Gynecomastia
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Permanent Treatment For Gynecomastia (Man-Boobs) at affordable cost in Mumbai

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What is Gynaecomastia?

Gynae means 'woman' and mastos means 'breast' in Greek. It can be defined as the presence of >2 cm of palpable, firm, subareolar gland and ductal breast tissue. Gynecomastia is the abnormal non-cancerous enlargement of one or both breasts in men due to the growth of breast tissue as a result of a hormone imbalance between estrogen and androgen. It is also known as male breasts or male boobs or male chest. Gynecomastia is different from "pseudogynecomastia" which is defined as an excess of skin and adipose tissue in the male breasts without the development of true breast glandular tissue. Pseudogynecomastia is commonly present in men with obesity.
The main indication of treatment is social embarrassment.

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How does obesity cause pseudogynaecomastia?

It is most commonly seen in today's era in males with obesity and it is induced by obesity. Fat is known as one of the largest endocrine organ in the body and has severe functions including secretary functions.Excess fat in the body is responsible for peripheral aromatization of androgens(male Hormones)Estrogens(female Hormones),in addition obesity is known to reduced Testosterone levels and increased Estrogen levels can gives rise to development of breasts in males with obesity .There is also associated fat deposition with it in the chest wall.

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Causes

What are the causes of Gynaecomastia?

A. Physiological causes

• • Newborn: This is the result of maternal oestrogens, and the gynaecomastia resolves after a few weeks.
• • Adolescence: This is common around the age of 14, may be unilateral and may be tender. It resolves spontaneously within one to two years. It may be due to the relatively delayed testosterone surge with relation to oestrogen at puberty, or due to a temporary increase in aromatase activity.
• • Increasing age: associated with low testosterone levels.

B. Pathological

(1) Lack of testosterone

• • Congenital absence of testes. There are absent levels of testosterone with normal estradiol levels and patients experience severe gynaecomastia
• • Androgen resistance.
• • Klinefelter's syndrome (XXY syndrome). Associated with gynaecomastia in 80% of cases. Men with Klinefelter's syndrome have an increased risk of breast cancer and this needs to be considered (risk is increased up to 20 times that of other patients with gynaecomastia).
• • Viral orchitis
• • Trauma
• • Castration
• • Renal disease and dialysis.

(2) Increased oestrogen levels

• • Testicular tumours (eg, Leydig's cell tumour) which secrete estradiol.
• • Hermaphroditism
• • Neoplasms producing human chorionic gonadotrophin (hCG) - eg, lung: hCG stimulates Leydig's cells to excrete estradiol. Also, gastric carcinomas, renal cell carcinomas and hepatomas.
• • Adrenal tumours: these can release oestrogens.
• • Congenital adrenal hyperplasia (high androgens and oestrogens).
• • Liver disease or cirrhosis. In liver disease there is an increased production of androstenedione by the adrenal glands, increased aromatisation of androstenedione to oestrogen, loss of clearance of adrenal androgens by the liver and a rise in SHBG, resulting in gynaecomastia.
• • Hyperthyroidism.
• • Obesity
• • Aromatase excess syndrome. Mutation of the aromatase gene causes excess oestrogen levels, prepubertal gynaecomastia and premature epiphyseal fusion.

(3) Medication

• • Oestrogens or oestrogenic action: diethylstilbestrol, herbal remedies with phytoestrogens, creams and cosmetics containing oestrogen, and possibly tea tree oil and lavender oil products, phenytoin, clomifene
• • Digoxin. (By virtue of an oestrogen-like effect. The effect is enhanced if liver derangement is co-existent.)
• • Inhibitors of testosterone synthesis: eg, metronidazole, ketoconazole, spironolactone, chemotherapy, gonadotrophin-releasing hormone (GNRH) agonists such as leuprolide and goserelin.
• • Inhibitors of testosterone action: eg, cyproterone, flutamide, bicalutamide, finasteride, dutasteride, H2 receptor antagonists, proton pump inhibitors (PPIs), marijuana.
• • Androgens causing high oestrogen levels: anabolic steroids, excessive testosterone replacement therapy.
• • Medications which increase prolactin levels: eg, antipsychotics, tricyclic antidepressants, metoclopramide, verapamil.
• • Antiretrovirals. The exact mechanism by which antiretrovirals cause gynaecomastia is unknown. It often presents as unilateral and tender gynaecomastia. Efavirenz has been implicated and stopping it results in resolution of gynaecomastia. However, there can be more sinister causes for the gynaecomastia which should not be missed - eg, lymphoma.
• • Obesity
• • Others - eg, amiodarone, isoniazid, methyldopa, diazepam, calcium-channel blockers, angiotensin-converting enzyme (ACE) inhibitors, alcohol, amfetamines, growth hormone, isoniazid, theophylline, heroin.

(4) Idiopathic.

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How to Diagnose Gynaecomastia?

