Gynecomastia

What is gynecomastia in men (male breast)?

Gynecomastia refers to an increase in mammary gland tissue in men. A swelling of the nipple can be seen externally. From a palpable enlargement of the breast tissue of two centimetres in diameter one speaks of a gynecomastia. In most cases no cause for gynecomastia can be found. This is also referred to as idiopathic gynecomastia. The treatment of the first choice of idiopathic gynecomastia is surgical correction.

When does the health insurance pay for the treatment of gynecomastia?

The legislator has decided that the correction of a gynecomastia is paid for by the health insurance company if there is a "disfigurement worth of illness". Judges have defined "disease-related disfigurement" as follows:

  • In the case of a disfigurement, there must be a considerable conspicuity which leads to the expectation that those affected constantly attract a lot of attention (Federal Social Court, judgment of 28.02.2008, B 1 KR 19/07 R).
  • The conspicuousness must already be noticeable "in passing" in fleeting encounters in everyday situations (Federal Social Court, judgment of 28.02.2008, B 1 KR 19/07 R).
  • There is no distortion if the body parts can be concealed by wearing suitable clothing (Landessozialgericht Nordrhein-Westfalen, judgment of 14.12.2017, L 5 KR 608/16).

The psychological consequences of a disfigurement can be well proven scientifically. The Federal Social Court is of the opinion that psychological problems resulting from a deformity should be treated primarily with psychotherapy or psychiatry (Federal Social Court, judgment of 28.02.2008, B 1 KR 19/07 R).

The health insurance fund or the medical service of the health insurance funds decides on the assumption of costs. The decisions vary from case to case, from insurer to insurer, from state to state and from year to year. The arguments of the insurance companies and the judges often do not agree with the concerns of the patients and the recommendations of the doctors. Doctors speak of a deformity (deviation from the normal form) and not of a "disfigurement worth of illness". Symmetry or pain do not significantly influence the decisions of health insurance companies. The application for reimbursement must be made by the insured patient. The application is supported by a written statement from a specialist doctor. The issue of a specialist's opinion only makes sense if there is a considerable deviation from the normal breast shape and, at the discretion of the plastic surgeon, there is a chance of success.

If there is a rare suspicion of malignant neoplasm, a tissue sample must be taken. For this purpose, an application for reimbursement of costs is not necessary.

You can find out more under compulsory health insurance.

What are the special features of gynecomastia during puberty?

Gynecomastia occurs particularly frequently between the ages of thirteen and fourteen. These are important formative years of self-discovery in which gender roles and sexual maturity develop. In most adolescents, the male breast recedes after one year. If the male breast lasts longer, it is unlikely to improve without treatment. In a scientific study, up to two thirds of young people with gynecomastia were overweight or obese (Rosen H, et al., 2010, Ann Plast Surg). In obesity, excess fatty tissue produces more female hormones (estrogen). The breast tissue grows under the influence of female hormones. Excess fat and mammary gland tissue leads to the formation of a male breast. Weight loss is an important part of the treatment. However, if overweight has persisted for several years, the mammary gland tissue remains despite weight loss. Children suffer from the physical consequences of overweight and teasing. Gynecomastia increases discomfort and reduces self-esteem (Kinsella C Jr et al. 2012 Plast Reconstr Surg). The shame moves teenagers in different ways to hide their breasts. Thus, those affected wear several shirts, wrap the breast in plastic foil or tape, walk with shoulders pulled forward or arms crossed. The strain of suffering often leads to the avoidance of sporting activities such as swimming and social retreat. This results in postural back pain and depressive mood. Since unilateral gynecomastia is particularly noticeable, the strain is often greater. Psychotherapeutic or psychiatric treatment is inadequate because the cause is not eliminated. Since gynaecomastia has been proven to be associated with a high level of suffering and does not disappear after a certain period of time, life-long psychotherapy would be necessary.

How do you recognize a gynecomastia?

