What is it?
Adult gynecomastia is swelling of the male breast tissue. The occurrence of gynecomastia reaches its peak between the ages of 50 and 80. In this age group, at least 1 in 4 men are affected.
What causes adult gynecomastia?
Gynecomastia is caused by an imbalance of the hormones testosterone and estrogen. Many things can upset this balance. The most common direct cause is untreated or unrecognized adolescent gynecomastia. This may occur when a young male is overweight and the gynecomastia is not obvious until the weight is lost, which often occurs in adulthood. Below are some of the major causes of adult gynecomastia and their prevalence:
- Adolescent gynecomastia persistent: 25%
- Drug induced: 10 – 25 %
- No detectable cause: 25 %
- Malnutrition and liver disease: 8 %
- Primary hypogonadism (deficient testes): 8%
- Tumors of the testes: 3 %
- Secondary hypogonadism (low sperm count): 2 %
- Hypothyroidism: 1.5 %
As you can see, 25% of the gynecomastia cases are unresolved from adolescence. The other causes are unknown, hormone, or drug-induced.
Assessing adult gynecomastia
Before proceeding with surgery for adult onset of male breast enlargement, a gynecomastia surgeon will want to determine the direct cause of the condition. If it is not obvious from the medical history and physical exam, hormone testing is appropriate. A medical history may include the following:
- Age of onset and duration of the condition
- Any recent changes in nipple size and any pain or discharge from the nipples
- History of mumps, testicular trauma, alcohol use, or drug use
- Family history of gynecomastia
- History of sexual dysfunction, infertility, or hypogonadism (a condition in which the production of sex hormones and germ cells are inadequate)
A physical examination may include the following:
- Thorough examination of the breasts, with attention to size and consistency
- Assessment for any nipple discharge or axillary lymphadenopathy (obvious enlargement of lymph nodes in the area of the arm and breast)
- Testing to differentiate between true gynecomastia and pseudogynecomastia (enlarged breast tissue caused by fat accumulation)
- Assessment of glandular tissue
- Examination of the testicles, with attention to size and consistency, as well as nodules or asymmetry
- Observation of any signs of feminization
Diagnosing adult gynecomastia
In order to properly diagnose adult gynecomastia, the doctor has the patient lie flat on his back with his hands clasped beneath his head. Using the separated thumb and forefinger, the doctor slowly brings the fingers together from either side of the breast. In patients with true gynecomastia, a rubbery or firm mound of tissue can be felt surrounding the nipple and areola; whereas in patients with pseudo-gynecomastia, no such disk of tissue is found. If all tests return a normal result, the condition is often referred to as a “non-detectable cause or idiopathic.”
Causes and treatment of pseudo-gynecomastia
Unlike gynecomastia, in which the male breast is enlarged due to glandular tissue, pseudo-gynecomastia develops due to fat deposits. The condition is usually attributed to aging and/or weight gain. The average patient states that his male breasts were not present in his teens, but developed at a later time in life as he gained weight. For the pseudo-gynecomastia patient, it is often possible to get a pleasing result with just liposuction.
As men age, their blood levels of testosterone gradually decrease, creating an imbalance between the testosterone and estrogen levels. In many cases, this accounts for hormone-induced gynecomastia in older adult men. The chart below illustrates the slow decline in testosterone levels in the blood stream.
Low testosterone levels (Low T)
Testosterone is a powerful male hormone produced in the testicles and is responsible for stimulating sperm production and sex drive. It also is responsible bone density and muscle mass. “Low T” is a common and popular term for low testosterone levels. The reduced testosterone triggers a syndrome known as “andropause.” This condition is similar to menopause in females. As men age, testosterone production naturally declines and can cause a variety of symptoms. Signs of low testosterone often go undetected and are mistaken as a natural part of aging.
Signs and symptoms of Low-T
Gynecomastia can occur as the balance between testosterone and estrogen favors higher estrogen levels, causing male breast development as well as:
- Reduced libido: Testosterone plays a major role in the male sex drive. As men age and testosterone levels decrease, the sex drive also lessens.
- Reduced semen volume: Testosterone is vital to semen production, the fluid that assists in sperm motility. The more testosterone a man has, the greater his semen production.
- Loss or reduction of facial and body hair
- Lack of overall energy and fatigue
- Loss of muscle mass and strength, especially in the arms, legs, or chest
- Increase in total body fat. The cause is unclear.
- Reduced bone mass (osteoporosis)
- Mood changes: Testosterone is thought of as “fuel” for men. It is a hormone that controls multiple body systems, as well as mental health and mood. Men with low testosterone are more likely to experience depression, short attention span, and irritability.
For a closer look at the controversy and pros and cons of testosterone replacement, read the Time Magazine article: Are You Man Enough? The Truth About Low Testosterone.
Medical conditions that may cause male breast enlargement
- Malnutrition and liver disease
- Men with disorders of the sex organs may have reduced testosterone production and high levels of estrogen, which can lead to gynecomastia
- Some genetic disorders, for example Klinefelter’s syndrome, also called XXY male
- Reduction of blood flow
- Chronic renal disease
- Cancer rarely causes gynecomastia with the exception of testicular tumors, which can produce hormones that may contribute to the development of gynecomastia
Drugs associated with male breast enlargement
- Calcium channel blockers used for controlling high blood pressure
- Spironolactone (Aldactone), a diuretic that also has anti-androgen capabilities
- ACE inhibitor medications for high blood pressure such as captopril (Capoten) and enalapril (Vasotec)
- Various antibiotics such as isoniazid, metronidazole (Flagyl), and ketoconazole (Nizoral, Kuric, Xolegel, Extina)
- Anti-ulcer drugs including cimetidine (Tagamet), ranitidine (Zantac), and omeprazole (Prilosec)
- Anti-androgen therapy for cancer of the prostate
- Methyldopa [Aldomet] used to treat hypertension
- Highly active anti-retroviral therapy [HAART] for the treatment of HIV. The drug can lead to fat accumulation, which may in turn lead to pseudo-gynecomastia or true gynecomastia
- Diazepam (Valium), an anti-depressant
- Digitoxin, heart medication
- Drugs such as marijuana, alcohol, and heroin
- Skincare products containing tea tree and lavender oils
Examples of adult gynecomastia
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