Gynaecomastia

The basic signs and symptoms are:

• Enlargement of the breast in men, affecting either one breast or both breasts.
• Feeling of a small, rubbery lump under the nipple.
• The palpable mass feels tender, firm, mobile, and appears as a disc-like mound of tissue that is not as hard as breast cancer.
• Soreness, pain, and tenderness in the nipples, typically occurring in the initial months.

Note: If the palpable mass is felt over only one breast and is hard, fixed, and peripheral to the nipple, it may indicate breast cancer. Breast cancer is also associated with nipple discharge, skin changes, or lymphadenopathy (swelling of the lymph nodes).

Gynaecomastia refers to the enlargement of the breast in males. Before understanding the exact cause, it is important to know the structure of the breast and the basic differences between male and female breasts.

Structure of the Breast

Each breast has around 15 to 20 lobes arranged like petals. Each lobe contains smaller structures called lobules that produce milk in females through tiny bulbs. All these structures are linked through ducts, which lead to the nipple, with the dark area at the center called the areola.

What is the Difference Between Male and Female Breast Development?

The development of male and female breasts occurs in a similar way until puberty from gestation.

• At birth, there is a rapid decline in fetal prolactin and estrogen, previously supplied by the mother's body. This halts breast development after birth.
• The complex hormonal interplay during puberty results in the growth and maturation of female breasts in adulthood.
• Breast development is initiated by several hormones, including estrogen, progesterone, prolactin, growth hormone, and IGF-1 (insulin-like growth factor-1).
• Males have testosterone, which has an antiproliferative effect (suppressing cell growth) on breasts, inhibiting their maturation throughout life.

Causes of Enlarged Breasts in Males

Testosterone is converted into estrogen by the enzyme aromatase. An excess of this conversion increases estrogen levels, which can lead to breast development in males. This can occur due to:

• Changes in the level of testosterone
• Increased activity of the enzyme aromatase

Did You Know?

Hormonal fluctuations are not always the cause of gynaecomastia. In some cases, mutations (changes in genetic structure) in the chromosomes that lead to overexpression of the enzyme aromatase can also cause gynaecomastia.

Risk Factors For Gynaecomastia

Obesity

Obese individuals are at high risk of developing gynaecomastia due to elevated estrogen levels resulting from increased aromatase activity in adipose tissue. Leptin, a hormone that regulates weight, increases in obesity and promotes gynaecomastia.

Family History

Individuals with a family history of gynaecomastia are at higher risk. This rare familial form is characterized by elevated aromatase activity among affected family members.

Certain Medications

The use of specific medications increases the risk of gynaecomastia, including:

• Hormonal preparations: Estrogen vaginal creams, gonadotropins, exogenous androgens, growth hormone, flutamide, and finasteride.
• Antihypertensives: Calcium channel blockers (e.g., verapamil, nifedipine, diltiazem), Angiotensin-converting enzyme inhibitors (e.g., captopril, enalapril), amiodarone, methyldopa, spironolactone, reserpine, and nitrates.
• Psychoactive drugs: Diazepam, phenytoin, etomidate, and haloperidol.
• Drugs for infectious diseases: Efavirenz, isoniazid, ethionamide, griseofulvin, metronidazole, and minocycline.
• Anticancer drugs: Busulfan, vincristine, and methotrexate.
• Drugs of abuse: Amphetamines, heroin, methadone, ethanol, and marijuana.
• Others: Theophylline, omeprazole, auranofin, diethylpropion, domperidone, penicillamine, sulindac, heparin, zanoterone, cimetidine, and ranitidine.

Interesting Fact! The topical estrogen spray used to relieve menopausal hot flushes is also associated with gynecomastia in children through skin contact.

Occupation

Bodybuilders and athletes are at high risk of gynaecomastia if they use aromatizable androgens for muscle building.

Hypogonadism

Hypogonadism is characterized by reduced testosterone levels. Conditions that can cause gynecomastia due to hypogonadism include:

• Klinefelter syndrome (a genetic condition where a male is born with an extra X chromosome).
• Kallmann syndrome (characterized by delayed or absent puberty and an impaired sense of smell).
• Kennedy disease (a genetic neuromuscular disorder causing progressive muscle weakness and wasting).

Medical Conditions

Certain medical conditions are associated with an increased risk of breast development, including:

• End-stage kidney disease.
• Liver disease.
• Spinal cord disease.
• Thyrotoxicosis.
• Infertility.
• Diabetes.

