This condition is called pseudogynecomastia or false gynecomastia. Although distressing to many teen boys who think that they are developing breasts, they should be reassured that gynecomastia is normal, common, and usually doesn't progress to the point that it is easily noticeable by their peers. And most importantly, in most cases, gynecomastia goes away without any treatment. In approximately 90% of cases, pubertal gynecomastia usually resolves in months to several years. Gynecomastia secondary to an underlying treatable cause usually responds to treatment or removal of the primary cause.
Incidence of the condition
Not too many people know that gynecomastia is the most common cause for male breast evaluation. Several studies have shown that almost 38% of boys aged 10-16 years reported a breast tissue greater than 5 cm in diameter. In another series, gynecomastia was noted in approximately 10% of boys aged 12-17 years. In yet another report, gynecomastia was noted in 36% of young military recruits and in approximately 57% of men older than 50 years.
Possible causes of gynecomastia
There are several potential pathologic causes of gynecomastia are and the most common are:
- medications including hormones
- increased serum estrogen
- decreased testosterone production
- androgen receptor defects
- chronic kidney disease
- chronic liver disease
- HIV
- other chronic illness
Unfortunately, the fact is that in 25% of cases, the cause of the gynecomastia is not known.
Medications
Everyone should know that medications cause 10-20% of cases of gynecomastia in post-adolescent adults. What medications are involved? Well, some of the most common include cimetidine, Omeprazole, Spironolactone, Finasteride and certain antipsychotics. It is important to know that some of these medications act directly on the breast tissue, while others lead to increased secretion of Prolactin from the pituitary by blocking the actions of dopamine in the anterior pituitary. People should also know that substance called Androstenedione, used as a performance enhancing food supplement, can lead to breast enlargement by excess estrogen activity. Medications used in the treatment of prostate cancer, such as anti-androgens and GnRH analogs can also cause gynecomastia. Although, not too many people know about it- it is also proven that chronic use of Marijuana use is also thought by some to be a possible cause, but this is controversial.
Increased estrogen levels
Several researches done in the past have shown that increased estrogen levels that can occur in certain testicular tumors, and in hyperthyroidism can cause gynecomastia. It is also proven that some adrenal tumors cause elevated levels of androstenedione which is converted by the enzyme aromatase into estrone, a form of estrogen. Other tumors that secrete HCG can increase estrogen. A decrease in estrogen clearance can occur in liver disease, and this may be the mechanism of gynecomastia in liver cirrhosis. It is also proven that obesity tends to increase estrogen levels.
Decreased testosterone production
It is proven that decreased testosterone production can cause gynecomastia. This disorder can occur in congenital or acquired testicular failure, such as Klinefelter%26rsquo;s Syndrome. Diseases of the hypothalamus or pituitary can also lead to low testosterone. Abuse of anabolic steroids has a similar effect.
Obesity
Obesity can cause enlarged breasts in males. But this is due to excess fat tissue in the breasts.
Other causes include:
- Exposure to estrogen or androgen hormones
- Liver disease
- Kidney failure
- Side effect of some medications
- Marijuana use
- Overactive thyroid (hyperthyroidism)
- Tumors of the pituitary gland
- Testicular tumors
Histological Findings
It is important to know that characteristic histological findings of gynecomastia include proliferation of ductules and stroma consisting of connective-tissue elements such as fibroblasts, collagen, and myofibroblasts and occasional acini. Gynecomastia of short duration consists of a prominent ductular component with loose stroma. Long-standing gynecomastia consists of dense stroma with few ductules.
Diagnosis of gynecomastia
Patient%26rsquo;s history
Every doctor should ask patient questions about symptoms, such as how long he had the breast tissue, and whether or not the area is tender. Doctor will also probably ask about the illnesses the patient has had in the past, the medicines he take, and other matters relating to his health.
Physical examination.
When it is a case of a teenager, he will probably will not need more tests, since gynecomastia is common in teenage boys. As many as 65% of 14-year-old boys have gynecomastia. Good thing is only that the breast enlargement usually goes away on its own in 2 or 3 years. However, younger boys and adult men with gynecomastia may need to have some tests, because it is more possible that some kind of disease is causing the problem.
Testing, although not usually necessary in teen boys, might include:
- liver function tests
- plasma DHEAS or urinary 17-ketosteroids
- plasma estradiol
- plasma hCG%26amp;#225
- plasma LH and testosterone
Teens who are very overweight may have pseudogynecomastia, in which they have enlarged breasts because of increased fat and not true breast tissue.
Gynecomastia treatment
Treating the underlying cause of the gynecomastia may lead to improvement in the condition. Patients should stop taking medications which can cause gynecomastia. Anti-estrogen medications, such as Tamoxifen and clomiphene or androgens can be used. After some time, however, the breast tissue tends to remain and harden, leaving surgery the only treatment option. There are people who choose to live with the condition and use a bra as an option for treatment. In some cases, male breast reduction surgery may be an option. Gynecomastia during puberty usually goes away without treatment after several months.
Surgical treatment
Indications
It is extremely important to keep in mind that surgery to correct gynecomastia can be performed only on healthy, emotionally stable men of any age. Surgery may be discouraged for obese men, or for overweight men who have not first attempted to correct the problem with exercise or weight loss. Also, it is proven that individuals who drink alcohol beverages in excess or smoke marijuana are usually not considered good candidates for surgery.
The surgery
There are several options for surgery! If excess glandular tissue is the primary cause of the breast enlargement, it will be simply excised, or cut out, with a scalpel. In a typical procedure, an incision is made in an inconspicuous location--either on the edge of the areola or in the under arm area.
If liposuction is used to remove excess fat, the dren is usually inserted through the existing incisions. If gynecomastia consists primarily of excessive fatty tissue, your surgeon will likely use liposuction to remove the excess fat. Using strong, deliberate strokes, the surgeon moves the cannula through the layers beneath the skin, breaking up the fat and suctioning it out.
If liposuction is used to remove excess fat, the dren is usually inserted through the existing incisions. If gynecomastia consists primarily of excessive fatty tissue, your surgeon will likely use liposuction to remove the excess fat. Using strong, deliberate strokes, the surgeon moves the cannula through the layers beneath the skin, breaking up the fat and suctioning it out.
In extreme cases where large amounts of fat or glandular tissue have been removed, skin may not adjust well to the new smaller breast contour. Sometimes, a small drain is inserted through a separate incision to draw off excess fluids. Once closed, the incisions are usually covered with a dressing. The chest may be wrapped to keep the skin firmly in place.
Possible complications
When male breast-reduction surgery is performed by a qualified plastic surgeon, complications are possible and, in most cases- they are rare and usually minor. Some of the most common include
- Infection
- skin injury
- excessive bleeding
- adverse reaction to anesthesia
- excessive fluid loss or accumulation
- noticeable scars
- permanent pigment changes in the breast area
- slightly mismatched breasts or nipples
Post op
Every patient will feel some discomfort for a few days after surgery. However, discomfort can be controlled with medications prescribed by surgeon. Reasonably- the affected are will be swollen and bruised for awhile. Although the worst of your swelling will dissipate in the first few weeks, it may be three months or more before the final results of your surgery are apparent.
Although there are no rules- in most cases any stitches will generally be removed about 1 to 2 weeks following the procedure. Surgeon could also advise a patient to avoid sexual activity for a week or two, and heavy exercise for about three weeks. Every patient should also avoid exposing the resulting scars to the sun for at least six months.
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