People of both sexes have some breast tissue and whether this develops into visible breasts depends on various factors, most importantly the action of hormones. Gynaecomastia is the development of this breast tissue in males and is common. It is often seen in new born babies due to the mother’s hormones acting on the baby’s breast tissue but usually disappears in the first few weeks after birth. The next age at which it is seen frequently is during puberty. In fact, it affects up to two thirds of all boys during this time but, again, most gynaecomastia during puberty disappears without any treatment within two years. In between 5% and 10% of boys who have gone through puberty, the breast development during puberty does not fully disappear and they will be left with visible breast tissue. Gynaecomastia is also commonly seen in old age, affecting about one third of men. The term Gynaecomastia was first described by the Roman doctor, Galen between 150 and 200AD.
As well as this physiological or ‘normal’ gynaecomastia, there are other causes that are not as expected. Any imbalances in hormone production or regulation can result in the condition, as can certain syndromes such as Klinefelter’s or even certain tumors. Liver and kidney disease can cause it, as can being overweight. There are a large variety of drugs that cause gynaecomastia, both prescription drugs and recreational drugs including athletic performance enhancing steroids, marijuana and alcohol excess. Despite all of these known causes, in about a quarter of all cases the reason for developing gynaecomastia is unknown.
Although gynaecomastia is a continuous spectrum, it is helpful to consider the condition in terms of different types. One important consideration is the age at which the gynaecomastia started. This, together with how long it has been present and whether it is continuing to develop over time will help to determine whether it is a feature of the patient’s normal development, which will resolve without medical intervention, whether it was a part of the patient’s normal development but that it hasn’t resolved as it should have, whether it is caused by a drug that can be stopped, or whether it is caused by a disease or hormonal imbalance that will need to be treated.
Another feature that can divide gynaecomastia into different types is the type of tissue that has developed in the breast. Under the skin, as well as the blood vessels, nerves, ducts and connective tissue, holding everything in shape, the breast consists of two main types of tissue: dense glandular tissue, which is responsible for producing milk after childbirth, and fat. In gynaecomastia, all of these tissues develop but the extent of development of each type varies. The breast can be mainly glandular, mainly fat or a mixture of the two. It is fairly common to see mainly fat on the outside of the developed breast and mainly glandular tissue close to the nipple, but the type of tissue involved is important for planning treatment.
It is also important to consider the severity of the gynaecomastia. In moderate to severe gynaecomastia, there is not only development of excess breast tissue, but together with that, there is often an expansion of the overlying skin, and it may be necessary to remove some of this skin at the time of surgery. In the most severe cases, it is sometimes necessary to perform an extensive skin reduction, similar to a female breast reduction.-
The condition can affect children in different ways. Common complaints are embarrassment about his chest that he doesn’t like to wear tight clothes or to undress in front of his peers, and especially that he doesn’t like to go swimming. Occasionally the breast tissue can be painful or can cause discharge from the nipples, which can worsen the embarrassment. Teasing is a common worry and psychosocial concerns can make it difficult for young men with gynaecomastia to enjoy sports and to form relationships.
Diagnosis of gynaecomastia is made by clinical assessment, which will involve a series of questions about the different aspects of development, especially around the time of puberty. It will include a physical examination of your chest and other areas of the body that may give information about the cause of the condition. Depending on your age and assessment findings, further investigations and assessment by a Pediatric Endocrinologist, may be recommended.
Signs to look for are a swelling or lump under the nipple, which can be on one side or on both. This is often found in young men going through puberty and can be a normal finding, but rapid growth, a difference between the two sides, development of breasts without any other signs of puberty or any discharge from the nipple should be assessed thoroughly.