Gynaecomastia

Obesity

Individuals who are overweight or obese have an increased risk of developing gynaecomastia due to higher estrogen levels. This occurs because of elevated aromatase activity in adipose tissue. The hormone leptin, which regulates weight, also increases in obesity and can promote breast tissue growth.

Family History

If a close family member has experienced gynaecomastia, there is an increased risk of developing the condition. This rare familial form often involves an elevation of aromatase activity in affected relatives.

• Certain Medications
• Certain drugs can increase the likelihood of developing gynaecomastia. Examples include:
• Hormonal treatments: Estrogen vaginal creams, gonadotropins, exogenous androgens, growth hormone, flutamide, and finasteride
• Antihypertensive drugs: Calcium channel blockers (e.g., verapamil, nifedipine, diltiazem), ACE inhibitors (e.g., captopril, enalapril), amiodarone, methyldopa, spironolactone, reserpine, and nitrates
• Psychoactive medications: Diazepam, phenytoin, etomidate, haloperidol
• Antibiotics for infections: Efavirenz, isoniazid, ethionamide, griseofulvin, metronidazole, minocycline
• Cancer medications: Busulfan, vincristine, methotrexate
• Drugs of abuse: Amphetamines, heroin, methadone, ethanol, marijuana
• Other drugs: Theophylline, omeprazole, auranofin, diethylpropion, domperidone, penicillamine, sulindac, heparin, zanoterone, cimetidine, and ranitidine

Interesting Fact!

Topical estrogen sprays, often used for menopausal hot flashes, have been associated with gynaecomastia in children due to skin contact.

Occupation

• Bodybuilders and athletes who use aromatizable androgens for muscle growth are also at higher risk of developing gynaecomastia.

Hypogonadism

• Hypogonadism, characterized by low testosterone levels, can also lead to gynaecomastia. Conditions related to hypogonadism that can cause this include:
• Klinefelter syndrome (a genetic disorder with an extra X chromosome in males)
• Kallmann syndrome (a condition with delayed or absent puberty and impaired sense of smell)
• Kennedy disease (a genetic disorder causing progressive muscle weakness)

Medical Conditions

• Certain health conditions are linked to a greater likelihood of developing gynaecomastia, including:
• End-stage kidney disease
• Liver disease
• Spinal cord disease
• Thyrotoxicosis
• Infertility
• Diabetes

Stress

• Stress may contribute to gynaecomastia by stimulating the adrenal glands to produce excess estrogen precursors.

Cancer

• Certain types of cancer or tumors can elevate estrogen levels, increasing the risk of gynaecomastia. These include:
• Testicular cancer
• Germ cell tumors
• Sex-cord tumors
• Fibrolamellar hepatocellular carcinoma
• Adrenal tumors

The diagnostic process for gynaecomastia includes a detailed medical history and various physical and laboratory evaluations to identify its underlying cause.

Medical History

Understanding the patient’s medical history is essential in diagnosing gynaecomastia. The clinician will inquire about:

• Use of medications and alcohol consumption
• Exposure to chemicals
• Symptoms of systemic conditions like hyperthyroidism, liver disease, mumps, or renal failure
• Weight fluctuations
• Onset and duration of breast enlargement
• Pain or discharge from the nipples
• History of undescended testes
• Issues like infertility, erectile dysfunction, and reduced libido to rule out hypogonadism
• Body mass index
• Family history of gynaecomastia

Physical Examination

A thorough physical examination is crucial for distinguishing between gynaecomastia, pseudogynecomastia, and breast cancer. The clinician may ask the patient to lie down with their hands behind their head, then palpate the breast area to assess the following:

• True Gynaecomastia: Presence of a ridge of glandular tissue near the nipple-areolar complex
• Pseudogynecomastia: Difficulty in bringing the fingers together near the nipple
• Breast Cancer: Detection of a firm, immobile, irregular mass outside the areola, often accompanied by skin dimpling and nipple discharge

Additionally, the abdomen and testicles will be examined to identify signs of conditions like liver disease, kidney disease, or hyperthyroidism.

Laboratory Evaluation

Gynaecomastia involves hormone fluctuations, so a series of blood tests are conducted to determine the root cause. These tests include:

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

Further testing will depend on the findings from the medical history, physical examination, and hormone levels.