Gynecomastia is clearly visible when the upper body is free. Small manifestations of a gynecomastia are clearly visible when viewed in a semi-profile, i.e. at forty-five degrees averted from the upper body. The turned breast forms the body silhouette and the protruding nipple stands out. When palpating the breast, the size of the mammary gland below the nipple can be estimated. An ultrasound examination allows a more detailed examination. If there are any doubts, an additional X-ray examination of the breast can be carried out.

Can a gynecomastia recede or be trained away?

Excess mammary gland tissue can partially recede during the first twelve months. After this period, the coarse collagen fibres and other protein deposits in the breast tissue increase. The solid collagen tissue does not regress on its own. Regular intensive training leads to the breakdown of body fat tissue. Sport also has many positive effects on all organ systems. However, a regression of the mammary gland tissue cannot be achieved through sport.

When does gynecomastia regress during puberty?

Gynecomastia occurs in one to two thirds of boys between the ages of ten and sixteen. Up to the age of seventeen, ten percent of boys still have gynecomastia. As young people with gynecomastia are often overweight, weight loss is often recommended for the treatment of gynecomastia. Normalizing body weight is beneficial for all organs. However, the pain, shame and psychological strain of a pronounced gynecomastia can be unnecessarily prolonged. The severely stretched skin of the breast and the excess breast tissue are not improved by weight loss. In healthy adolescents with gynaecomastia that has existed for more than a year, an operation for correction is advisable.

Há algum medicamento para ginecomastia?

Um desequilíbrio entre os hormônios masculino e feminino estimula o crescimento do tecido mamário durante a puberdade. Após doze meses, o mais tardar, o corpo reconstrói o tecido mamário para que não volte a regredir. Não existem medicamentos aprovados para o tratamento da ginecomastia. Observou-se uma certa melhoria com a utilização de medicamentos aprovados, por exemplo, para o tratamento do cancro da mama. Se a redução do peito é devido a estas drogas é duvidoso. Uma tentativa de tratamento só faz sentido se a mama estiver apenas ligeiramente dilatada e tiver apenas uma chance de sucesso nos primeiros meses após a ginecomastia ocorrer durante a puberdade. A medicação deve ser tomada por três a seis meses. Às vezes, observa-se um retorno da ginecomastia após a descontinuidade da medicação. Estudos científicos anteriores examinaram um pequeno número de pacientes muito diferentes e não compararam os resultados com outros métodos de tratamento. Para uma ginecomastia com duração superior a doze meses, a cirurgia é o tratamento de primeira escolha. Comparada ao efeito descrito das drogas, a cirurgia proporciona resultados mais rápidos, mais eficazes e esteticamente melhores. Além disso, a recorrência de ginecomastia após a cirurgia é excluída. A lipoaspiração e a remoção de tecido glandular mamário têm demonstrado melhorar a qualidade de vida dos pacientes (Fagerlund A, et al., 2015, J Plast Surg Hand Surg Surg).

As drogas aqui mencionadas inibem o efeito dos hormônios femininos (estrogênio). Os inibidores da aromatase previnem a conversão dos precursores hormonais em hormonas femininas activas. Os antagonistas dos estrogénios bloqueiam a transmissão do sinal das hormonas femininas. Os ensaios de tratamento com as seguintes substâncias activas já foram descritos:

Tamoxifeno (bloqueador do receptor de estrogênio): Dosagens de 10 a 20 miligramas por dia. Os efeitos colaterais do tamoxifeno aumentam com a idade e a duração do tratamento. Os efeitos colaterais incluem: desejo sexual reduzido, rubor de calor, perda de cabelo, ganho de peso, trombose, náuseas, vômitos, problemas gastrointestinais, insônia, depressão, ansiedade, suor.

  • Clomifeno (bloqueador do receptor de estrogênio): Doses de 50 miligramas por dia.
  • Danazol (Suprime a atividade da glândula pituitária): Dosagens de 2 vezes 200 miligramas por dia.
  • Testolactone (inibidor da aromatase): doses de 450 miligramas por dia.
  • Anastrazol (inibidor da aromatase): Dosagens de 1 miligrama por dia.

Does radiation of the breast help against gynecomastia?

