Gynecomastia is an increase in mammary tissue in men. A swelling of the nipple can be seen externally. From a palpable enlargement of the breast tissue of two centimeters in diameter one speaks of a gynecomastia. In most cases, no cause can be found. One then speaks of idiopathic gynecomastia. The treatment of first choice for idiopathic gynecomastia is surgical correction of the male breast. On this page you will find all information about the various forms of the disease, symptoms and possible alternatives to surgical treatment. If you would like to read more about gynecomastia surgery, visit our page about surgery afterwards. There you will find everything about the procedure including the anesthesia and local anesthesia, liposuction, healing process, pre- and post-operative care in the first days and weeks, possible complications and risks of the male breast surgery. You will also be informed whether the operation has to be carried out on an outpatient basis in a special operating room or in a clinic.
Gynecomastia is clearly visible when the upper body is bare. Slight manifestations of gynecomastia can be seen well when viewed in half profile, i.e. with the upper body turned away at forty-five degrees. The averted breast forms the body silhouette and the protruding nipple stands out. By palpating the breast, the size of the breast gland below the nipple can be estimated. An ultrasound scan allows for a more detailed medical examination. If there are any doubts, an additional chest x-ray can be performed.
The legislature has decided that the correction of a gynecomastia is paid for by the health insurance company if there is a "disfigurement". Judges have defined "disfigurement" as follows:
- In the case of a disfigurement, there must be a significant abnormality that leads to the expectation that those affected will constantly attract a lot of glances (Federal Social Court, judgment of February 28, 2008, B 1 KR 19/07 R).
- The conspicuousness must already be noticeable "in passing" at a casual encounter in everyday situations (Federal Social Court, judgment of 02.28.2008, B 1 KR 19/07 R).
- There is no disfigurement if the parts of the body can be covered by wearing appropriate clothing (Landessozialgericht Nordrhein-Westfalen, judgment of December 14, 2017, L 5 KR 608/16).
The psychological consequences of a distortion can be proven scientifically. The Federal Social Court is of the opinion that psychological problems resulting from a deformity should primarily be treated with psychotherapy or psychiatry (Federal Social Court, judgment of February 28, 2008, B 1 KR 19/07 R).
The health insurance company or the medical service of the health insurance companies will decide 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 put forward by insurance companies and judges are often inconsistent with patient concerns and doctors' recommendations. Doctors speak of a deformity (deviation from the normal shape) and not of a "disfigurement". The symmetry or symptoms such as pain do not significantly influence the decisions of the health insurance companies. The insured patient must submit the application for reimbursement of costs. The application is supported by a specialist doctor's written statement (possibly a medical indication). Issuing a specialist medical opinion only makes sense if there is a significant deviation from the normal breast shape and, at the discretion of the doctor (plastic surgeon), there is a chance of success.
If there is a rare suspicion of a malignant neoplasm, a tissue sample must be taken. An application for the assumption of costs is not required for this.
You can find out more under Obligation of health insurance companies to provide benefits.
Excess mammary gland tissue can partially recede in the first twelve months. After this period, the coarse collagen fibers 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. A regression of the mammary gland tissue cannot be achieved through sport.
Gynecomastia is particularly common between the ages of thirteen and fourteen. This is also referred to as puberty gynecomastia. These are important formative years of self-discovery, in which gender roles and sexual maturity develop. In most adolescents, the male breast, also popularly known as the female breast as in women, regresses after a year. If the man's breast persists for a longer period of time, it is unlikely to improve without treatment. In a scientific study, up to two thirds of adolescents with gynecomastia were overweight or obese (Rosen H, et al., 2010, Ann Plast Surg). This usually has hormonal causes: if you are obese (very overweight / obese), there is a hormonal disorder because the excess fat tissue produces more female sex hormones (estrogen). The mammary gland tissue grows due to the disturbed hormonal balance. Excess fat and glandular tissue in the breast leads to an enlarged breast in affected men. Weight loss is an important part of treatment. If overweight has persisted for several years, however, the male mammary gland tissue remains despite weight loss. Children suffer from the physical consequences of being overweight and the teasing. Gynecomastia increases the discomfort and reduces self-esteem (Kinsella C Jr et al. 2012 Plast Reconstr Surg). Shame moves adolescents in various ways to hide their large breasts. Affected people wear several shirts, wrap their chests in plastic wrap or adhesive tape, walk with shoulders pulled forward or arms crossed. The psychological stress often leads to avoidance of sporting activities such as swimming and social retreat. This results in postural back pain and a depressed mood. Since unilateral gynecomastia is particularly noticeable, the burden is often greater. Psychotherapeutic or psychiatric treatment is insufficient as the cause is not eliminated. Since it has been proven that real gynecomastia is associated with high levels of suffering and psychological stress and does not resolve after a certain time, lifelong psychotherapy would have to be carried out.
