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Gynecomastia


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What is gynecomastia? 

The enlargement of the mammary glands in men, resembling the bust of a pubescent girl, has come to be known as gynecomastia. The term derives from the Greek words gynes - woman, and mastos - mammary glands. The earliest-known account of gynecomastia dates back to circa 1330 BC: it’s possible that the pharaoh Tutankhamen and his brothers suffered from gynecomastia, since they were depicted with enlarged breasts. On the other hand, detractors of this theory think that such an ancient depiction could have had a symbolic meaning that emphasized their fertility. Лечение гинекомастии в клинике

Classification of gynecomastia 

  1. False gynecomastia (pseudo-gynecomastia, adipomastia) - enlargement of the mammary glands due to fatty deposits; there are no alveolar formations of the parenchyma
  2. True gynecomastia

а) Physiological::

  • гgynecomastia during infancy
  • gynecomastia during adolescence
  • сage-related (involutory) gynecomastia 

б) Pathological (true gynecomastia in pathological states):

  • associated with low testosterone (male hormones)
  • associated with the elevated production of estrogen (female hormones)
  • associated with the administration of drugs
  • idiopathic gynecomastia (condition of unknown origin)

Causes of gynecomastia in men:

The cause of gynecomastia in men can be physiological and pathological. The combination of false and true gynecomastia in one man is frequently observed in pubescent-adolescent dispituitarism. Thus, gynecomastia may occur in cases of both endocrine and non-endocrine disease. A distinction is made between diffusive and nodular, unilateral and bilateral enlargement of the mammary glands. Unilateral gynecomastia is explained by the elevated local tissular sensitivity of the mammary glands to blood estrogen. That said left-sided gynecomastia is encountered more frequently, and in the case of a bilateral process - more pronounced on the left side.

There are 4 clinical grades of gynecomastia:

  • grade I - minimal subareolar nodosity
  • grade II - subareolar induration smaller than the diameter of the areola
  • grade III - induration equal to the diameter of the areola
  • grade IV - induration exceeding the diameter of the areola

In terms of size, gynecomastia is nominally divided into mild, moderate and pronounced, calculating grade according to the following formula: CxH, where C - circumference of the gland (cm), H - height of the gland (cm). The data yielded from this formula are denoted by standard units and have the following correspondence: mild gynecomastia - up to 6, moderate - from 6 to 10, pronounced - over 10 standard units.

Symptoms of gynecomastia. Diagnostics:

Signs of gynecomastia: enlargement of the mammary glands (the breasts start resembling a female’s), discomfort upon touching of the breasts and nipples, heaviness of the breasts, possible discharge from the nipples. In most men, large breasts cause no painful sensations - pain and discomfort is only experienced when wearing certain clothes. So, in most cases, men turn to plastic surgery out of aesthetic considerations. The standard array of diagnostic methods used in diagnosing gynecomastia traditionally includes radiological investigation of the chest, as well as (based on clinical indicators) methods for diagnosing the functioning of the thyroid and the liver, and certain hormone tests. Indicators may lead to mammography (X-ray and ultrasound), whose results sometimes prompt the ordering of additional diagnostics.

Treatment for gynecomastia in men:

СThe method for treating gynecomastia in men depends on its causes. Physiological gynecomastia in boys (infants) does not require treatment and subsides on its own. Gynecomastia in boys during sexual maturation also requires no treatment - the size of the mammary glands shrinks as the endocrine profile establishes itself. If the diagnosis is true hormonal gynecomastia in an adult male, its treatment is based on the drugs prescribed by the attending physician, which should correct the body’s hormone levels. In the remaining cases (formation of fatty deposits), gynecomastia in men is treated surgically.

Most men contact surgeons with the aim of having them perform a cosmetic operation. As a rule, patients with “physiological” gynecomastia need information on the essence of any underlying pathology and require observation. If the factor responsible for causing the enlarged mammary glands is identified, attempts must be made to eliminate it: withdraw any problematic drugs, commence treatment of the respective disease. However, these measures do not guarantee the involution of mammary tissue. The task of conservative treatment is to shift the testosterone/estrogen balance in favor of testosterone (male hormone). This can only be achieved either by increasing testosterone (male hormone) or by decreasing estrogen (female hormone).

