Gynecomastia is a pathology of the mammary glands in men, manifested by a one– or two-sided increase in their size due to hypertrophy of glandular or adipose tissue. It is manifested by compaction and enlargement of the breast, a feeling of heaviness, painful sensations during palpation. It can regress on its own. If conservative therapy is ineffective, surgical treatment is indicated, since the long-term existence of gynecomastia poses a risk in the development of a malignant breast tumor.
ICD 10
N62 Breast hypertrophy
Meaning
Mammary glands with gynecomastia can reach from 2 to 10 cm (usually about 4 cm) in diameter. The incidence of gynecomastia ranges from 50 to 70% among healthy adolescents aged 13-14 years, about 40% – in young men, up to 60% – 70% – in older men. Gynecomastia gives men physical discomfort and psychological difficulties.
Classification
There are true gynecomastia and false (or pseudogynecomastia). True gynecomastia is characterized by hypertrophy of glandular tissue and stroma, pseudohynecomastia is caused by massive deposits of adipose tissue that increase the volume of mammary glands, and is observed in men with obesity.
There is a true gynecomastia, as a variant of the physiological norm in certain age periods, and pathological gynecomastia, which is a symptom of serious pathologies in the body.
True idiopathic (physiological) gynecomastia can be of three types:
- gynecomastia of the newborn period – swelling of the mammary glands is noted in 60-90% of newborns. This condition is caused by the influence of the mother’s sex hormones, which entered the child’s body in utero. It does not require treatment, the mammary glands decrease after 2-4 weeks.
- gynecomastia of puberty – develops in 30-60% of adolescents aged 13-14 years; in 80% of cases there is a bilateral enlargement of the glands. It is caused by the immaturity of the male reproductive system and the predominance of female sex hormones over male ones. It usually regresses independently within 1-2 years.
- gynecomastia of the elderly is observed in men aged 50-80 years due to a decrease in testosterone production and the predominance of estrogens.
With gynecomastia, there may be a bilateral symmetrical increase in both mammary glands (80%) or an asymmetric increase in one gland.
Causes
Normally, the mammary glands in men are an underdeveloped, rudimentary organ consisting of a small amount of glandular and adipose tissue, short ducts and a nipple. The development and functioning of the mammary glands depends on the effects of female sex hormones – estrogens and pituitary hormone – prolactin. Normally, the amount of estrogens in the male body does not exceed 0.001% of the androgen content, and they are quickly destroyed in the liver.
For a number of reasons, the percentage of androgens / estrogens changes towards an increase in the latter or there is a decrease in the sensitivity of tissues to the action of testosterone. Under the influence of estrogens, the development and growth of male mammary glands begins according to the female type with intensive development of glandular tissue. With the development of pituitary adenoma, which produces prolactin, fat deposition and connective tissue development occur in the mammary glands. With gynecomastia, the glands increase in size and thicken.
True pathological gynecomastia in men can be caused by the following groups of causes:
- violation of the ratio of testosterone and estrogen in the male body. This condition can be observed with hormone-active tumors of the pituitary gland, testicles, adrenal glands, stomach, pancreas, lungs, primary and age–related hypogonadism (insufficient functioning of the sex glands), prostate adenoma, inflammatory processes in the testicles, Addison’s disease, etc.;
- hyperprolactinemia – increased secretion of prolactin in pituitary tumors, hypothyroidism;
- diseases accompanied by metabolic disorders – with diffuse toxic goiter, diabetes mellitus, obesity, pulmonary tuberculosis, etc.;
- diseases of non–endocrine nature – with intoxication, cirrhosis of the liver, renal or cardiovascular insufficiency, HIV infection, chest injuries, herpetic lesion of the chest, normalization of nutrition after exhaustion, etc.;
- taking drugs acting on the receptors of breast tissue, increasing the production of estrogens or prolactin, blocking gonadotropin receptors, having a toxic effect on the testicles, etc. (corticosteroids, anabolic steroids, cimetidine, spironolactone, isoniazid, metronidazole, ranitidine, captopril, enalapril, reserpine, methyldofa, nifedipine, amiodarone, verapamil, digitoxin, theophylline, antidepressants, diazepam, creams containing estrogens and many others;
- drug use (heroin addiction, marijuana use) and alcoholism.
Gynecomastia symptoms
With gynecomastia of the newborn period, there is a slight swelling and enlargement of the mammary glands, sometimes with colostrum-like secretions. In other forms of gynecomastia , the mammary glands can increase from 2 to 10 — 15 cm in diameter and reach a mass of up to 160 g . The nipple increases, the areola becomes sharply pigmented and expanded to 2-3 cm in diameter. In rare cases, there is a milky discharge from the nipple. Usually enlarged glands are painless, there may be a feeling of pressure, increased sensitivity of the nipples, discomfort when wearing clothes.
