Gynecomastia is an increase of size of the breast in men, produced by a benign proliferation of glandular breast tissue. Their cause is an imbalance between the stimulating effects of estrogen (female sex hormones) and the inhibitory effects of androgens (male sex hormones) in the breast tissue, when the first increase, or the seconds down.
The mammary gland is regulated by the action of various hormones including estrogen, progesterone, and prolactin. Both estrogen and progesterone stimulate breast growth and the development of breast glandular tissue. Before puberty, there are no differences between the mammary glands of both sexes, however, from this, the hormonal changes that occur in the body conducive to the development of the mammary gland in women. In the male are kept low concentrations of estrogens, dominate the action of androgens, so you breast them does not occur.
The true Gynecomastia usually appears as a lump or an increase of the breast volume, which can be unilateral (affecting a single mother) or bilateral (in both), and which can accompany breast hypersensitivity or pain. It is important to make a differential diagnosis between true Gynecomastia and other pathologies, mainly two:
- Pseudoginecomastia: the enlargement of the breast occurs by deposition of fatty tissue, without proliferation of glandular tissue. It is common in obese males.
- Breast cancer: tends to manifest itself as a generally unilateral mass, eccentric location with respect to the nipple (in Gynecomastia usually concentric), firm or hard consistency to the touch (in Gynecomastia is touch Gummy), painless most of the time, and that it can be associated with other symptoms such as changes in the skin, retraction of the nipple, Mammary secretion which may be bloody , or palpable nodes, primarily at the level of the armpit. Male breast cancer is very common (is less than 1% of breast cancers), however it is essential to know to differentiate it from gynecomastia.
Who affect gynecomastia?
Gynecomastia is a relatively common problem in the population, and there are three peaks of prevalence throughout life:
- Infants: between 60 and 90% of the newborns have Gynecomastia, produced by the passage of maternal estrogen through the placenta. It is a transient Gynecomastia that disappears in 2-3 weeks.
- Puberty: Gynecomastia in puberty affects mainly young people aged between 10 and 14 years, and is due to the transient and physiological increase in estrogen that occurs at this age. As it occurs in the newborn, is a transient phenomenon, takes to forward between 18 months and 3 years. It is rare that persists after 17 years old. Gynecomastia affects from 19 to 69% of children and adolescents between 10 and 14 years.
- Elderly: is due to an increase of the fatty tissue with a greater peripheral aromatisation (a process that occurs in adipose tissue and which consists of the conversion of androgens into estrogens), to a decline in the production of testosterone by the testes and the use of drugs. It is estimated that you between 40 and 65% of males aged between 50 and 80 years have Gynecomastia, a percentage that increases in hospitalized patients.
Obese males with gynecomastia
Most cases of Gynecomastia are physiological cause (self-evaluation Gynecomastia, pubertal Gynecomastia or Gynaecomastia senile), or unknown, but it is important to rule out some pathologies which can cause pathological Gynecomastia and that can be severe. The mechanism by which breast growth occurs is not well known, although it is considered that the main cause is an imbalance between estrogen action and the androgen in the breast of the male (and not necessarily of hormone levels in blood).
Causes that can cause a pathological Gynecomastia are multiple and varied:
- Excessive production of estrogen secretory tumors of estrogen or its predecessors: of Sertoli and Leydig cell tumors (20-30% present with gynecomastia), testicular tumors secretory of hCG or human chorionic gonadotropin (2-6% have gynecomastia), adrenal tumors. Other tumors such as lung, liver, gastric and renal cancer, also can produce hCG, and therefore placed with gynecomastia.
Aromatization (conversion) increased peripheral androgen to estrogen: obesity, chronic liver diseases such as cirrhosis (67% prevalence of gynecomastia), hyperthyroidism (10-40% present with gynecomastia), malnutrition, chronic renal failure, inherited disorders of aromatase, feminizing adrenal tumors (they are very rare, but nearly 98% of those affected develop gynecomastia).
- Insufficient production of testosterone causes congenital (present from birth): congenital anorchia (absence of testes), Klinefelter Syndrome, syndromes of resistance to androgen (testicular feminization, Reifenstein syndrome, absence from androgen receptors birth), disease of Kennedy, deficit of the synthesis of testosterone, pituitary or hypothalamic disease.
