What is Gynecomastia?
Gynecomastia is a benign proliferation of male breast tissue due to physiological or pathological causes, leading to a breast-like appearance. The word gynecomastia is derived from the Greek words “gyne (woman) and mastia (breast)”. Gynecomastia is a condition in which male breast tissue grows abnormally and often reversibly. This growth results from an increase in glandular tissue in the breast and is usually due to a hormonal imbalance. The balance of estrogen and testosterone hormones plays a critical role in the development of breast tissue in men. When gynecomastia occurs, the effect of estrogen relatively increases or the effect of testosterone decreases.
Gynecomastia can frequently occur due to hormonal fluctuations during puberty, in newborns, and in older age. In addition to changes in physical appearance, it can also lead to psychological distress, especially in adolescents and young adults.
How Common Is Gynecomastia?
Gynecomastia is a common condition, with its frequency varying between 32% and 65% depending on age and the criteria used for its definition. The incidence shows three distinct peaks in a man’s life: the first peak is observed in infancy, the second in adolescence, and the third in middle-aged and older men. Gynecomastia in infancy is a common condition that usually resolves spontaneously within the first year of life. It affects about 50% of boys in mid-puberty and resolves spontaneously in over 90% of cases within 24 months.
What Are The Causes Of Gynecomastia?
Many different factors influence the development of gynecomastia. These can be summarized as hormonal imbalances, medication use, certain chronic diseases, and lifestyle factors:
- Physiological Gynecomastia: Infancy, adolescence, middle age, and old age.
- Idiopathic Gynecomastia: In patients with normal androgen levels but excessive hair growth, no polycystic ovaries detected on ultrasound, and no menstrual irregularities, this condition is defined as idiopathic hirsutism.
- Pharmacological Gynecomastia – Medication Use: Some medications, such as anti-androgens, certain antidepressants, chemotherapy drugs, and heart medications, can cause gynecomastia.
- Hormonal Imbalance: An imbalance between testosterone and estrogen hormones is the most important cause of gynecomastia. Testosterone levels may decrease, while estrogen levels may remain constant or increase.
- Pathological Gynecomastia (45-50%): Persistent pubertal gynecomastia, cirrhosis, chronic kidney failure, hyperthyroidism, primary hypogonadism, secondary hypogonadism, testicular tumors.
- Obesity: Increased fat tissue in the body promotes estrogen production and facilitates the development of gynecomastia.
- Alcohol and Drug Use: The use of alcohol, cannabis, and certain illicit substances can increase the risk of gynecomastia.
- Aging: In older age, a decrease in testosterone levels predisposes to gynecomastia.
Gynecomastia can sometimes also present as an “idiopathic” condition where the cause cannot be identified. Therefore, a comprehensive evaluation is necessary.
What Are The Symptoms Of Gynecomastia?
When evaluating gynecomastia, it is first necessary to differentiate between true gynecomastia, lipomastia, and breast cancer. Once true gynecomastia is determined, a thorough history and careful physical examination should be performed to investigate the underlying cause, and medication history should be inquired about. All medications that could cause gynecomastia, over-the-counter drugs (including testosterone precursors), dietary supplements, and herbal products used should be asked about. Improvement in gynecomastia after discontinuing or changing a medication or product for a few months suggests that the medication is responsible, but does not prove it.
The most prominent finding in gynecomastia is the enlargement of the male breast and sometimes tenderness or pain. While the growth is mostly symmetrical, it can sometimes be unilateral. Glandular tissue less than 2 cm is considered normal, while 2 cm or more is considered gynecomastia. Soft or firm nodules may be felt in the breast upon palpation.
In some patients, the following symptoms may be observed:
- Tenderness and pain on or around the nipple
- Redness or swelling of the breast skin
- Decreased self-confidence due to changes in aesthetic appearance
- In rare cases, nipple discharge
Gynecomastia should be carefully evaluated to avoid confusion with breast cancer. Although male breast cancer is rare, further investigations may be necessary for differential diagnosis, especially in hard, fixed, and rapidly growing masses.
How Is Gynecomastia Diagnosed?
Diagnosis begins with a detailed anamnesis and physical examination. Our doctor will inquire in detail about the patient’s complaints and history, such as medication use, substance abuse, and coexisting diseases.
During the physical examination, the structure of the breast tissue, the presence of nodules, size, and tenderness are evaluated.
In all adult men evaluated for gynecomastia, serum total testosterone concentration should be measured between 08:00 and 10:00 AM.
In men with incidentally detected, asymptomatic, non-tender gynecomastia, additional tests may not be necessary as they have low diagnostic value. In such cases, the most likely cause of gynecomastia is idiopathic. In contrast, in men with new-onset gynecomastia and evidence of known pathological conditions such as cirrhosis, chronic kidney disease, or hyperthyroidism, tests appropriate for their primary disease should be performed.
