GYNAECOMASTIA  is feminine enlargement of Ole male breast secondary to proliferation of both epithelial and stromal tissue. Both breasts are involved in 90% of patienls. There is a firm disc of tissue underlying the nipple and the areola may be pigmented.
Histologically there are in the early stages prominent, dilated and tortuous duetules in loose connective tissue which are later replaced with dense hyalinized fibrous tissue .
It is seen in over 60% of neonates, 36% of healthy young adult men, 57% of healthy older men, > 70% of hospitalized elderly men and 55% at autopsy.

Causes of Enlarged breast in males

The cause of gynaecomastia is increase in the effective oestrogen/androgen ratio. This is usually due to an alteration
in their serum levels, but it may also result from aromatization of androgens to oestrogen at the tissue level.

The Major causes are:

1. Physiological
Neonatal
Pubertal (25%)
Ageing

2. Drugs (25%)
Oestrogens
Digitalis, amiodarone
Cimetidine, omeprazole
Spironolactone
Methyldopa
Captopril
Diazepam
Isoniazid

3. Tumours

Testicular tumours (3%)

HCG producing malignant tumours

Feminizing adrenal tumours

4. Metabolic
Cirrhosis of the liver (8%)
Hyperthyroidism (1.5%)
Starvation/re-feeding
Renal disease

5. Hypogonadism (10%)
Flagging testes
Klinefelter’s disease
Maldescended testes
Cannabis (marijuana)
Tricyclic anti-depressants
Calcium channel-blockers
Viral orchitis (e.g. mumps)
Pre-pubertal orchitis
Lepromatous leprosy
Ketoconazole

Trauma to the testes
Castration
Angiotensin-converting enzyme inhibitors

Testicular feminization
Cancer chemotherapy agents such as flutamide, and finesteride

6. ldiopathic (25%)

 

1. Physiological

There are 3 peaks – neonatal. pubertal, and ageing – of incidence. Transitory bilateral gynaecomastia in neonates is due to transplacental passage of ocstrogens and other hormones from the mother to the fetus. It settles in a few weeks.
At puberty, there is increased secretion of pituitary gonadotrophins. Luteinizing hormone stimulates Leydig cells of the testes to secrete testosterone and oestrogens. But increase in oestrogen production may be relatively more than that of testosterone and result in increase of the oestrogen/androgen ratio.

About 60% of boys may develop some degree of gynaecomastia at puberty (due also to increased production of
growth hormone) which in most cases resolves within 2 years or by age 17 years. Only about 10% may persist for more than 3 years.
During ageing, testicular function declines and testosterone production is affected. But the concentration of serum
oestradiol remains normal and accumulation of adipose tissue, which is converted to oestrogen by aromatization, maintains a normal serum oestrogen. About 30% of middle-aged men develop gynaecomastia.

2. Drugs

They constitute a common cause of gynaecomastia. Oestrogen and anti-androgen (cyproterone acetate, flutamide) therapy in prostatic cancer leads to gynaecomastia by inhibiting
testosterone DHT biosythesis. Some drugs e.g. tricyclic antidepressants, methyldopa, isoniazid and phenothiazines disturb gonadotrophin control and elevating serum prolactin.

3. Tumours

Testicular tumours that produce HCG e.g. chorionic carcinoma may cause gynaecomastia . The HCG stimulates
production of oestrogens and testosterone by Leydig cells.

But the testosterone is converted to oestrogens by the tumour itself and the peripheral tissues by aromatisation.

Leydig cells tumours may also cause gynaecomastia as they secrete oestradol. HCG-producing bronchial carcinoma has a similar effect.
Excessive amounts of the androgen androstenedione produced by some adrenal tumours may be converted by aromatization to oestrogens. Some adrenal tumours produce oestrogens.

4. Metabolic factors

Hepatic cirrhosis: Because of reduced liver clcarance, greater amounts of adrenal androgens are  available for conversion to oestrogens whose clearance is also impaired.
Hyperthyroidism (40% of male patterns), re-feeding after starvation and renal failure may all lead to oestrogen/androgen imbalance.

In hyperthyroidism, the raised serum human binding globulin (SHBG) increases leading to decreased free
testosterone levels.

5. Hypogonadism

There is depressed androgen production while that of oestrogen, at least from aromatization of adrenal androstenedione, continues nonnally.

6. Idiopathic
In 25% of patients, no cause can be ascribed.

Clinical Features

Most patients are asymptomatic.
The main complaint is enlargement usually of both breasts but occasionally of only one. There is usually a well-defined, smooth, often tender, enlargement of the breast.

There may be erectile dysfunction, loss of libido and infertility. A history of liver, testicular or endocrine disorder and medicaments must be sought.
A full examination of the breasts and body is done and in particular liver and testicular abnormalities, hair distribution, and signs of toxic goitre are looked for.

Grading of Gynaecomastia may be done.
Grade 1: Minor breast development.
Grade 2a: Moderate breast development without redundant skin.
Grade 2b: Moderate breast development with minor redundant skin.
Grade 3: Gross breast development with much redundant skin.

Differential Diagnosis

Other disease conditions that may cause breast enlargement in males are:

1. Carcinoma of the breast. It is a hard mass with indefinite edges. It may be attached to the skin and/or underlying muscle and axillary nodes may be palpable.
2. Adipose tissue. There is a diffuse fatty breast (pseudogynaecomastia) which is part of generalized increase in
subcutaneous body fat. The patient is obese.
3. Other swellings are lipomas, neurofibromas, dermoid cysts, haematoma and lympangioma.

Tests

Investigations include liver function tests, thyroid function tests, serum creatinine, serum testosterone (total and free) oestradiol, LH, FSH and prolactin. Imaging may become necessary. So may fine needle aspiration cytology (FNAC) to exclude carcinoma. 

Treatment

Over 80% regress spontaneously.
1. If the patient is on a drug that could be the cause, then it should be changed or stopped if possible and the patient
examined after one month. Hyperthyroidism is treated if
present.
2. If a primary cause is found, such as a testicular or adrenal tumour or liver disease, it is treated.
3. In the majority of patients no cause can be ascribed.
Adolescents should be reassured as the condition regresses spontaneously. However, it may be embarrassing or occasionally persistent. Excision of the breast tissue is then done through an infra-mammary incision with preservation of the nipple.

Endoscopic-assisted subcutaneous mastectomy can also be done through a small distant incision and so avoid a breast scar.

4. Danazol 100mg b.d for 3 months helps to reduce the degree and size of the gynaecomastia and need for surgery in about 50% of patients.

5. Tamoxifen 20mg daily causes complete regression in about 80% of middle-aged patients.

Cost of gynaecomastia surgery

Most surgeries for breast enlargement in males are done under general anesthesia and this shoots the price of surgery up.  I visited a plastic surgeon in his private hospital who told me he does gynaecomastia surgery for #350,000 Naira.  In public hospitals the surgery price may be #280,000 Naira.

Gynaecomastia
Enlarged male breasts before and after surgery
Credit: Dr Richard Maxwell

Source: Principles and Practice of Surgery by Badoe

 

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