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. Because teenagers with gynecomastia are often overweight, weight loss is often recommended as a treatment for gynecomastia. A normalization of body weight is beneficial for all organs. The pain, shame and psychological stress of pronounced gynecomastia can, however, be unnecessarily prolonged. The excessively stretched skin of the breast and excess breast tissue will not be improved by losing weight. In healthy adolescents with gynecomastia that has existed for more than a year, surgery to correct it is useful.
A disturbed hormonal balance, i.e. an imbalance between male and female hormones, stimulates the growth of breast tissue during puberty. After twelve months at the latest, the body rebuilds the breast tissue so that it no longer recedes. There are no drugs that are approved for the treatment of gynecomastia. A certain improvement could be observed when taking drugs that are approved for the treatment of breast cancer, for example. It is doubtful whether the breast reduction was due to these drugs. A treatment attempt is only useful if the breast has been slightly enlarged and only has a chance of success in the first few months after the onset of gynecomastia during puberty. The medication must be taken for three to six months. Sometimes a return of gynecomastia is seen after stopping the medication. Previous scientific studies have examined a small number of very different patients and have not compared the results with other treatments. For gynecomastia that lasts longer than twelve months, aesthetic surgery is the treatment method of first choice. Compared to the described effects of the medication, gynecomastia surgery delivers faster, more effective and better aesthetic results. In addition, the recurrence of gynecomastia after a surgical procedure is impossible. Liposuction and the removal of the tissue of the male mammary glands have been shown to improve the quality of life of patients (Fagerlund A, et al., 2015, J Plast Surg Hand Surg).
The drugs mentioned here inhibit the effects of female hormones (estrogen). Aromatase inhibitors prevent the conversion of the hormone precursors into active female hormones. Estrogen antagonists block the transmission of signals from female hormones. Treatment attempts with the following active ingredients have already been described:
Tamoxifen (estrogen receptor blocker): dosages of 10 to 20 milligrams per day. Tamoxifen side effects increase with age and the length of treatment. Side effects include: decreased sexual desire, hot flashes, hair loss, weight gain, thrombosis, nausea, vomiting, gastrointestinal complaints, sleep disorders, depression, anxiety, sweating.
- Clomiphene (estrogen receptor blocker): dosages of 50 milligrams per day.
- Danazol (suppresses the activity of the pituitary gland): doses of 200 milligrams twice a day.
- Testolactone (aromatase inhibitor): dosages of 450 milligrams per day.
- Anastrazole (aromatase inhibitor): dosages of 1 milligram per day.
Low-dose X-rays and electron beams are used for gynecomastia treatment as an alternative to the surgical route. However, its use is limited to patients with prostate cancer who develop gynecomastia as a result of their hormone treatment. Ionizing radiation is used in radiation therapy. The rays break down chemical compounds. Highly toxic free radicals are created which, for example, damage the genetic material of cells. Cancer can develop as a result of radiation treatment. Low-dose radiation to the breast increases the risk of breast cancer, lung cancer, stomach cancer and narrowing of the coronary arteries (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 as a result of radiation in their lifetime.
- 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 treating cancer (over 50 gray) is higher than the risk of low-dose radiation for treating benign tissue growth (3 to 50 gray).
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 event of an operation.
There are several non-invasive methods of reducing the accumulation of small fat in the body such as:
- Radio frequency,
- Electromagnetic pulses and
- Laser lipolysis.
These procedures can lead to a slight reduction in adipose 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 treating a slight increase in adipose tissue in the male breast. In this case, in contrast to real gynecomastia, one speaks of false gynecomastia. This is also known under the terms pseudogynecomastia or pseudo-gynecomastia or lipomastia. For more information on pseudogynecomastia and treatment, see the dedicated pseudogynecomastia page.