Here are 6 interesting facts about diabetes!

Stress

Stress increases the risk of developing gynaecomastia by stimulating the adrenal glands to secrete excess estrogen precursors.

Keep stress at bay. Explore mental wellness products from our extensive range.

Cancer

The following cancers/tumors can increase the risk of gynaecomastia through elevated estrogen levels:

• Testicular cancer.
• Germ cell tumor.
• Sex-cord tumor.
• Fibrolamellar hepatocellular carcinoma.
• Adrenal tumors.

Did you know about refeeding gynaecomastia?

Refeeding gynaecomastia is a reversible form observed in men recovering from a malnourished state. Lack of nutrition can temporarily reduce testosterone levels, and most cases regress within several months after resuming a normal diet. This type was first observed in men returning home from prison camps during World War II.

The following are the treatment approaches for gynaecomastia:

Medical History

The knowledge of detailed medical history plays a crucial role in diagnosing gynaecomastia. The clinician inquires about:

• Medications and alcohol abuse
• Chemical exposures
• Symptoms of underlying systemic illness such as hyperthyroidism, liver disease, mumps, and renal failure
• Weight loss or gain
• Onset and duration of breast enlargement
• Pain and discharge from the nipples
• Undescended testes (testicle that doesn't move down into its proper place in the scrotum before birth)
• Infertility, erectile dysfunction, and libido to rule out hypogonadism
• Body mass index
• Family history of gynaecomastia

Physical Examination

The physical examination of the breast is essential in differentiating gynaecomastia from pseudogynecomastia and breast cancer. These conditions may be distinguished by having the patient lie on his back with his hands behind his head. The examination is performed by placing a thumb on each side of the breast and slowly bringing them together. The following observations differentiate the three conditions:

• True gynaecomastia: Feeling of a ridge of glandular tissue at the nipple-areolar complex
• Pseudogynecomastia: Inability of the fingers to meet until they reach the nipple
• Breast cancer: Feeling of an immobile, unilateral hard, irregular mass located outside the areola, which may be accompanied by skin dimpling and nipple discharge

The abdomen and testicles are also examined. Signs of liver, kidney disease, or hyperthyroidism can be determined through physical examination.

Laboratory Evaluation

Gynecomastia is a complex interplay of fluctuations in several hormones. The following blood tests are performed to assess the exact cause of gynaecomastia:

• Testosterone
• Estradiol
• Luteinizing hormone (LH)
• Human chorionic gonadotropin (hCG)

Further testing is done according to history, physical examination, and blood levels of the aforementioned hormones.

Imaging Tests

• Scrotal/Testicular USG: This involves ultrasound scanning of the scrotum to assess any abnormalities in the testis, particularly if an abnormal testicular mass is detected during physical examination. Testicular ultrasound is also required if serum HCG levels are found to be elevated.
• Mammography (MMG): An X-ray imaging method used to examine the breasts when there is suspicion of cancer. This method is highly sensitive and accurate for differentiating true gynecomastia from breast cancer, reducing the need for biopsies.
• Breast Ultrasonography (USG): The sonography of breasts is widely used in diagnosing gynecomastia cases and is more comfortable for male patients.
• Abdominal CT: This involves the use of X-rays to detect the presence of non-testicular tumors, indicated when HCG levels are high and ultrasound does not show a testicular mass.
• Karyotyping: In this test, chromosomes are examined under a microscope using a blood sample. A karyotype test shows consistent results at any time in a person's life and is performed if the individual has low testosterone levels along with a family history of Klinefelter syndrome.

Biopsy

Biopsy involves the examination of tissue, particularly for cancer. It is performed in high-risk individuals who exhibit signs of cancer, such as patients with Klinefelter syndrome.

Obesity, a lifestyle disorder characterized by excessive body fat accumulation, increases the risk of various health problems, including gynaecomastia. Our obesity screening package can assist in identifying the causes of obesity, which may stem from a combination of inherited factors, poor diet, and sedentary lifestyle choices.

A well-balanced, nutritious diet and an active lifestyle, including at least 30 minutes of exercise daily, can help reduce the risk of obesity and, consequently, gynaecomastia (further discussed in the home care section).

Prevention of Gynaecomastia in Prostate Cancer

Men with prostate cancer are at a heightened risk of developing gynaecomastia due to anti-androgen therapy. Gynaecomastia in this context can be prevented by:

• Medications such as oral tamoxifen
• Radiation therapy

Most cases of pubertal gynaecomastia resolve on their own within one to two years. Treatment is initiated after a confirmatory diagnosis of the underlying cause of gynaecomastia. Individuals in whom no abnormalities are detected are observed closely, with a breast exam recommended every 3 to 6 months.