Low-dose X-rays and electron radiation are used to treat gynecomastia. However, the application is limited to patients with prostate cancer who develop gynecomastia due to hormone treatment. Ionising radiation is used in radiation therapy. The radiation breaks down chemical compounds. Highly toxic free radicals are produced which, for example, damage the genetic material of cells. Cancer can develop as a result of radiation treatment. Low-dose radiation of the breast increases the risk of breast cancer, lung cancer, stomach cancer and narrowing of the coronary vessels (McKeown SR et al., 2015, Br J Radiol). The risks of radiation treatment are influenced by the following parameters:

  • The younger the patient, the more likely it is that cancer will develop in the course of life as a result of radiation.
  • The body of children and adolescents is particularly sensitive to radiation.
  • Radiation treatment close to the trunk is associated with a higher risk than treatment of the hands or feet.

The risk of high dose radiation for cancer treatment (over 50 grays) is higher than the risk of low dose radiation for benign tissue growth (3 to 50 grays).

After radiation treatment, the body tissue changes permanently. Even decades after radiation treatment, a high risk of wound healing disorders must be expected in the case of an operation.

Does cryolipolysis (cool sculpting) help with gynecomastia?

There are various non-invasive procedures for reducing small fat accumulations in the body such as for example:

  • Cryolipolysis,
  • Ultrasound,
  • Radio frequency,
  • Electromagnetic impulses and
  • Laser lipolysis.

These procedures can lead to a slight reduction of fat tissue after repeated use. A tightening of the skin or a reduction of the breast tissue cannot be achieved by non-invasive procedures such as cryolipolysis. Non-invasive procedures are only suitable for the treatment of a slight increase in fatty tissue in the breast (pseudogynecomastia).

How is gynecomastia divided into stadiums?

Numerous classifications have been described in order to divide gynecomastia into degrees of severity. Most classifications divide gynecomastia into rankings (low, medium and high). The classifications describe the size of the breast, the sagging of the breast and the type of excess tissue (breast tissue, fat tissue, skin). The classifications are named after the plastic surgeon who published the classification (Cohen, Tanner, Simon, Rohrich, Webster, Monarca, Waltho). Objectifiable values such as height, body weight, chest circumference or underbust circumference are not taken into account in the classifications. Few classifications divide the male breast into measurable sizes (for example, smaller than 250 grams, 250 to 500 grams, more than 500 grams). However, the excess breast or fat tissue can only be weighed after removal and not during the examination.

Simon's classification is widely used in Germany. However, it has two major disadvantages:

  • The classification depends on the subjective evaluation of the examiner.
  • The classification allows only a very limited conclusion about the appropriate treatment method in each case.

Classification by Simon (Simon BE et al., 1973, Plast Reconstr Surg)

Stage Description
I Gering visible enlargement of the breast without excess skin
IIa Moderate breast enlargement without excess skin
IIb Moderate breast enlargement with little excess skin
III Female shaped breast with underbreast crease, ptosis and distinct excess skin  

What are the causes of gynecomastia?

In about two thirds of cases, the cause of gynecomastia remains unexplained. The term idiopathic gynecomastia describes the fact that no cause for gynecomastia can be found. Hormone-like side effects of numerous drugs are the most frequent cause of gynecomastia. Treatable causes of male breast affect predominantly middle-aged (35 to 65) and older (65 to 80) patients. In these cases, an imbalance in certain hormones can lead to breast growth. The imbalance is due to a reduction in male hormones (testosterone) or an increase in female hormones (estrogens). Various diseases can affect testosterone production in the testes. The signal transmission of male hormones can also be disturbed in the case of a rare hereditary disease. Certain tumours can also produce pregnancy hormones in men. These hormones (prolactin, human chorionic gonadotropin, or hCG for short) promote breast growth. Several examinations are necessary to uncover the causes of gynecomastia. The examinations are carried out by various specialists. Specialists in internal medicine, endocrinology and diabetology specialise in the examination of hormone levels. The testis is examined by urologists. Radiologists perform the imaging examination of the breast and, if necessary, the abdominal organs or the brain. Specialists in human genetics investigate indications of hereditary diseases.