Numerous classifications have been described to divide gynecomastia into degrees of severity. Most classifications divide gynecomastia into ranks depending on its severity (low, moderate and severe). The classifications describe the size of the breast, the sagging of the breast, and the type of excess tissue (breast tissue, adipose tissue, skin). The classifications are named after the expert and plastic surgeon who published the classification (Cohen, Tanner, Simon, Rohrich, Webster, Monarca, Waltho). Objective values such as height, body weight, chest girth or underbust girth are not taken into account in the classifications. Few classifications divide the male breast into measurable sizes (for example, less 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 widespread in Germany. However, it has two major disadvantages:
- The classification depends on the subjective assessment of the examiner.
- The classification allows only very limited conclusions to be drawn about the appropriate treatment method in each case.
|I||Slightly visible breast enlargement without excess skin|
|IIa||Moderate breast enlargement without excess skin|
|IIb||Moderate breast enlargement with little excess skin|
|III||Feminine shaped breast with underbust crease, ptosis and significant excess skin|
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 many medications are the most common cause of gynecomastia. Treatable causes of the male breast mainly affect patients of middle (35 to 65) and older (65 to 80) age. In these cases, an imbalance in certain hormones can lead to breast growth. The imbalance is due to a decrease in male sex hormones (testosterone) or an increase in female hormones (estrogens). Various non-choronic as well as chronic illnesses 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 tumors can also produce pregnancy hormones in men. These hormones (prolactin, human chorionic gonadotropin, or hCG for short) promote breast growth. Several exams are needed to check for other causes of gynecomastia and to identify the correct one. The examinations are carried out by various specialists. Specialists in internal medicine, endocrinology and diabetology specialize in examining hormone levels. The testicle is examined by urologists. Radiologists perform imaging tests of the chest and, if necessary, the abdominal organs or the brain. Specialists in human genetics investigate clues about hereditary diseases.
|Medication||See "Which medications can cause gynecomastia?"|
|Dysfunction of the testes||5α-reductase deficiency||Hereditary disease in which the production of testosterone is restricted.|
|Androgen resistance (Goldberg-Maxwell-Morris syndrome)||Hereditary disease in which the signal transmission of testosterone is impaired.|
|Anorchy||Absence or underdevelopment of the testicles.|
|Hemochromatosis||Mostly hereditary increased absorption of iron in the body, which leads to a reduced function of the testicles.|
|Klinefelter Syndrome||Congenital defect in the genome.|
|Kallmann Syndrome||Congenital developmental disorder of the brain.|
|Testicular torsion or testicular injury||Twisting of the testicle with the risk of loss of function.|
|Viral orchitis||Testicular inflammation mostly caused by the mumps virus with the risk of loss of function.|
|Tumors||Malignant adrenal tumors||Can produce estrogens.|
|Malignant stomach tumors||Can produce hCG.|
|Large cell lung cancer||Can produce hCG.|
|Benign tumor of the pituitary gland||May produce prolactin.|
|Malignant kidney tumor||May 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.|
|Male breast cancer||Breast tissue growth.|
|Thyroid Disease||Hyperthyroidism||May lead to an increase in estrogens.|
|Underactive thyroid||May lead to an increase in prolactin.|
|Kidney disease||Hormones are no longer excreted.|
|HIV (Human Immunodeficiency Virus)||Reduced function of the testicles.|
In about twenty percent of cases, drug side effects are the cause of gynecomastia. Drugs can cause gynecomastia in a number of ways:
- they can mimic the action of female hormones or inhibit the action of male hormones,
- they increase the formation or disrupt the breakdown of female hormones (estrogens, prolactin),
- they reduce 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.
The mechanism that causes gynecomastia to develop is not yet understood for many drugs.