With unilateral gynecomastia, the probability of a tumor lesion of the breast increases. Hormone-active tumors that produce estrogen and chorionic gonadotropin cause a rapid increase in the mammary glands, their soreness and a feeling of bursting. Gynecomastia caused by hyperprolactinemia is accompanied by oligospermia, impotence and symptoms of damage to the central nervous system.
During gynecomastia , there are three stages:
- developing (proliferating) – initial changes, the first 4 months, when reverse development of gynecomastia is possible with appropriate medical treatment;
- intermediate – characterized by the maturation of glandular tissue; lasts from 4 months to a year;
- fibrous – the appearance of connective and adipose tissues in the breast is noted; regression of the pathological process is practically impossible.
The appearance of bloody discharge from the nipple, seals in the gland, changes in the skin of the gland, ulceration, enlarged axillary lymph nodes makes you suspect breast cancer.
Diagnostics
The initial examination for gynecomastia includes examination of the patient, palpation of the mammary glands and testicles, assessment of the severity of secondary sexual characteristics, clarification of family, medical history and existing diseases, the presence of alcohol and drug addiction.
If there are signs of gynecomastia, an endocrinologist is consulted. The extensive possibilities of laboratory diagnostics that endocrinology has today allow for a thorough hormonal examination of the patient. The blood levels of estradiol, testosterone, LH, FSH, thyrotropin, prolactin, hCG, hepatic transaminases, nitrogen, creatinine, urea are determined in the laboratory.
To exclude tumor processes, lung X-ray, CT of the adrenal glands, CT of the brain, etc. is performed. organs (according to indications). If a tumor lesion of the testicles is suspected (with an increase in the content of chorionic gonadotropin and testosterone), ultrasound of the scrotum organs is performed. To determine the nature of gynecomastia (true or false), breast tumor detection, ultrasound of the mammary glands is used. Ultrasound of axillary lymph nodes, mammography and breast biopsy are performed in cases of suspected cancer.
Gynecomastia treatment
Physiological types of gynecomastia usually disappear spontaneously and do not require medical correction. Sometimes hormonal drugs can be prescribed to suppress high concentrations of estrogens in physiological gynecomastia in adolescents: clomiphene, tamoxifen, dihydrotestosterone, danazol, testolactone. If medical treatment does not lead to a reduction in the size of the mammary glands, then plastic surgery comes to the rescue. Breast tissue removal and liposuction (removal of fat in adjacent areas) are performed.
The treatment of pathological gynecomastia is determined by the underlying disease that caused the enlargement of the mammary glands. To normalize the ratio of testosterone and estrogen in gynecomastia, conservative hormone therapy with testosterone is carried out. It is effective in the first 4 months after the occurrence of gynecomastia. With an excess of estrogens in the male body, antiestrogenic therapy with tamoxifen is prescribed, which blocks the effect of estrogens on the mammary glands. Gynecomastia caused by taking medications usually disappears on its own after the drug is discontinued.
Surgical treatment for gynecomastia is carried out in cases when conservative therapy is ineffective or it is obviously clear that medical treatment will not give the desired result (with tumor lesions). Surgical treatment of gynecomastia the following types of surgery are performed: it consists in removing breast tissue and restoring its physiological contour. The following types of operations are used:
- subcutaneous mastectomy with preservation of the areola from the paraareolar access;
- subcutaneous mastectomy from paraareolar access with liposuction;
- endoscopic mastectomy (with small breast enlargement).
Subcutaneous and endoscopic mastectomy operations are well tolerated by patients, do not require prolonged hospitalization (usually 2 days) and long-term rehabilitation. For the first 2-3 weeks after mastectomy, it is required to wear elastic tightening underwear to form the correct muscle contour and shrink the skin. After 5-7 days, it is already possible to start normal work, and after a month – to sports training.
Forecast
Gynecomastia of newborns and adolescents is characterized by a favorable course. In the post-pubertal period, gynecomastia disappears within 2 years in 75% of young men, in the next 3 years – in another 15%.
The outcome of pathological forms of gynecomastia depends on the possibility of eliminating the cause of the disease. Prognostically, medicinal gynecomastia is more favorable, gynecomastia caused by chronic diseases is less favorable.
Prolonged gynecomastia increases the likelihood of breast cancer in men.