Enlarged male breasts

Disease Description (Causes and Symptoms)

• Definition: A condition in which the breast takes on a feminine appearance in males due to the development of glandular tissue similar to that in females (or fat accumulation) (gynecomastia).
• Causes and pathophysiology:
  • Proliferation of glandular tissue (hormonal imbalance: relatively increased estrogen or decreased androgen) or fat accumulation (pseudogynecomastia).
  • Physiological causes: newborns (effect of maternal estrogen, 60–90% of all infants), puberty (temporary around 10–12 years of age, occurring in 30–60%, improving in most cases by 16–17 years of age), and older adults (common between 50–80 years of age due to a relative decrease in male hormones).
  • Pathological causes: testicular dysfunction (orchitis, Klinefelter syndrome, Kallmann syndrome, etc.), testicular tumors or hCG-secreting tumors, adrenal tumors, hepatic or renal failure, hyperthyroidism, pituitary tumors, AIDS, etc.
  • Medications/substances: antihypertensive drugs, peptic ulcer medications (e.g., cimetidine), some cardiac medications, tranquilizers, estrogen medications, prostate cancer treatments, diuretics, anticancer drugs, tuberculosis medications, antifungal drugs (athlete’s foot medications), marijuana, heroin, anabolic steroids, etc. (accounting for approximately 10–20% of all cases).
  • Environmental hormones (exogenous estrogen-like substances) have also been suggested as possible contributing factors.
• Main symptoms:
  • Usually asymptomatic. A firm lump or localized enlargement may be felt in the breast.
  • Pain or tenderness may occur on palpation, and nipple discharge occurs rarely.
  • Approximately 75% of cases are bilateral, but it may occur on only one side.
  • If the breast diameter is 4 cm or more, the likelihood of spontaneous recovery is low (based on data).

Treatment Methods

• Observation (conservative management): Physiological or recently developed pubertal gynecomastia often improves after observation for 6–24 months (when there is no pain or worsening).
• Medication:
  • Selective estrogen receptor modulator (SERM), e.g., tamoxifen 10–20 mg/day — effective for relieving pain and reducing glandular tissue. Generally used for approximately 3–6 months.
  • Testosterone supplementation: Consider supplementation when there is clear evidence of hypoandrogenism (low testosterone) (indications depend on the cause).
  • Aromatase inhibitors (such as anastrozole) have limited effectiveness in established glandular tissue.
  • Medication is determined according to the cause, duration, and the patient’s condition.
• Surgical treatment:
  • Indications: When there is no response to conservative or medication treatment and cosmetic problems or persistent pain are present, or when the patient wishes to undergo surgery due to asymmetry or size. In cases with a mixture of glandular tissue and fat, liposuction and glandular tissue excision (subcutaneous mastectomy) are performed together.
  • Procedure: Removal of subcutaneous glandular tissue through a periareolar incision, combined with ultrasound-assisted liposuction. Surgery takes approximately 2 hours, and a 1-day hospital stay is generally recommended.
  • Recovery: Restriction of strenuous activity (1–2 weeks), with dressings/compression garments recommended.
• Lifestyle management:
  • Stop or replace causative medications, when possible, in consultation with a healthcare professional.
  • Obesity-related pseudogynecomastia may improve with weight loss and exercise; liposuction may be considered.
  • Discontinuation of alcohol and drugs (marijuana, heroin) is recommended.
• Precautions and complications:
  • Surgical complications: bleeding/hematoma, infection, scarring, decreased or increased nipple sensitivity, asymmetry, and possible recurrence.
  • Rarely, differentiation from male breast cancer is necessary (suspicion is warranted in cases of a firm, irregular mass; nipple retraction, skin fibrosis, or bloody discharge; or enlarged lymph nodes).
  • Recurrence is possible if the underlying disease (hepatic or renal failure, hormone-producing tumors, etc.) is not treated.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare/submit:
  • A list of medications currently being taken (including prescription and nonprescription drugs, supplements, steroids, and narcotics).
  • Medical history (liver or kidney disease, endocrine disease, testicular disease, and history of cancer).
  • Recent weight changes and history of alcohol or drug use (including marijuana, opioids, anabolic steroids, etc.).
  • When symptoms began and how they have progressed (changes in size, presence or absence of pain, whether one or both sides are affected), presence of nipple discharge, and history of surgery or trauma.
  • Previous test results, if available (blood tests, ultrasound, mammography, etc.).
• Information to tell the healthcare professional in advance:
  • Any blood-clotting disorder or use of anticoagulants.
  • Information about a partner’s possibility of pregnancy is not necessary (for male patients).

Examples of General Questions to Ask the Doctor

• “What appears to be the cause of this condition? What additional tests should be performed?”
• “What are the effects and side effects of this medication (e.g., tamoxifen)?”
• “How likely is recurrence after treatment (medication/surgery)?”
• “What should I change in my lifestyle (exercise, alcohol, drugs, etc.)?”
• “If breast cancer is suspected, what additional tests would be performed?”

Examples of Condition-Specific Questions

• “My breast is firm and irregular on only one side. Is it necessary to differentiate this from cancer? What findings require immediate testing?”
• “If my current medication (e.g., spironolactone/cimetidine/antipsychotic medication) is the cause, how quickly will it improve after stopping the medication?”

Additional guidance: If suspicious findings are present (a rapidly enlarging lump, a firm and irregular mass, bloody nipple discharge, a fixed mass, or localized enlarged lymph nodes), prompt imaging (mammography and ultrasound) and a biopsy (if necessary) should be performed to rule out malignancy. Blood tests (total and free testosterone, estradiol, LH/FSH, hCG, prolactin, TSH, and liver and kidney function tests) and testicular ultrasound can help determine the cause.