The choice of method and hormone-therapy plan depends on the specific clinical situation. In general, it’s worth mentioning that despite the numerous products available for drug therapy, in most cases they don’t live up to expectations. Conservative treatment, particularly in cases where the underlying cause of gynecomastia has not been eliminated, is accompanied by a recidivism rate of from 5% (in juvenile gynecomastia) to 60% (in certain forms of pathological gynecomastia).

Indications for surgical treatment:

  • nodal form of gynecomastia (in juvenile gynecomastia, dynamic observation or conservative treatment is permitted for a year);
  • gynecomastia with pronounced pain syndrome or emergent cosmetic defect;
  • nodal or non-nodal form of gynecomastia in cases where it is impossible to exclude the malignant nature of the neo-formation. 

The first cases of the surgical treatment of gynecomastia date back to the mid-17th century. A detailed description of the method for performing the operation is provided to Lenehin (1771). The traditional surgical intervention in cases of gynecomastia involves subcutaneous mastectomy via periareolary access. The technique of such an operation provides for the minimal pronouncement of post-operative cicatrical changes, even contour of the mammary glands without a significant “cratering” defect of the soft tissue in the subareolar zone. In a number of cases, the large size of the mammary glands requires the excision of skin with repositioning of the nipple-areola complex or the removal of excess subcutaneous tissue in order to correct the overall shape of the chest.

It’s important to bear in mind that gynecomastia is a risk factor for the development of malignant tumors of the male mammary glands.
The results of surgical intervention are satisfactory to the patient, insofar as they solve the problem of both physical and emotional discomfort: pre-op, these people usually experience considerable anxiety in connection with their transsexual appearance and feminine attributes.

Before and after photos of gynecomastia in men

 


Photos of male gynecomastia allow the physician to determine the type of gynecomastia at hand: false or true.

In the gynecomastia photos, you can see the appearance of a man’s chest before and after the operation.

Causes of the onset of gynecomastia (etiology and pathology)

Gynecomastia is accompanied by the overgrowth of all of the tissue forming the normal mammary glands. Bilateral enlargement of the mammary glands in men can be predicated on:

  • fatty deposits (in which case it’s considered false gynecomastia)
  • metabolic, hormonal disruptions 
  • drug therapy

The presence of a node in the mammary glands is an immediate indicator for surgical treatment (subcutaneous mastectomy with urgent histological investigation of the mass).

Physiological gynecomastia in most men takes place at certain stages of the body’s development.

  • In infant boys, it is explained by the transfer of estrogen (female hormone) from the body of the mother or from the placenta (found in 60-90% of all cases, but in most instances this subsides over a matter of weeks).
  • In adolescence (roughly 30% of all cases)
  • In middle-aged men (roughly 30% of all cases)
  • In men over age 70 (roughly 40%).

Another cause of the development of gynecomastia could be an increase in the mass of fatty tissue in the body, resulting in elevated estrogen levels.
Drug-induced gynecomastia Drugs are the most common factor stimulating the growth of the mammary glands in men over 50. An example of this would be the prescribing of estrogen in the case of prostate cancer. Also worth mentioning is the possible introduction of estrogen into the body through the skin (particularly in the case of industrial-purpose estrogen). Certain drugs can also have a pro-estrogen or anti-androgen effect. Note that in most cases of drug-induced gynecomastia, the actual mechanism of the drugs’ influence on the tissue of the mammary glands remains unknown. This certainly applies in the case of the drugs prescribed in cardiology: digitalis, spironolactone, calcium-channel blockers, methyldopa, captopril. These formulations are known as factors for the development of drug-induced gynecomastia. Chemotherapy and radiation therapy, particularly after the removal of a tumorous testicle, can also lead to the development of gynecomastia due to the reduced production of testosterone by the remaining testicle.
Cases have also been reported of the development of gynecomastia in many men who use heroin and hashish. Testicular tumor is an infrequent but important cause of gynecomastia.
Metabolic disorders Disrupted functioning of the liver in cases of cirrhosis reduces the intensity of the breakdown of androgen, resulting in an increase in the specific weight of its metabolism in the extraneous tissue. The mechanism for the development of gynecomastia is similar in cases of kidney failure and malnutrition. Thyrotoxicosis (elevated functioning of the thyroid) can also prompt the development of gynecomastia.
Hypogonadism Disrupted development of the sex glands is frequently accompanied by the overproduction of estrogen, leading to the stimulated growth of the mammary glands. Frequent causes of the insufficient functioning of the male sex glands include aging, undescended testicles or their traumatic injury, and viral infection (parotitis).



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