Possible causes of gynaecomastia

Causes Based disease Explanation
Meds. See "What meds can cause gynecomastia?"    
Malfunction of the testicles 5α-Reductasemangel Erbitary disease in which the formation of testosterone is restricted.
  The disease is a genetic disorder in which the signal transmission of testosterone is impaired.  
  The testicles are missing or underdeveloped.  
  Haemochromatosis Most often hereditary increased uptake of iron in the body, which leads to a reduction in the function of the testicles.
  The symptoms are a clinical syndrome, a genetic defect in the genome.  
  Kallmann Syndrome - Born developmental disorder of the brain.  
  Testicular torsion or testicular injury with risk of loss of function.  
  The most common cause of testicular inflammation is the mumps virus with the risk of loss of function.  
Tumors Malignant adrenal tumors Can produce estrogens.
  Malignant gastric tumors can produce hCG.  
  Large cell lung cancer can produce hCG.  
  Benign tumor of the pituitary gland can produce prolactin.  
  Malignant kidney tumor can produce hCG.  
  Rare testicular tumors (Leydig or Sertoli cell tumors) mostly benign tumors that produce hormones.  
  Embryonic tumors (teratocarcinoma, chorionic carcinoma, or mixed gonadal tumors) can produce hCG.  
  Breast cancer in men proliferation of breast tissue.  
Thyroid disease Overactive thyroid glands Can lead to an increase in estrogens.
  Thyroid hypothyroidism may lead to an increase in prolactin.  
Kidney disease   Hormones are no longer excreted.
Liver diseases   Unclear.
HIV (Human Immunodeficiency Virus)   dysfunction of the testicles.

What medications can cause gynecomastia?

In about twenty percent of cases, the side effects of drugs are the cause of gynecomastia. Drugs can cause gynecomastia in several ways:

  • They can mimic the effect of female hormones or inhibit the effect of male hormones,
  • they increase the formation or disturb the breakdown of female hormones (estrogens, prolactin),
  • they decrease the production of male hormones (androgens), or
  • They provide an excess of hormone precursors (for example testosterone or androstenedione) that can be converted into female hormones.

Many drugs do not yet understand the mechanism that leads to the development of gynecomastia.

Medicines that can cause gynecomastia

Drug use mechanism that causes gynecomastia Frequency in percent      
Antibiotic. Ethianomide. Unknown.      
Antibiotic, isoniazid, multifactorial.      
Antibiotics Metrodinazole Decreases the production of male hormones  
Treatment of viral diseases Antiviral medications Unknown  
Treatment of schizophrenia haloperidol increases prolactin production  
Treatment of schizophrenia Olanzapine Unknown  
Treatment of schizophrenia Risperdon Unknown 2 to 3
Asthma treatment, theophylline, unknown.      
Hypertension treatment, amiodarone, unknown.      
Hypertension treatment. Amlodipine. Unknown.      
High blood pressure treatment Captopril Unknown  
Hypertension treatment. Diltiazem. Unknown.      
Treatment of hypertension Digitoxin Can mimic the effects of estrogen  
High blood pressure treatment. Enalapril. Unknown.      
Hypertension treatment hydrochlorothiazide.      
High blood pressure treatment. Methyldopa. Unknown.      
Hypertension treatment, nebivolol, unknown.      
Hypertension treatment, Nifedipine, Unknown.      
Hypertension treatment, nitrenedipine, unknown.      
Hypertension treatment, ramipril, unknown.      
High blood pressure treatment, Reserpin, Unknown.      
Treatment of hypertension Spironolactone Inhibits the effects of androgens and progesterone 9
High blood pressure treatment. Valsartan. Unknown.      
Hypertension treatment Verapamil Unknown      
Treatment of depression Amitriptyline Increases the formation of prolactin  
Treatment of depression Doxepin Increases the formation of prolactin  
Depression treatment, duloxetine, unknown.      
Depression treatment, fluoxetine, unknown.      
Depression treatment, Mirtazapine, Unknown.      
Depression treatment, paroxetine, unknown.      
Depression Treatment Venlafaxin Unknown  
Treatment of epilepsy phenytoin strengthens the effect of estrogens  
Epilepsy treatment, valproic acid, unknown.      
Treatment of hair loss Finasteride Decreases the production of male hormones 3 to 4
Hair Loss Treatment Minoxidil Unknown      
Treatment of fungal diseases Ketoconazole Decreases the formation of male hormones 7 to 8
Treatment of fungal diseases Itraconazole Diminishes the formation of male hormones  
Treatment of prostate cancer Bicalutamid Inhibits the action of androgens  
Treatment of prostate cancer Flutamide Inhibits the action of androgens  
Treatment of rheumatism penicillamine inhibits the action of androgens  
Treating pain, cannabis. Inhibiting the effects of androgens.      
Nausea treatment. Domperidone. Unknown.      
Treatment of nausea Metoclopramide Increases formation of prolactin  
Tranquilizer Diazepam Increases sex hormone binding globulin  
Tranquillizer phenothiazide increases the formation of prolactin  
Cholesterol reducer, prevastatin.      
Cholesterol reducer Rosuvastatin Decreases the production of male hormones 1 to 2
Muscle growth Anabolic steroids Decreases the formation of male hormones  
Anesthetics Etomidates Improve the formation of estrogen  
Strengthening and strengthening agents Ginseng Unknown  
Suppression of the defensive forces Cyclosporin Multifactorial  
Suppression of the immune system, methotrexate, inhibits the effects of androgens.      
Suppression of gastric acid Omeprazole Inhibits the action of androgens  
Suppression of gastric acid Pantoprazole Inhibits the action of androgens  
Suppression of gastric acid, ranitidine, inhibits the effects of androgens.      

