What is Gynecomastia? Causes, Symptoms, and Grades Explained

Gynecomastia is defined as the benign enlargement of the male breast tissue, resulting from the proliferation of the glandular component. It is the most common breast condition in men, often presenting as a rubbery or firm mass extending concentrically from the nipple. This condition is distinct because it involves the actual development of breast ducts and stroma, rather than just adipose tissue. It can occur unilaterally or bilaterally and is frequently associated with breast pain or tenderness, particularly in its early stages. The prevalence of this condition varies, affecting a significant portion of the male population at different life stages, including neonates, adolescents, and older men.

In contrast, pseudogynecomastia, also known as lipomastia, is characterised by the accumulation of subareolar fat without enlargement of the glandular tissue. This condition is clinically similar in appearance to true gynecomastia but is fundamentally different in its tissue composition. Pseudogynecomastia is most commonly observed in obese men, where increased total body fat leads to fat deposition in the chest area. Unlike true gynecomastia, the enlarged breast mound in pseudogynecomastia is soft to palpation and lacks the firm, discoid tissue characteristic of glandular growth.

Distinguishing between these two conditions is critical for appropriate management. Physical examination plays a key role; true gynecomastia presents as a palpable, firm ridge of tissue, whereas pseudogynecomastia feels consistent with the surrounding fatty tissue. When physical examination is inconclusive, imaging modalities such as breast ultrasonography can effectively differentiate between the dense glandular tissue of true gynecomastia and the radiolucent fat of pseudogynecomastia. Ultrasound can visualise the specific subareolar nodule or flame-shaped tissue indicative of glandular proliferation.

The distinction determines the surgical approach if treatment is required. Pseudogynecomastia is often treated effectively with liposuction alone, as the primary issue is adipose tissue. True gynecomastia, however, typically requires the surgical removal of the fibroglandular breast tissue, often in combination with liposuction to achieve a contoured result. Failure to identify the glandular component can lead to incomplete treatment and patient dissatisfaction if only liposuction is performed on a patient with true glandular hypertrophy.

The primary pathophysiological mechanism behind gynecomastia is an imbalance of androgens and estrogens, where the stimulatory effects of estrogen on breast tissue override the inhibitory effects of androgens. This hormonal disruption can be caused by a decrease in testosterone production, an increase in estrogen production, or an increase in the conversion of androgens to estrogens by the enzyme aromatase. Physiological gynecomastia is common and occurs during three distinct life phases: the neonatal period due to maternal estrogens, puberty due to transient hormonal fluctuations, and old age due to declining testosterone levels and increased adiposity.

Pathological causes are varied and can include systemic illnesses and endocrine disorders. Conditions such as liver cirrhosis, renal failure, and hyperthyroidism are known to alter hormone metabolism and binding proteins, leading to breast enlargement. Furthermore, testicular tumours (such as Leydig cell tumours) or adrenal tumours can directly secrete estrogens or precursors, while pituitary disorders may lead to secondary hypogonadism. Genetic conditions like Klinefelter syndrome are also significant risk factors, representing a form of primary hypogonadism associated with gynecomastia and an increased risk of male breast cancer.

Medications and recreational drugs are a frequent cause of non-physiological gynecomastia. A wide array of drugs has been implicated, including anti-androgens used for prostate cancer, spironolactone, cimetidine, and certain heart medications like digoxin. Recreational substances such as alcohol, marijuana, and heroin can also disrupt hormonal balance. Notably, the use of anabolic steroids by athletes and bodybuilders is a well-documented cause, as exogenous androgens can be aromatised into estrogens, stimulating breast tissue growth.

Risk factors such as obesity play a dual role. Adipose tissue contains the aromatase enzyme, which converts testosterone into estradiol, thereby increasing systemic estrogen levels. Consequently, increased body mass index (BMI) is strongly correlated with the prevalence of gynecomastia. Additionally, ageing is a significant risk factor; as men age, testosterone levels naturally decline while SHBG (sex hormone-binding globulin) levels rise, reducing the amount of free, biologically active testosterone available to inhibit breast tissue proliferation.

The diagnostic evaluation of gynecomastia begins with a detailed history and physical examination. The history should focus on the duration of breast enlargement, the presence of pain or tenderness, and any changes in testicular size. It is crucial to review a complete list of medications and recreational drugs, as drug-induced gynecomastia is common. The physical exam involves palpating the breast to distinguish the firm, concentric glandular tissue of gynecomastia from the soft adipose tissue of pseudogynecomastia and checking for signs of malignancy, such as hard, eccentric masses or skin changes.