If the initial total testosterone is low, free testosterone and the gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH) should be additionally measured and repeated at least once between 08:00 and 10:00 AM.
For further diagnosis, the following tests may be performed:
- Hormonal tests: Such as testosterone, estrogen, LH, FSH, HCG, prolactin, and thyroid hormones.
- Imaging: Breast ultrasonography, mammography, adrenal CT, and MRI if necessary.
- Blood tests: Liver and kidney function tests, tumor markers.
- Biopsy: A tissue sample may be taken in suspicious cases.
A multidisciplinary approach is preferred for accurate diagnosis and determination of the underlying cause.
What Are The Treatment Methods For Gynecomastia?
The basic principle in gynecomastia treatment is to identify and correct the underlying cause. Treatment options include:
The treatment of gynecomastia varies depending on the etiology, the onset of symptoms, and the presence of pain/tenderness. Pubertal gynecomastia spontaneously regresses in 90% of cases within 2 years without treatment, starting from the age of 17. In adults, symptoms such as breast pain and tenderness due to inflammatory glandular proliferation may subside within 6 months, while spontaneous regression is rare in cases lasting longer than 1 year due to fibrotic transformation.
The main principle in treatment is to determine the underlying cause. Treatment of endocrine or systemic diseases, or identifying and, if possible, discontinuing/changing the causative medication, is crucial. In patients with drug-induced gynecomastia, glandular tissue may regress spontaneously within 1 month after discontinuing the drug during the early, painful proliferative phase. Regular follow-up of patients during this period is important.
If symptoms do not regress within 3 months despite drug discontinuation, or if the drug cannot be discontinued, medical treatment should be considered.
- Observation: For newly developed gynecomastia cases occurring in puberty, a period of observation is recommended. Hormonal balance usually normalizes over time.
- Medical Treatment: If there is a hormonal imbalance, anti-estrogen medications (such as tamoxifen) or testosterone replacement therapy may be used. Selective estrogen receptor modulators (SERMs), testosterone, and aromatase inhibitors are treatment options. Medical treatment options should be considered especially in the following cases:
- Severe and painful gynecomastia,
- Recently started cases (lasting less than 6 months),
- Situations where no treatable underlying causes have been found or have not improved despite treatment.
- Medication Change: If gynecomastia is caused by medication use, a switch to alternative medications can be made.
- Surgical Intervention: In cases of severe gynecomastia, unresponsiveness to medical treatment, cases lasting longer than 1 year, fibrotic stage, psychological distress, and suspicion of malignancy, surgical intervention may be performed. In adolescents, surgery should not be performed before testicular volume reaches adult size. Usually, a combination of subcutaneous mastectomy (removal of glandular tissue) and liposuction is performed. The most important side effects are shape irregularities and loss of sensation. The prevalence of breast cancer is quite low.
- Lifestyle Changes: Weight control, alcohol cessation, and stopping substance use contribute to treatment.
Frequently Asked Questions
How Are Connection Between Gynecomastia And Weight Gain?
Increased body fat can increase estrogen production in men and trigger the development of gynecomastia. Weight loss often helps alleviate symptoms.
Is Gynecomastia Caused Only By A Hormonal Imbalance?
No, although hormonal imbalance is the most common cause, certain medications, chronic diseases, and environmental factors can also play a role.
How Long Does Recovery Take After Gynecomastia Surgery?
The recovery process after surgery usually takes a few weeks. Most patients can return to their daily activities within a week.
Does Gynecomastia Recur After Surgery?
With correct surgical techniques and controlled underlying causes, the risk of recurrence is quite low.
Are Natural Methods Effective In The Treatment Of Gynecomastia?
Regular exercise and weight control can be helpful, but medical treatment is absolutely necessary for underlying hormonal problems.
How Does Gynecomastia Affect The Quality Of Life For Men?
Especially in adolescents, social inhibition, loss of self-confidence, and psychological stress can be observed; therefore, treatment should be supported not only physically but also psychologically.
What To Do If Gynecomastia Develops During Medication Use?
Medication change or dosage adjustment may be necessary. It is absolutely important to consult a doctor.
When Are Gynecomastia Hormone Tests Performed?
If gynecomastia is suspected, comprehensive hormone tests are performed for diagnosis and treatment planning. They should be done between 08:00 and 10:00 AM.
Does Gynecomastia Go Away On Its Own?
In some cases, especially gynecomastia that develops in puberty, it can resolve spontaneously within a few months; however, medical intervention may be required in prolonged cases.
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