Approach to Treatment

The approach to treatment varies based on the underlying cause. The different approaches include:

• Any detected endocrinologic or systemic disease is treated first.
• Any detected tumor is surgically removed, followed by chemotherapy.
• Medications causing gynaecomastia should be discontinued, considering the ongoing therapy needs.
• Breast removal is indicated if a breast biopsy indicates cancer.

Acute gynaecomastia (less than 6 months) with no other clinical findings is generally reversible with medications. However, regression is unlikely if the breast enlargement is chronic.

Treatment Options

Medications

The medications used in gynaecomastia include:

• Androgens: These drugs alter testosterone levels, helping to balance the testosterone/estrogen ratio. Common examples include:
• Testosterone: Most commonly used in hypogonadism characterized by low serum testosterone levels.
• Dihydrotestosterone: A non-aromatizable androgen that does not convert into estrogen, showing good response in prolonged pubertal gynaecomastia.
• Danazol: A weak androgen that inhibits gonadotropin secretion, leading to decreased testosterone production and reduced estrogen, aiding in breast regression.
• Antiestrogens: These drugs decrease estrogen activity, the main trigger for breast development. Common examples include:
• Clomiphene citrate: Mostly used in painful gynaecomastia.
• Tamoxifen: Shows excellent results when the exact cause of gynaecomastia is unknown.
• Aromatase Inhibitors: These drugs inhibit the enzyme aromatase, which converts testosterone into estrogen. Common examples include:
• Letrozole: Associated with decreasing breast size.
• Anastrozole: Effective in pubertal gynaecomastia and in individuals with Sertoli cell tumors; beneficial for those with familial aromatase excess.

Liposuction

This procedure is performed on individuals with excess fat. It involves removing excess fat and fluid through a vacuum tube, thereby reducing breast size.

Surgery

Surgical removal of breast tissue is recommended in the following cases:

• Longstanding gynaecomastia.
• If gynaecomastia interferes with daily, social, or career choices.
• Suspicion of breast cancer.

Things to Avoid Before Gynecomastia Surgery

• Avoid sunbathing for at least 2-3 weeks before surgery, as tanning of the chest skin may increase the risk of permanent scarring.
• Avoid smoking and alcohol for at least 2 weeks before surgery.
• Avoid blood thinners, aspirin-containing products, herbal supplements, and Vitamin E supplements.

Post-operative Care

• Pat dry the dressings after bathing.
• Keep your compression shirt or garment on at all times, except to shower and wash the garment.
• Avoid swimming for at least two weeks.
• Avoid lifting weights over 10 lbs for 2 weeks.
• Refrain from heavy activity, straining, or sports that may put strain on the incision for two weeks.

Use cold compresses

Gynaecomastia causes tenderness and soreness of the breasts. Cold compression helps reduce pain by contracting the swollen nerves.

Make dietary modifications

Foods to include

• Lean proteins (chicken, turkey, and fish)
• Fruits and vegetables
• Whole grains (oats, brown rice, and whole wheat)
• Healthy fats (avocado, nuts, and olive oil)
• Low-fat dairy products (milk and yogurt)
• Legumes (beans and lentils)
• Foods rich in antioxidants (berries and leafy greens)

Foods to avoid

• Soy products
• Beetroot
• Processed foods
• Frozen food
• Fried food

Exercise regularly

Individuals should engage in regular physical activity and exercise, including strength training exercises that target chest muscles. This helps reduce overall body fat, making gynaecomastia less noticeable. The exercises that help in gynecomastia include:

• Swimming
• Walking
• Running
• Bench press
• Push-ups
• Bent forward cable crossover
• Rowing machine

Try home remedies

The following home remedies can be an adjunct to conventional treatment of gynaecomastia. However, it is advisable to consult your healthcare provider before starting any of these:

