing hormone, and follicle stimulating hormone may also be evaluated to determine if hypogonadism may be the cause of gynecomastia.

Early histological features expected to be seen on examination of gynecomastic tissue attained by fine-needle aspiration biopsy include the following: proliferation and lengthening of the ducts, an increase in connective tissue, an increase in inflammation and swelling surrounding the ducts, and an increase in fibroblasts in the connective tissue. Chronic gynecomastia may show different histological features such as increased connective tissue fibrosis, an increase in the number of ducts, less inflammation than in the acute stage of gynecomastia, increased subareolar fat, and hyalinization of the stroma. When surgery is performed, the gland is routinely sent to the lab to confirm the presence of gynecomastia and to check for tumors under a microscope. The utility of pathologic examination of breast tissue removed from male adolescent gynecomastia patients has recently been questioned due to the rarity of breast cancer in this population

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