Laboratory investigations are tailored based on the clinical findings. For adolescents with typical pubertal gynecomastia or adults with long-standing, asymptomatic enlargement, extensive testing may not be necessary. However, if the condition is of recent onset, progressive, or symptomatic, a hormonal workup is indicated. This typically includes measuring serum levels of testosterone, estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and human chorionic gonadotropin (hCG) to rule out testicular or pituitary tumours. Liver and kidney function tests may also be included to exclude systemic metabolic causes.

Imaging studies serve as an adjunct to physical examination. Breast ultrasonography is the primary imaging modality used to confirm the presence of glandular tissue and differentiate it from fatty deposition. It is particularly useful when the physical exam is equivocal. Mammography may be utilised if there is a suspicion of breast cancer, particularly in older men or those with asymmetric, hard lumps. Testicular ultrasound is recommended if a testicular mass is suspected or if there are elevations in serum estradiol or hCG.

Pathologic examination of the excised tissue is generally performed after surgery to rule out occult malignancy, although this practice has been debated for routine cases in adolescents. While the incidence of malignancy in gynecomastia specimens is extremely low, especially in young patients, histological analysis can confirm the benign nature of the proliferation. In cases where the clinical picture is suspicious or in older patients, biopsy prior to surgery may be indicated, although it is not standard for typical gynecomastia.

The management of gynecomastia depends on the aetiology, duration, and severity of the condition. For physiological cases, such as pubertal gynecomastia, observation and reassurance are often the first line of treatment, as the condition frequently resolves spontaneously within one to two years. If a reversible cause is identified, such as a specific medication, discontinuing the offending agent may lead to regression. Medical therapy with anti-estrogens like Tamoxifen or aromatase inhibitors has been used, particularly in the early, proliferative phase of the disease, but these are less effective once the tissue has become fibrotic.

Surgery is recommended when gynecomastia persists for more than 12 months, as the tissue typically undergoes irreversible fibrosis and hyalinization, making medical therapy ineffective. Surgical intervention is also indicated for patients who experience significant pain, tenderness, or psychosocial distress due to the appearance of their chest. The primary goal of surgery is to restore a normal male chest contour and alleviate the emotional burden associated with the deformity.

Surgical options include a variety of techniques ranging from minimally invasive procedures to open excision. Liposuction-assisted surgery is effective for removing the fatty component of the breast and can be sufficient for patients with pseudogynecomastia or mixed types where the glandular component is minimal. However, for true gynecomastia with dense fibrous tissue, liposuction alone is often inadequate. In these cases, it is frequently combined with direct surgical excision (subcutaneous mastectomy) to ensure complete removal of the glandular tissue.

For severe cases involving significant skin redundancy (graded as Simon grade III or IV), simple excision may not suffice, and skin resection techniques similar to mastopexy may be required to remove excess skin and reposition the nipple-areola complex. Minimally invasive techniques, such as the use of an arthroscopic shaver or pull-through technique, allow for glandular removal through small incisions, minimising scarring. The choice of technique is tailored to the specific anatomical presentation of the patient to optimise aesthetic outcomes.

Recovery following gynecomastia surgery typically involves a period of reduced activity and the use of supportive garments. Patients are generally instructed to wear a compression garment for 4 to 6 weeks postoperatively to minimise swelling, prevent fluid accumulation, and help the skin retract and adhere to the chest wall. Most patients can return to light activities relatively quickly, but strenuous exercise, particularly involving the chest muscles, is usually restricted for several weeks to ensure proper healing.

Complications, while generally low, can occur. The most common early complication is hematoma formation, which is a collection of blood that may require surgical drainage. Seromas, or fluid collections, are also possible but can often be managed with aspiration. Infection is a risk with any surgery but is relatively infrequent in gynecomastia procedures. To mitigate these risks, some surgeons may utilise drains for a short period, although recent evidence suggests they may not always be necessary.

Aesthetic complications can include contour irregularities, asymmetry, or a “saucer deformity” caused by over-resection of the tissue deep to the nipple-areola complex. Changes in nipple sensation, either temporary or permanent numbness, can also occur. Scarring is inevitable with open excision but is typically well-concealed along the areolar border; however, hypertrophic or visible scarring remains a possibility, particularly in patients prone to keloids.

Overall, patient satisfaction with gynecomastia surgery is generally high, provided that realistic expectations are set. The procedure is considered safe, with a low rate of recurrence if the glandular tissue is adequately excised. Long-term follow-up usually shows stable results, with significant improvements in the patient’s quality of life and self-confidence.