What is gynecomastia, and how does it differ from fat build-up?
True gynecomastia is an enlargement of the glandular breast tissue. It usually appears as a rubbery or firm mass directly beneath the nipple, may affect one or both sides, and is sometimes painful or tender to touch.
Pseudogynecomastia, by contrast, is a build-up of fat in the chest without real glandular enlargement, and is often linked to weight gain. Many cases are a mix of both. Telling them apart matters because it decides the appropriate treatment.
Hormonal causes and life stages
Gynecomastia mostly results from an imbalance between oestrogen and testosterone in the body. There are three life stages when this imbalance is normal and, in most cases, temporary:
Newborns
Slight enlargement may appear because of the mother’s hormones and usually resolves within weeks.
Puberty
Common in teenagers because of hormonal changes, and in many cases it settles on its own, usually within a period ranging from several months to about two years.
Later life
As testosterone gradually falls and the proportion of body fat rises, gynecomastia may appear in middle-aged and older men.
Medicines, substances and medical conditions
Gynecomastia may be linked to external factors or to medical conditions that need assessment. Identifying the cause matters, because treating it may be enough in some cases, and because surgery without addressing the cause may be followed by recurrence.
- Some medicines, such as certain diuretics, certain prostate treatments, and some stomach, heart and psychiatric medicines. Do not stop any medicine on your own; discuss it with your doctor.
- Anabolic steroids and hormonal supplements used by some athletes to build muscle.
- Heavy alcohol use and the use of certain substances such as cannabis.
- Chronic liver disease and kidney failure.
- An overactive thyroid.
- Underactive testes or other hormonal disorders, and rarely certain hormone-producing tumours.
- Obesity, as fatty tissue helps convert some testosterone into oestrogen.
How is it diagnosed?
Diagnosis starts with a detailed medical history covering medicines, supplements, lifestyle and how long the enlargement has been present, followed by a clinical examination of the chest and sometimes of the testes and thyroid. The examination often shows whether the enlargement is glandular or fatty.
Depending on the case, the doctor may request blood tests for hormones and for liver, kidney and thyroid function, and may request an ultrasound or breast imaging. Assessment becomes more important when a lump is on one side only, hard, fixed, or accompanied by nipple discharge, skin changes or enlarged glands in the armpit, as male breast cancer, which is rare but possible, must be ruled out.
Treatment options
Treatment depends on the cause, how long the gynecomastia has been present and its degree. In puberty, monitoring and waiting is often advised; if a medicine is the cause, the treating doctor may switch it where possible; and in pseudogynecomastia, weight loss and exercise can noticeably improve the appearance.
Certain medicines may be used in selected cases under medical supervision, especially when the gynecomastia is recent and painful. When the enlargement has been present for a long time, however, the glandular tissue often becomes fibrous and no longer responds to medicines or weight loss, and surgery becomes the practical option.
Surgery usually combines liposuction to remove excess fat with removal of the glandular tissue through a small incision at the edge of the areola. In advanced cases with loose skin, some skin may need to be removed. Patients usually wear a compression garment for several weeks; many return to desk work within about a week and to strenuous exercise after several weeks, as the doctor advises.
Who is not a candidate for surgery, and what are the risks?
Surgery may not be suitable at present for teenagers who have not finished puberty, as gynecomastia settles on its own in many of them; for anyone still using anabolic steroids or the causative medicine; for people with uncontrolled medical conditions; or for those planning major weight loss soon.
Surgical risks include bleeding and haematoma, fluid collection, infection, anaesthesia risks, asymmetry between the two sides, contour irregularities of the chest, scarring, changes in nipple sensation, recurrence if the cause persists, and occasionally the need for a revision procedure.
When to see a doctor, and what to ask
See a doctor if new breast enlargement appears, especially if it is on one side, painful, hard, or accompanied by discharge or changes in the skin or nipple, or if gynecomastia persists in a teenager for a long time or causes clear distress.
Useful questions at consultation include: Is my case true gynecomastia, fat build-up or both? What is the likely cause? Do I need tests before any treatment? Are non-surgical options enough? And what is a realistic surgical result in my case, bearing in mind that results vary from person to person?
Bothered by the appearance of your chest?
Treatment starts with understanding the cause and assessing the case carefully. Read about gynecomastia treatment and liposuction, or book your consultation.