• Turmeric (haldi): Curcumin, a major ingredient of turmeric, promotes the production of testosterone and reduces swelling in some cases of gynaecomastia. It can be consumed by mixing one tablespoon of turmeric powder in one cup of hot milk.
• Vitamin E: Rich in antioxidants, Vitamin E helps in gynaecomastia by blocking the aromatase enzyme and naturally reducing estrogen levels. Individuals should consume Vitamin E-rich foods such as:
  • Sunflower and soybean oil
  • Almonds
  • Peanuts
  • Peanut butter
  • Spinach
  • Pumpkin
  • Red bell pepper
• Flax seeds (alsi): High in omega-3 fatty acids, flax seeds increase testosterone levels and decrease estrogen levels. The lignans present in flax have anti-estrogenic properties, which help manage gynaecomastia. They can be added to smoothies, cereals, and yogurt.
• Fish oil: Oil from cold-water fish such as tuna, mackerel, and salmon is a rich source of omega-3 fatty acids, which help combat gynaecomastia by boosting testosterone levels. These fish can be consumed directly, and their supplements are readily available for medicinal benefits. Shop Fish Oil Supplements
• Zinc: Zinc helps manage gynaecomastia by regulating testosterone levels. Zinc-rich foods include:
  • Raisins
  • Cashews
  • Oysters
  • Lobster
  • Chickpeas
• Green tea: Rich in antioxidants with fat-burning properties, the intake of green tea helps prevent fat deposition around the breasts. Shop for green tea from our extensive collection.

Plant-based therapies

• Milk thistle: Known as silymarin, it is used to treat liver disorders. Since breast enlargement can be a sign of liver dysfunction, it is used to regress breast size. Its crushed seeds can be taken with water or consumed as a supplement as directed by your physician. Shop for Milk Thistle supplements.
• Dandelion: A wildflower that helps flush excess estrogen, protecting the breast from its effects. Its leaves can be added to salads, sandwiches, and teas.
• Passionflower: Known as a natural testosterone booster, it is widely available in several herbal supplements. It can also be consumed in tea made by adding dried passion flowers to boiling water.
• Red clover: A herb known for its effects on estrogen metabolism, it helps normalize estrogen and testosterone levels. It can be consumed in tea made by boiling approximately 4 grams of dried flower tops in 1 cup of boiling water.

Gynaecomastia does not cause any physical complications itself. However, the feminine appearance can lead to psychological or emotional problems in men, including:

• Embarrassment
• Lower self-esteem
• Excessive worry
• Anxiety
• Depression
• Eating disorders such as Anorexia and Bulimia
• Social phobia
• Avoidance

Gynaecomastia is medically harmless but can reduce overall quality of life. The following measures help to manage symptoms at physical, psychological, and emotional levels.

Reduce Stress

Chronic stress can aggravate the symptoms of gynaecomastia by causing hormonal imbalances. The following measures can be taken to reduce stress:

• Practice mindfulness and meditation
• Indulge in yoga
• Do deep breathing exercises

Make Conscious Clothing Choices

Individuals with gynaecomastia should wear loose-fitting clothing that doesn't cling tightly to the chest. Dark-colored clothing also helps improve visible appearance.

Wear Compression Garments

Men with gynaecomastia should wear compression shirts or undershirts. This helps flatten the chest area and reduces the visibility of gynaecomastia.

Maintain Good Posture

Proper posture can improve body alignment and minimize the prominence of gynaecomastia. Individuals should stand straight without bending their shoulders.

Dealing with the Psychological Aspect

Gynaecomastia can have a long-lasting effect on emotional health. The unwanted change in physical appearance, especially during puberty, can lead to bullying and self-consciousness. Feelings of insecurity can lead to depression and anxiety, emotional isolation, loneliness, and sometimes the development of harmful habits such as drug abuse and alcoholism. Individuals may alter their activities, avoiding gym class or sports. Adolescent boys often experience difficulty in developing relationships.

Educating and understanding the following facts helps reduce emotional burden:

• It is a medically harmless condition.
• Most cases of physiological gynaecomastia resolve on their own after puberty or adolescence.
• Gynaecomastia is not a sign of breast cancer.

How to Cope with It?

• Self-acceptance
• Communicate with loved ones; it helps manage stress and anxiety.
• Engage in fun-loving activities.
• Seek support from a therapist.

Role of Family

Family and friends should understand the signs of instability in their loved ones and provide support. Peers should look for the following signs of instability:

• Is he becoming withdrawn?
• Has he stopped participating or showing interest in his usual activities?
• Has there been a noticeable decrease in performance and motivation at school or work?
• Does he avoid intimacy?

Noticing symptoms early will help minimize the long-term damage of gynaecomastia.

Note: Individuals with gynaecomastia can suffer from inferiority complexes, which is the feeling of inadequacy compared to peers. Here is a detailed video by our expert to understand inferiority complex and ways to identify it.