Imaging Tests

• Scrotal/Testicular Ultrasound: An ultrasound of the scrotum is used to detect testicular abnormalities, particularly when a mass is found during the physical exam or if hCG levels are elevated.
• Mammography (MMG): This X-ray imaging method is used to investigate the possibility of breast cancer, as it is highly sensitive and can help differentiate between gynaecomastia and cancer, thus minimizing the need for biopsies.
• Breast Ultrasonography (USG): This method is commonly used for diagnosing gynaecomastia, offering comfort and precision for male patients.
• Abdominal CT: If hCG levels are elevated and testicular ultrasound shows no abnormalities, this X-ray-based test can detect non-testicular tumors.
• Karyotyping: A blood sample is analyzed for chromosomal abnormalities. This test is typically recommended if low testosterone levels are present alongside a family history of Klinefelter syndrome.
• Biopsy: This test examines tissue for cancerous cells and is generally done if the individual is at high risk or exhibits signs of breast cancer, such as in patients with Klinefelter syndrome.

Obesity, a lifestyle condition marked by excessive fat accumulation, raises the risk of gynaecomastia, along with other health complications.

A comprehensive obesity screening can help identify underlying causes, which may include genetic factors, poor diet, and a sedentary lifestyle. Adopting a balanced diet and engaging in at least 30 minutes of physical activity each day can lower the chances of obesity and, consequently, gynaecomastia.

Preventing Gynaecomastia in Prostate Cancer

Men with prostate cancer who undergo anti-androgen therapy are at an increased risk of developing gynaecomastia. Prevention strategies include:

• Medications like oral tamoxifen
• Radiation therapy

Specialists to Consult

If you experience sudden breast pain, tenderness, new or rapid breast enlargement, or a breast size greater than 5 cm, consult the following specialists:

• Endocrinologist: Experts in hormone-related disorders, as gynaecomastia involves several hormonal changes.
• Andrologist: Specializes in male reproductive health and can help diagnose and treat gynaecomastia in men.
• Reproductive Endocrinologist: For cases where gynaecomastia is linked to infertility or other reproductive issues, reproductive endocrinologists are ideal.
• Oncologist: If cancer is suspected, an oncologist is the appropriate specialist to consult.
• Surgeon: If surgery is needed, a surgeon will handle the procedure.

Most cases of pubertal gynaecomastia tend to resolve on their own within one to two years. Treatment typically begins after a thorough diagnosis to identify the cause of the condition. If no abnormalities are found, individuals are generally monitored closely with regular breast exams every 3 to 6 months.

Treatment Approach

The treatment strategy varies depending on the underlying cause. Common approaches include:

• Treating any identified endocrine or systemic diseases first
• Surgically removing any detected tumors, followed by chemotherapy if necessary
• Discontinuing medications that may be causing gynaecomastia, depending on the need for the ongoing therapy
• Performing breast removal surgery if a biopsy reveals cancer
• Acute gynaecomastia (lasting less than 6 months) without additional clinical findings is usually reversible with medication. However, if the condition is chronic, regression is unlikely.

In general, treatment options include:

Medications

Several medications can be used to treat gynaecomastia, including:

• Androgens: These drugs adjust testosterone levels to balance the testosterone/estrogen ratio. Examples include:
• Testosterone: Primarily used for treating hypogonadism (low testosterone levels).
• Dihydrotestosterone: A non-aromatizable androgen that does not convert into estrogen, often used for prolonged pubertal gynaecomastia.
• Danazol: A weak androgen that inhibits gonadotropin secretion, decreasing testosterone production and estrogen levels, promoting breast regression.
• Antiestrogens: These drugs lower estrogen activity, the primary driver of breast tissue development. Examples include:
• Clomiphene citrate: Often used for painful gynaecomastia.
• Tamoxifen: Provides excellent results when the cause of gynaecomastia is unknown.
• Aromatase Inhibitors: These medications block the enzyme aromatase, which converts testosterone into estrogen. Common examples include:
• Letrozole: Helps decrease breast size.
• Anastrozole: Particularly effective in pubertal gynaecomastia or cases involving Sertoli cell tumors and familial aromatase excess.

Liposuction

For individuals with excess fat, liposuction may be performed to remove fat and fluid via a vacuum tube, reducing the size of the breasts.

Surgery

Surgical removal of the breast tissue is considered in cases of:

• Long-standing gynaecomastia
• When gynaecomastia impacts daily activities, social interactions, or career
• Suspicion of breast cancer

Precautions Before Surgery

Certain actions should be avoided before undergoing gynaecomastia surgery, including:

• Avoid sunbathing for at least 2-3 weeks before surgery to prevent tanning, which can increase scarring risks.
• Refrain from smoking and consuming alcohol at least 2 weeks prior to surgery.
• Avoid blood thinners, aspirin-containing products, herbal supplements, and Vitamin E.