Acquired throughout life: Orchitis, castration, testicular trauma, viral infections, chemotherapy or radiation therapy, renal failure.
- Drugs are probably the most common cause of secondary gynecomastia. They include the following: hormones: estrogen, testosterone, antiandrogens (acetate cyproterone, finasteride, ketoconazole, flutamide and spironolactone), anabolic steroids, growth hormone HCG (human chorionic gonadotropin).
Inhibitors of 5-alpha reductase (finasteride and dutasteride): used in the treatment of benign prostate hypertrophy and prostate cancer prevention.
Bicalutamide and flutamide: used in adjuvant hormonal therapy in prostate cancer.
Spironolactone (used to treat, among other, cardiovascular diseases): between 5-10% of patients treated with spironolactone leave treatment due to the occurrence of gynecomastia.
Antiulcer: especially cimetidine, but also ranitidine, omeprazole and metoclopramide may cause gynecomastia.
Used in neurology and Psychiatry drugs: haloperidol was which showed Gynecomastia as a significant side effect, although they may produce it others such as diazepam, phenytoin, opioids, and tricyclic antidepressants.
Other drugs (antitumor, antimicrobial drugs used for cardiovascular diseases, etc.): methotrexate, minoxidil, agents alkylating, penicillamine, digoxin, inhibitors of ACE, amiodarone, metronidazole, theophylline, isoniazid, antiretrovirals, methyldopa, minocycline, amphetamines, reserpine, penicillamine, heroin, methadone…
The secretion of milk through the nipple can be a symptom of gynecomastia
The main symptom of Gynecomastia is the visible increase in the mammary gland. It is usually asymptomatic, although in the case of development fast of the lesion, may appear local pain.
Depending on the cause that produces it, Gynecomastia must be accompanied by a few symptoms or others. Sometimes the secretion of milk may occur through the nipple, which may indicate that there is hyperprolactinemia. The appearance of other symptoms such as retraction of the nipple or bloody discharge through this must be alert to the possible existence of breast cancer, so if these symptoms should consult a physician.
In the majority of cases with clinical history, physical examination and a blood hormone test, it is sufficient to achieve the Gynecomastia diagnosis and its cause. However, sometimes this is not enough, and other more complex testing is required.
- Clinical history: is important, when it comes to the anamnesis (clinical interview by a physician the patient about their backgrounds and their symptoms), collect some basic data on the sick, including their age, the time evolution of Gynecomastia, and what are the associated symptoms (increased size or palpable mass, secretion by the nipple) (, retraction of this, changes in the skin, pain, or other symptoms). In addition, it is obligatory to ask about the consumption of drugs or other substances that may have resulted in the growth of the mammary gland. Finally, should ask the patient on a personal history of testicular, liver or kidney disease, and a family history of gynecomastia.
- Physical examination: it is important to carry out a physical examination as thorough and detailed as possible including, of course, breast scan. Weight, height and body mass of the patient index, should be measured to rule out that Gynecomastia is due to obesity. The physical examination should include a bilateral breast examination (inspection and palpation of the breast with the patient lying down, covering it between two fingers and approaching them to detect resistance or palpable mass), abdominal scan (to evaluate hepatic, gastric, renal or adrenal disease), palpation (to rule out goiter or thyroid masses) thyroid and testicular (looking for gonadal tumors). Finally, the physical examination should serve to confirm or rule out the presence of lymph nodes.
- Blood test: in patients presenting a physiologic, asymptomatic Gynecomastia, or due to drugs, not necessary the realization of a blood test. However, if it is a persistent Gynecomastia or cause not elucidated by medical history and physical examination, is recommended to perform a complete analytics that allows knowing the blood levels of various hormones (hCG, LH, FSH, prolactin, testosterone and estradiol), as well as to assess hepatic, renal and thyroid function. Basically the analytical aims to find the cause of the Gynecomastia, discarding so in the case of a secondary gynecomastia. Analytical results should always be interpreted by a physician.
