What is gynecomastia? Gynecomastia is the enlargement of breast glandular tissue that occurs in males. It is caused by the inadequate balance of estrogen and testosterone. As you may know, testosterone is the more dominant hormone in males. It is what helps define a male’s key characteristics, such as larger muscles, hairy body parts, and deepened voice. In contrast, estrogen is the more dominant hormone found in females, and allows them to grow breasts and controls their menstrual cycle. It is important to understand that both sexes carry both hormones. This means all males have estrogen as well. In gynecomastia, the imbalance is that males tend to have less testosterone and more estrogen which causes the increase in breast glandular tissue.
So, what are the patient’s signs and symptoms? Typically, most males are asymptomatic and in fact, seek medical attention due to the embarrassment of enlarged appearing breasts. Yet, tenderness to the touch of the breasts and nipple sensitivity can be symptoms that motivate patients to seek help.
When does gynecomastia occur? Typically, gynecomastia occurs at three separate stages of a male’s lifespan. These stages include a) infancy b) prepubertal years, and c) adult life ranging from 50-80 years old. During pregnancy, the placenta of the mom produces higher than normal values of estrogen, which is then cycled into the fetal blood supply. Thus, causing gynecomastia is common in male infants, and will self resolve over a few weeks. In prepubertal ages, ages 10-12 years old, males undergo hormonal changes that may cause gynecomastia. Finally, as adults get older, gynecomastia may occur for a number of estrogen peaking causes that can be physiological or drug or medicine related. Physiological means that for some reason the body decides to either produce more estrogen than normal values, or not enough testosterone. Typically, hormone production may be altered by improper signals from our endocrine system. Our endocrine system is a set of important glands that send messages to each other on when to either stop or start producing certain hormones. In gynecomastia, the hypothalamus which is located in our central brain sends a message to our pituitary gland, which then sends a message to our adrenal glands and our testicles to produce testosterone. For some reason this messaging system can be disrupted. It could be a tumor on your adrenal gland or a testis, it could be lack of response from your pituitary gland or hypothalamus. Whatever the reason, it is important to check accurate hormone levels from our doctor to evaluate what the actual cause is and from there an appropriate treatment plan can be addressed to help with gynecomastia. Second, gynecomastia can be caused by a certain number of medications that may be prescribed as well as by drug abuse. Some examples of prescription medications include finasteride, spironolactone which are anti-androgens drugs. Another set of medications include antibiotics and antifungals like ketoconazole and isoniazid. Moreover, antiulcer drugs like omeprazole and cimetidine can cause hormonal imbalances. Finally,medicatinons such as androgens and growth hormone will directly affect hormone production. So, let’s talk about finasteride. Finasteride is a type of medication that can be used to treat benign hyperplasia prostate as well as male pattern baldness. Well, let’s talk about how BPH and male pattern baldness occur, which I am sure you have already figured out. They both are caused by a buildup of androgens, specifically dihydrotestosterone which is a male’s major testosterone hormone. So, the more dihydrotestosterone someone has, the greater risk they have developing BPH and male pattern baldness. 5-alpha-reductase is the enzyme that takes testosterone and produces it to dihydrotestosterone, so by stopping this conversion we can then decrease dihydrotestosterone. This is the basis for finasteride, a medication that blocks the enzyme, 5-alpha-reductase. So technically there is not an increased buildup of estradiol or estrogen, instead a decrease in testosterone which results in an imbalance of estrogen to testosterone ratio therefore leading to gynecomastia. Other prescription medications essentially work the same way by disrupting the mechanism of the estrogen to testosterone ratio. Drug abuse including alcohol, amphetamines, heroin, marijuana, and methadone are all also known to cause an estrogen/testosterone imbalance leading to gynecomastia. In particular, marijuana is a popular prepubertal used drug and a known cause of teenage gynecomastia.
In sum, it is important for patients to appreciate when they believe they are experiencing signs and symptoms of gynecomastia, characterized as growth in their breasts. It is critical to consider all factors that may be causing gynecomastia prior to considering any treatment. A comprehensive workup is even more critical in cases that involve localized tenderness or painful nodules. In such cases, an imaging study such as an MRI must be considered to rule out breast cancer, although rare in males, as the source of a growing breast lump. Consultation with a breast specialist is critical for males who are concerned about gynecomastia in order to complete a comprehensive workup and customized surgical plan.