The diagnosis is obvious by visual impression and sometimes Gynaecomastia may be associated with pain or discomfort during exercise. Following factors are taken into the account for precise diagnosis of Gynaecomastia;
The history :

• • Commonly, gynaecomastia is asymptomatic
• • Onset and duration of breast enlargement.
• • Tenderness
• • Presence of sexual dysfunction
• • Medication history.
• • Any use of drugs of abuse - eg, anabolic steroids, alcohol, heroin and marijuana
• • Past medical history, family history.

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Feel free to consult Dr. Brijendra Singh at Brij Laser and Laparoscopy Centre if you notice any of these symptoms.

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Physical Examination:

Is it true enlargement of breast tissue?

Enlargement of breast tissue may represent adipose tissue (pseudogynaecomastia) or true proliferation of breast tissue.

• • This can be examined by pinching breast tissue between the thumb and forefinger - true proliferation can be felt as a distinct disc of tissue under the skin. If there is any doubt ultrasonography or mammography may help.
• • Size and asymmetry.
• • Any evidence of liver disease or renal impairment - eg, palmar erythema, bruising, spider naevi, hepatomegaly.
• • Evidence to suggest lack of testosterone - eg, hairless, shiny skin, testicular size, testicular masses, tenor of voice.
• • Presence or absence of sexual characteristics.
• • Signs of hyperthyroidism or Cushing's syndrome.

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Investigations:

Since Gynaecomastia may be caused due to various diseases like thyroid disorder,renal or liver disease,certain drugs or tumors, thorough investigations are performed to diagnose the basic cause.These should be performed on a clinical basis, i.e. according to the history and examination. For example, if the patient is on gynaecomastia-inducing medication then these tests may not be necessary.

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Blood tests:

Blood tests are not indicated in those with fatty breast enlargement, physiological pubertal or senile changes, an identified drug cause, or a clinically apparent cancer.

• • Renal function
• • Liver FTs.
• • Thyroid FTs.

Hormone profile:

• • Estradiol
• • Testosterone
• • Prolactin
• • Beta-hCG level.
• • Alpha-fetoprotein (AFP).
• • Luteinising hormone (LH):
  • LH high and testosterone low - indicates testicular failure.
  • LH and testosterone both low - indicates increase in oestrogens.
  • LH and testosterone both high - androgen resistance or neoplasm secreting gonadotrophins.
• • Chromosomal karyotyping may need to be consider

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Imaging:

• • Ultrasonography or mammography of breasts in all cases of suspicious or unilateral breast enlargement. Also if there is clinical doubt about whether there is gynaecomastia or fatty enlargement.
• • Ultrasonography of testes if there is any abnormality on examination, or if there is a raised beta-hCG or AFP.
• • CXR if a lung lesion is suspected.

Biopsy:

Needle core biopsy for those with suspicious clinical or radiological findings. Biopsy will provide a definitive diagnosis - eg, proliferation of ductules and loose connective tissue confirms gynaecomastia. If no underlying cause is found, it is said to be idiopathic.

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Are there any associated conditions with Gynaecomastia in males with obesity?

In obese males,Hypogonadism or pseudohypogonadism can be an association and mainly due to the excess fat in the body giving rise to increase levels of estrogens and leptin. The treatment is mainly focus on weight management. This condition is also known as MOSH syndrome or male obesity secondary Hypogonadism.

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Treatment

Treatment of Gynaecomastia :

Early treatment of Gynaecomastia can resolve with

• • Diagnosis and Treatment basic cause
• • Medical treatment
• • Treatment of obesity

Chronic gynecomastia does not respond to medical treatment and surgical removal of glandular breast tissue is usually required. Cosmetic Surgery is the most effective known treatment for gynecomastia. Surgical approaches to the treatment of gynecomastia include subcutaneous mastectomy, liposuction-assisted mastectomy, laser-assisted liposuction, and laser-lipolysis without liposuction.

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Liposuction with subcutaneous Mastectomy

It is the most common procedure for removing the breast fat, liposuction is a laser technology based on ultrasound. It is minimally invasive treatment and can be day care. Occasionally,a small incision is made in the areola or circular position of nipple and the thick glandular tissue is removed through it.

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Benefits of treatment for Gynaecomastia :

It helps the person to restore the contour of the chest wall and helps body sculpting.

Why to opt for Gynecomastia surgery?

• • Gynaecomastia is mostly a benign condition.
• • Complete resolution can occur if the underlying cause is identified and treatment initiated before fibrosis of breast tissue occurs.
• • Gynaecomastia can be physically embarrassing and psychologically distressing for patients and this should not be underestimated.
• • Workout, exercise, diet won't help much.
• • Medication, fat burner pills won't work in chronic cases.
• • Proper diagnosis and surgery is the 'only' permanent solution.

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Benefits of Minimally invasive surgery over traditional surgery

• • No visible scar
• • Uniform skin tightening
• • 30 minutes procedure
• • Same day discharge
• • Resume work in 2 days
• • No recurrence

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