- Imaging tests: recommended to differentiate true mass suspicious for cancer Gynecomastia, when history and physical examination so suggests it. These tests should not be taken routinely nor replace the physical examination, but that should be only when there is clinical suspicion of malignancy. Most commonly used Imaging tests are mammography (is a test useful for the detection of breast cancer, although not as much as in the female), ultrasound and computed axial tomography, and the choice of one or another will depend on each case in particular.
- Histological evidence (allow to remove tissue for analysis in the laboratory): should be only when there is suspicion of breast cancer by physical examination and Imaging tests. Fna (fine needle aspiration cytology), biopsy, or mastectomy can be.
Surgery is used if the Gynecomastia does not respond to medical treatment
Treatment of Gynecomastia depends on a large number of factors, among which are its cause, its duration, its severity, and the presence or absence of other symptoms. The following are the main pillars of the treatment of breast increase in male:
- Expectant attitude: is the most frequent attitude and recommended to be objective when a Gynecomastia true, taking into account that in the majority of cases it is a physiological, transient or secondary problem to a cause that can be treated or suspend (drugs). We must reassure the patient about the kindness of the problem and checks every 3-6 months to see the evolution.
- Drugs: Tamoxifen: is a selective modulator (SERM) estrogen receptor. It is the drug most studied and, for the moment, which shows better results. It presents good results in the decrease of the size of the breast, improvement of the symptoms like pain, and even referral completes in a few years in 50-80% of cases. Recurrences or important side effects were not observed. It is the first-line treatment.
Raloxifene: it is also a selective modulator of estrogen receptor which blocks the effects of estrogen in the breast. Although it seems to have good results its long-term effects are unknown.
Others: Danazol: is an androgen that decreases the production of FSH, LH and estrogen. It has adverse effects as the gain of weight.
Anastrozole: it is a selective inhibitor of aromatase which decreases estrogen levels and increases the concentration of testosterone.
- Surgery: is reserved for confirmed cases of breast cancer, or when it’s a true Gynecomastia, which persists despite medical treatment or assumes a major aesthetic or psychological problem for the patient. There are different techniques, being the most used subcutaneous mastectomy, reduction mammoplasty, or liposuction. The results tend to be pretty good from the aesthetic point of view.
- Preventive treatment of Gynecomastia in patients receiving adjuvant hormonal therapy for prostate cancer: due to the high incidence of Gynecomastia in these patients (which may result in discontinuation of treatment), preventive treatments have been proposed to prevent gynecomastia. The two most commonly used options are radiation and tamoxifen.
Treatments for Gynecomastia depending on the type of patient
In function of the age and other characteristics of the patient, different treatments are used to dealing with Gynecomastia:
- Adolescents: In the majority of adolescents with Gynecomastia recommended observation and reevaluation at 3-6 months, longer than most of the time this resolves spontaneously.
In young with manifest Gynecomastia, which found that indeed there is glandular tissue in the breast, and that are self-conscious by the severity of Gynecomastia, can be used for three months a SERM like tamoxifen. He is not recommended to use raloxifene (lack of experience with this drug in young patients).
He is not recommended since aromatase inhibitors which do not seem to be effective.
- Adults: In the majority of adult men with Gynecomastia is recommended, initially, observation and expectant attitude. There will be follow-up to those patients who have Gynecomastia induced by drugs or produced by an underlying disorder treatable (such as hypogonadism or hyperthyroidism), since once the trigger has been treated the Gynecomastia disappears.
In those men that does not identify the cause of the Gynecomastia and this persists more than three months, it is recommended to begin treatment with a SERM for 3 to 6 months, being the most widely used tamoxifen (there is little experience with raloxifene). Aromatase inhibitors are not very effective according to the results of recent studies.
In men with Gynecomastia persistent (more than one or two years), in that it involves a stigma and a complex, plastic surgery, is recommended since the breast tissue after so long is fibrous and will not exist response to drugs.
- Patients with prostate cancer: for the prevention of Gynecomastia in men with advanced prostate cancer undergoing high-dose antiandrogen monotherapy, recommended treatment with tamoxifen to reduce the risk of developing gynecomastia. Radiation can be prophylactically to prevent Gynecomastia in some cases.
The use of the aromatase inhibitors for the prevention of Gynecomastia, is not recommended since they seem to be effective.
In men who have already developed Gynecomastia treatment with antiandrogens, treatment with tamoxifen is recommended.