Gynecomastia is a term for male breast enlargement. An increase in breast tissue diameter by more than two centimeters concentrically around the nipple is suggestive of this condition. It may be due to an underlying endocrinological disorder such as hypogonadism or thyroid disease. Chronic liver and kidney disease in males may also induce breast enlargement. Intake of drugs or substances with antiandrogenic properties may also increase breast size. The pathophysiology involves decreased testosterone activity and increased estrogen production. The American Academy of Family Physicians has published a study in 2012 concerning a more efficient way to diagnose and treat the disorder.
The study was conducted by Dr. Gretchen Dickson, a family medicine specialist from the University Of Kansas School Of Medicine, defining gynecomastia as a benign condition characterized by a remarkable enlargement of the male breasts due to hyperplasia or hypertrophy of the breast glands. The condition has two types, physiologic and pathologic.
Physiologic breast enlargement, commonly seen in neonates, pubertal boys and senescent males, is often self-limited and may not require medical treatment, although monitoring for changes is necessary. Pathologic increase in breast size is usually caused by chronic diseases causing hormonal imbalance as mentioned above. Medications causing breast enlargement as a contributory factor must be discontinued. An algorithm has been made as a step-by-step guide through the diagnosis. Health education and counseling is necessary, as breast enlargement in males may cause discomfort, or even fear of a possible malignancy.
Clinical recommendations for managing the condition according to Dickson, aside from taking the clinical history and physical examination, highlighted the importance of routine testicular ultrasonography and breast mammography and ultrasonography. For the medical management, tamoxifen and raloxifene has been found helpful in preventing breast enlargement in older males with prostate cancer. However, the evidence rating given with the use of tamoxifen and raloxifene suggests further studies should still be done.
Certain medications and substances that cause breast enlargement in males were enumerated, these include antipsychotic agents, antiretrovirals, chemotherapy drugs, diuretics, etc. The drugs mentioned have antiandrogenic properties causing low levels of testosterone-estrogen ratio, which in turn triggers feminization. Spironolactone, an aldosterone antagonist and a potassium-sparing diuretic used in the treatment of hyperaldosteronism, hypokalemia, essential hypertension, ascites, edema and congestive heart failure, is also known to cause an increase in breast size. Discontinuing intake, with the guidance of a health professional, may result in significant regression of the breast size within three months, although more studies should still be conducted to confirm if the benefit outweighs the risk.
Surgical reduction of breast tissue can be done instead of conservative management. Inability to tolerate medical treatment can make surgical management as the top option. Breast reduction surgery is also considered to help reduce psychological affliction and to promote or regain confidence. However, surgical risks and complications must be well understood prior to undergoing the invasive approach.
Management of gynecomastia is multidisciplinary. A holistic method must be done, through proper counseling and health education. Obtaining a complete medical history, as well as undergoing physical examination and laboratory and imaging work-ups, is vital in the process.
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