Description

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, 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. 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 about 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 oestradiol 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 (e.g., Leydig's cell tumour) which secrete oestradiol. • Hermaphroditism • Neoplasms producing human chorionic gonadotrophin (HCG) - e.g., lung: HCG stimulates Leydig's cells to excrete oestradiol. 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: diethylstilbesterol, herbal remedies with phytoestrogens, creams and cosmetics containing oestrogen, and possibly tea tree oil and lavender oil products, phenytoin, clomiphene • Digoxin. (By an oestrogen-like effect. The effect is enhanced if liver derangement is co-existent.) • Inhibitors of testosterone synthesis: e.g., metronidazole, ketoconazole, spironolactone, chemotherapy, gonadotrophin-releasing hormone (GNRH) agonists such as leuprolide and goserelin. • Inhibitors of testosterone action: e.g., 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: e.g., 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 the resolution of gynaecomastia. However, there can be more sinister causes for the gynaecomastia which should not be missed - e.g., lymphoma. • Obesity • Others - e.g., amiodarone, isoniazid, methyldopa, diazepam, calcium-channel blockers, angiotensin-converting enzyme (ACE) inhibitors, alcohol, amphetamines, growth hormone, isoniazid, theophylline, heroin. (4) Idiopathic. How to Diagnose Gynaecomastia? The diagnosis is obvious by visual impression, and sometimes, Gynaecomastia may be associated with pain or discomfort during exercise. The following factors are taken into account for the 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 - e.g., anabolic steroids, alcohol, heroin, and marijuana • Past medical history, family history. 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 - e.g., palmar erythema, bruising, spider naevi, hepatomegaly. • Evidence to suggest lack of testosterone - e.g., hairless, shiny skin, testicular size, testicular masses, tenor of voice. • Presence or absence of sexual characteristics. • Signs of hyperthyroidism or Cushing's syndrome. 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. Liposuction with subcutaneous Mastectomy It is the most common procedure for removing breast fat. Liposuction is a laser technology based on ultrasound. It is a minimally invasive treatment and can be done on a day-care basis. Occasionally, a small incision is made in the areola or circular position of the nipple, and the thick glandular tissue is removed through it. Why opt for Gynecomastia surgery? • Gynaecomastia is mostly a benign condition. • Complete resolution can occur if the underlying cause is identified and treatment is 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, and diet won't help much. • Medication, fat burner pills won't work in chronic cases. • Proper diagnosis and surgery are the only permanent solutions. Benefits of minimally invasive surgery over traditional surgery • No visible scar • Uniform skin tightening • 30-minute procedure • Same day discharge • Resume work in 2 days • No recurrence Why choose Brij Laser and Laparoscopy Centre for Gynecomastia Surgery? • Highly experienced and skilful surgeon • 1000+ successful procedures • Post-surgery, no complications • Hassle-free Insurance Approval • All Insurances covered • No Hidden Charges • Paperwork by the Brij Laser and Laparoscopy team on your behalf • Cashless Insurance Facility • Private Room for Patients. • Easy follow ups @ patient's convenience. • Maintains a very good doctor-patient relationship • US FDA approved