Which specialist should I go to for gynecomastia?

More and more patients are finding information on the Internet. Many patients therefore come to the specialist for plastic and aesthetic surgery to correct the male breast. There is a good reason for this: The techniques for correcting gynaecomastia and restoring the breast are an important part of training to become a specialist in plastic and aesthetic surgery. Some patients with a male breast first entrust themselves to their general practitioner. The family doctor checks whether the side effects of certain drugs are the cause of gynecomastia. If necessary, the family doctor determines hormone levels (follicle-stimulating hormone: FSH, luteinizing hormone: LH, testosterone, estradiol, prolactin, sex hormone-binding globulin: SHBG, human chorionic gonadotropin: HCG). In adolescents, the importance of hormone testing is controversial, as the results of 99% of adolescents with gynecomastia show no pathological findings (Malhotra AK et al. 2018 Plast Reconstr Surg). Hormone levels vary depending on the time of day. Therefore the laboratory values are examined in the morning at the time of the maximum hormone release. If the hormone levels are abnormal, an examination by specialists in internal medicine, endocrinology and diabetology is advisable. Abnormalities of the testicles are examined by the urologist (tactile examination and ultrasound of the testicles). If there are indications of a hereditary disease, a human geneticist will examine the genetic material. The radiologist examines the size of the mammary gland and the composition of the mammary gland tissue using ultrasound or mammography. If the radiologist detects a suspicious change in the breast tissue, a tissue sample is examined histologically by the pathologist. If the laboratory results suggest a tumour, the radiologist will carry out further examinations (magnetic resonance imaging of the pituitary gland, ultrasound or computer tomography of the abdomen). In the unlikely event of breast cancer, the tumour is treated by the gynaecologist.

What can you expect during a consultation about gynecomastia?

In order to best meet your expectations, your complaints (pain or sensitivity of the chest, dissatisfaction with the appearance of the upper body, feeling of shame) will be recorded during the first interview. The conversation should also express complaints, which can be an indication of certain causes (reduced desire to have sex, fatigue, moodiness, change in body weight). Height and weight as well as the accumulation of certain diseases in the family are part of a thorough survey of important information. In order to assess the risks of treatment, the intake of medication or dietary supplements, smoking tobacco cigarettes or e-cigarettes and allergies are asked for. The examination documents the size and shape of the breast, as well as deformities of the thorax or the spine. The surgeon examines whether excess skin is present and assesses the elasticity of the skin. During the palpation examination, the size of the mammary gland tissue is determined. Finally, the breast and the position of the nipples are measured. The breast is photographed for surgical planning and quality control. If necessary, the surgeon will recommend further examinations (determination of hormone levels, ultrasound). When all the necessary information is available, the surgeon will recommend a treatment plan. It is very important to discuss your expectations openly with the surgeon. Often a poorly informed patient or surgeon is the cause of an unsatisfactory result, even if there are no complications during the operation. The individual steps of the operation, the follow-up treatment and the costs are presented to you in a transparent and comprehensible way. For any questions that may arise later, we will be happy to arrange a second consultation. We look forward to hearing from you!