|Use of medication||Active ingredient||Mechanism that causes gynecomastia||Frequency in percent|
|Antibiotic||Metrodinazole||Reduces the production of male hormones|
|Viral Disease Treatments||Antiviral Drugs||Unknown|
|Treatment of Schizophrenia||Haloperidol||Increases the formation of prolactin|
|Treatment of Schizophrenia||Olanzapine||Unknown|
|Treatment of Schizophrenia||Risperdon||Unknown||2 to 3|
|Treatment of Asthma||Theophyllines||Unknown|
|Treatment of high blood pressure||Amiodarone||Unknown|
|Treatment of high blood pressure||Amlodipine||Unknown|
|Treatment of high blood pressure||captopril||unknown|
|Treatment of Hypertension||Diltiazem||Unknown|
|Treating High Blood Pressure||Digitoxin||May Mimic the Effects of Estrogen|
|Treatment of Hypertension||Nebivolol||Unknown|
|Treatment of High Blood Pressure||Nifedipine||Unknown|
|Treatment of Hypertension||Nitrendipine||Unknown|
|Treatment for high blood pressure||Ramipril||Unknown|
|Treatment of Hypertension||Reserpine||Unknown|
|Treatment of high blood pressure||Spironolactone||Inhibits the effects of androgens and progesterone||9|
|Treatment of High Blood Pressure||Valsartan||Unknown|
|Treatment of Hypertension||Verapamil||Unknown|
|Treatment of Depression||Amitriptyline||Increases the formation of prolactin|
|Treatment of Depression||Doxepin||Increases the formation of prolactin|
|Treatment of Depression||Duloxetine||Unknown|
|Treatment of Depression||Fluoxetine||Unknown|
|Treatment of Depression||Mirtazapine||Unknown|
|Treatment of Depression||Paroxetine||Unknown|
|Treatment of Depression||Venlafaxine||Unknown|
|Treatment of epilepsy||Phenytoin||Enhances the effects of estrogens|
|Treatment of Epilepsy||Valproic Acid||Unknown|
|Hair Loss Treatment||Finasteride||Reduces the production of male hormones||3 to 4|
|Hair Loss Treatment||Minoxidil||Unknown|
|Treatment of fungal diseases||Ketoconazole||Reduces the production of male hormones||7 to 8|
|Treatment of fungal diseases||Itraconazole||Reduces the production of male hormones|
|Treatment of Prostate Cancer||Bicalutamide||Inhibits the effects of androgens|
|Treatment of prostate cancer||flutamide||Inhibits the effects of androgens|
|Treatment of rheumatism||Penicillamines||Inhibits the effects of androgens|
|Treatment of pain||Cannabis||Inhibits the effects of androgens|
|Treatment of Nausea||Domperidone||Unknown|
|Treatment of Nausea||Metoclopramide||Increases the formation of prolactin|
|Sedative||Diazepam||Increases sex hormone binding globulin|
|Sedative||Phenothiazide||Increases the formation of prolactin|
|Cholesterol lowering drug||Pravastatin||Reduces the production of male hormones|
|Cholesterol lowering drug||Rosuvastatin||Decreases the production of male hormones||1 to 2|
|Muscle building||Anabolic steroids||Reduces the production of male hormones|
|Anesthetics||Etomidate||Increase the formation of estrogen|
|Tonics and tonic||Ginseng||Unknown|
|Suppression of the immune system||Cyclosporin||Multifactorial|
|Suppression of the immune system||Methotrexate||Inhibits the effects of androgens|
|Stomach acid suppression||Omeprazole||Inhibits the effects of androgens|
|Stomach acid suppression||Pantoprazole||Inhibits the effects of androgens|
|Stomach acid suppression||Ranitidine||Inhibits the effects of androgens|
More and more patients are looking for information on the Internet to find out who are the right experts, i.e. experienced specialists, for their concerns. Many sufferers therefore come specifically to the specialist in plastic and aesthetic surgery to correct the male breast. There is a good reason for this: the techniques for correcting gynecomastia and restoring the breast are an important part of training to become a specialist in aesthetic and plastic surgery. The doctor is supported by a highly qualified surgical team. Some patients with a man's breast initially entrust their family doctor with gynecomastia treatment. The family doctor will check whether the side effects of certain medications are causing the gynecomastia. If necessary, the family doctor determines hormone values (follicle-stimulating hormone: FSH, luteinizing hormone: LH, testosterone, estradiol, prolactin, sex hormone-binding globulin: SHBG, human chorionic gonadotropin: HCG). The importance of a hormone test in adolescents is controversial, as the results in 99% of adolescents with gynecomastia do not show any pathological findings (Malhotra AK et al. 2018 Plast Reconstr Surg). Hormone levels fluctuate depending on the time of day. That is why the laboratory values are examined in the morning at the time of maximum hormone release. If the hormone levels are abnormal, an examination by specialists in internal medicine, endocrinology and diabetology is useful. Deviations from the norm in the testicles are examined by the urologist (palpation 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 nature of the mammary gland tissue with the help of ultrasound or mammography. If the radiologist detects a suspicious change in the breast tissue, the pathologist examines a tissue sample (histologically). If the laboratory tests suggest a tumor, the radiologist will perform additional tests (magnetic resonance imaging of the pituitary gland, ultrasound, or computed tomography of the abdomen). In the unlikely event that breast cancer is present, the tumor will be treated by the gynecologist.