Post-operative Care

After surgery, the following guidelines should be followed:

• Gently pat dressings dry after bathing
• Wear a compression shirt or garment at all times except when showering and washing the garment
• Avoid swimming for at least two weeks
• Refrain from lifting weights heavier than 10 lbs for 2 weeks
• Avoid strenuous activities, heavy lifting, or sports that could strain the incision for two weeks

While gynaecomastia itself does not cause any physical complications, its impact on appearance can lead to psychological and emotional issues in men, including:

• Embarrassment
• Reduced self-esteem
• Excessive worry
• Anxiety
• Depression
• Eating disorders like anorexia and bulimia
• Social phobia
• Avoidance of social situations

Cold Compresses

Cold compresses help alleviate pain and tenderness in the breasts by contracting the swollen nerves, providing relief.

Dietary Modifications

Incorporating certain foods into the diet can help reduce body fat and improve overall health, such as:

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

Foods to avoid include:

• Soy products
• Beetroot
• Processed and frozen foods
• Fried foods

Regular Exercise

Engaging in regular physical activity, particularly strength training exercises targeting the chest, can reduce overall body fat and make gynaecomastia less noticeable. Suggested exercises include:

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

Home Remedies

Some home remedies may complement conventional treatment, but it is best to consult a healthcare provider before trying any of these:

• Turmeric (Haldi): The curcumin in turmeric can help boost testosterone levels and reduce swelling in gynaecomastia. Mix one tablespoon of turmeric powder in hot milk to consume.
• Vitamin E: Rich in antioxidants, vitamin E can help reduce estrogen levels and block the aromatase enzyme. Foods high in vitamin E include:
• Sunflower and soybean oil
• Almonds
• Peanuts and peanut butter
• Spinach
• Pumpkin
• Red bell peppers
• Flax Seeds: These seeds, high in omega-3 fatty acids, can help manage gynaecomastia by boosting testosterone and lowering estrogen. Add flax seeds to smoothies, cereals, or yogurt.
• Fish Oil: Rich in omega-3 fatty acids, fish oil helps combat gynaecomastia by promoting higher testosterone levels. Cold-water fish like tuna, mackerel, and salmon are excellent sources.
• Zinc: Zinc helps regulate testosterone levels. Zinc-rich foods include raisins, cashews, oysters, lobster, and chickpeas.
• Green Tea: Known for its fat-burning properties, green tea helps prevent fat deposition around the chest.

Plant-Based Therapies

Certain herbs may aid in reducing gynaecomastia by supporting hormonal balance:

• Milk Thistle: Known as silymarin, this plant helps treat liver issues, and as liver dysfunction can contribute to breast enlargement, it may reduce breast size. The seeds can be crushed and taken with water or consumed as a supplement.
• Dandelion: This herb aids in flushing excess estrogen from the body. Add dandelion leaves to salads, sandwiches, or teas.
• Passionflower: Known for boosting testosterone, passionflower is available in many herbal supplements and can be consumed as tea made from dried flowers.
• Red Clover: This herb helps balance estrogen and testosterone levels, thus managing gynaecomastia. Prepare tea by boiling 4 grams of dried flowers in 1 cup of water.

Although gynaecomastia is harmless from a medical standpoint, it can affect overall quality of life. The following strategies can help manage the condition on both physical and emotional levels:

Reduce Stress

Chronic stress can worsen gynaecomastia symptoms by disrupting hormone levels. To manage stress, consider the following techniques:

• Practice mindfulness and meditation
• Engage in yoga
• Perform deep breathing exercises

Make Thoughtful Clothing Choices

Men with gynaecomastia should opt for loose-fitting clothing that doesn't cling tightly to the chest. Dark-colored clothing can also help minimize the visibility of the condition.

Wear Compression Garments

Compression shirts or undershirts can help flatten the chest and reduce the appearance of gynaecomastia.

Maintain Good Posture

Good posture can improve body alignment and minimize the prominence of gynaecomastia. Stand tall with your shoulders back to help improve your overall appearance.

Addressing the Psychological Impact

Gynaecomastia can have a lasting emotional effect, particularly during puberty when physical changes can lead to bullying and heightened self-consciousness. Feelings of insecurity may lead to anxiety, depression, social isolation, and potentially harmful behaviors like drug or alcohol abuse.

Adolescents may also avoid activities like gym class or sports, and boys in particular may struggle with relationships. Understanding and accepting the following facts can ease emotional distress:

• Gynaecomastia is a harmless medical condition
• Most cases are physiological and resolve on their own after puberty
• Gynaecomastia is not a sign of breast cancer

Coping Strategies

Self-Acceptance

Communicating with loved ones can help manage stress and anxiety, while engaging in enjoyable activities can shift focus away from the condition. Seeking support from a therapist may also help.

Role of Family

Family and friends play an important role in recognizing signs of emotional instability and offering support. Key signs of instability include:

• Withdrawal from social interactions
• Loss of interest in usual activities
• Decrease in school or work performance
• Avoidance of intimacy