What to do if you have unilateral gynecomastia?

In 95 percent of cases of gynecomastia there is a symmetrical enlargement of the male breast. In four to five percent of cases there is an asymmetrically enlarged male breast. In less than 0.5 percent of cases, gynecomastia is only present on one side (Lee SR et al., 2018, Aesthetic Plast Surg). One-sided gynecomastia is caused by an increase in mammary gland tissue (Al-Qattan M et al., 2005, Ann Plast Surg). In an estimated two percent of cases of unilateral gynecomastia, breast cancer can be detected (S.E. Janes et al., 2006, Breast). Unilateral gynecomastia is more often associated with breast cancer than bilateral gynecomastia (Agostini T et al., 2014, J Plast Reconstr Aesthet Surg). The removal of the mammary gland tissue is the best treatment for unilateral male breasts.

Is there a risk of breast cancer in gynecomastia?

The estimated risk of breast cancer in adolescents with gynecomastia is 0.012 percent or less (Koshy JC et al., 2011, Plast Reconstr Surg). In Germany, about 600 men are diagnosed with breast cancer every year. Breast cancer in men is over a hundred times less common than in women. Breast cancer in men corresponds to 0.17 percent of all tumours and less than 0.1 percent of all cancer-related deaths. Breast cancer in men occurs most frequently between the ages of fifty and sixty (Cutuli B et al., 1997, Eur J Cancer). Externally, skin retraction may be visible. Breast cancer can make the skin surface look like an orange peel. The following characteristics increase the risk of breast cancer in gynecomastia:

  • Irradiation,
  • Gene alterations (BRCA 1/-2 mutations),
  • Congenital chromosomal disorder (Klinefelter syndrome, twenty to fifty times higher risk).

How can you prepare for breast reduction?

  • In order to clarify the cause, a blood test and an appointment with a specialist in endocrinology as well as an ultrasound examination of the breast and testicles are recommended.
  • All your questions about possible complications and alternative treatments should be answered in advance.
  • Keep nicotine and alcohol consumption to a minimum.
  • Blood-thinning medication (e.g. ASS, Thomapyrin®) must be discontinued at least ten days before the operation after consultation with your treating physician.
  • Vitamin preparations (A, E) and food supplements (omega-3 fatty acids, St. John's wort preparations, etc.) must be discontinued at least 4 weeks before the operation.
  • Surgery limits the ability to travel by air.  Therefore, do not plan any professional or private air travel during the six weeks following the operation.
  • In the case of pronounced forms, the health insurance company will cover the operation costs in individual cases.  Then, two to three months before the planned operation, an application should be made for the assumption of costs.
  • A follow-up cost insurance should be taken out before performing aesthetic procedures.

What is to be considered after a breast reduction with the man?

  • This is followed by regular checks of your well-being and the results of the operation.
  • An elevation of the upper body of about 30 degrees (also during sleep) over 5 days is beneficial for the decongestant and healing of wounds.
  • Showering is possible immediately before the wound control from the third postoperative day.
  • Previously fitted compression garments should be worn continuously for 6 weeks.
  • Scar care (scar massage, sun protection, silicone overlay) from the 3rd postoperative week onwards helps to create inconspicuous scars.
  • Sport, saunas, swimming, heavy work and sunbathing should be avoided for at least 6 weeks.

Author's statement

Author: Stéphane Stahl, MD, PhD. There are no financial relationships with the pharmaceutical or medical device industries that could have influenced the above text. Any reproduction, even partial, is permitted for personal use only. All texts used on this website are protected by copyright.

 

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