In order to meet your expectations in the best possible way, your complaints will be recorded during the first interview. For example, it is asked whether there is pain, the sensitivity of the chest is impaired, dissatisfaction with the appearance of the upper body or even a feeling of shame. The conversation should also express complaints that could be an indication of certain causes (decreased desire for sex, tiredness, upset, change in body weight). Height and weight as well as the incidence of certain illnesses in the family are part of a thorough survey of important information. In order to assess the treatment risks, the use of medication or dietary supplements, the smoking of tobacco cigarettes or e-cigarettes and allergies are asked about. During the physical examination, the size and shape of the chest and deformations of the chest or spine are documented. The surgeon also examines whether there is excess skin 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 recommends 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 openly discuss your expectations with the surgeon. Often a poorly informed patient or surgeon is the cause of an unsatisfactory result, even if there are no complications from the surgical procedure. . The individual steps of the operation, the duration of the operation, the follow-up treatment in the weeks and months afterwards as well as the costs of the operation are presented to you in a transparent and comprehensible manner. In the course of a possible preparatory discussion, the patient is informed by the doctor about how to behave in the weeks before and after the surgical correction in order to ensure optimal healing. For any questions that may arise later and for further information, we would be happy to arrange a second interview online, by phone or in the clinic / practice. We look forward to you!
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 rare cases, in less than 0.5 percent of cases, gynecomastia is only present on one side (Lee SR et al., 2018, Aesthetic Plast Surg). Unilateral gynecomastia is caused by an increase in breast tissue (Al-Qattan M et al., 2005, Ann Plast Surg). Breast cancer can be detected in an estimated two percent of cases of unilateral gynecomastia (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 by a gynecomastia operation is the best treatment for the one-sided male breast.
It is estimated that the risk of breast cancer in adolescents with gynecomastia is no more than 0.012 percent (Koshy JC et al., 2011, Plast Reconstr Surg). In Germany around 600 men develop breast cancer every year. Breast cancer in men is over a hundred times less common than in women. Breast cancer in men represents 0.17 percent of all tumors 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). A retraction of the skin can be seen externally. Breast cancer can make the surface of the skin look like an orange peel. The following properties increase the risk of breast cancer in gynecomastia:
- Genetic changes (BRCA -1 / -2 mutations),
- Congenital chromosomal disorder (Klinefelter syndrome, 20 to 50 times increased risk).
The tissue removed by the aesthetic surgeon can be examined by a pathologist under a microscope. The aim of these investigations is to distinguish benign from malignant changes in the cells. A tissue examination is justified if the patient benefits from the examination. This is the case when breast cancer is suspected. Breast cancer can be suspected if the patient has an increased risk of breast cancer (familial occurrence of breast cancer, congenital chromosomal disorder, unilateral gynecomastia). In 0 to 2.5 percent of adolescents with gynecomastia, the tissue examination reveals an abnormal increase in the cells of the mammary gland tissue (technical term: atypical ductal hyperplasia). However, the meaning of this change is unclear. This finding does not affect further treatment. A routine histopathological examination of the removed mammary gland tissue is not required in young patients (Koshy JC et al, 2011, Plast Reconstr Surg). The detailed examination provides information about whether an operation is necessary for medical reasons.
On our in-depth page on gynecomastia surgery you will find comprehensive information that will give you an idea of what the result of the operation will be. As part of a personal consultation about the procedure, you can view pictures of the treatment results of a man's breast surgery. On the following page you will find more information on before and after pictures of breast surgery / gynecomastia surgery in men.
Nowadays, patients place a lot of value on patient reports and reviews that they can find on the Internet before they see a doctor or before an operation. The satisfaction of the patients is our top priority. If you would like to find out about the opinion of our patients about our high-quality advice and the treatment results with and without surgery, please visit our page on testimonials.