Introduction Breast enlargement in males causes psychosocial discomfort, uneasiness and misery. According to epidemiologic studies, 3 out of 10 males will suffer from this condition during their lifetime. Because of this, it is important to differentiate various causes of breast enlargement in men. Two of the most common conditions that should be considered are gynecomastia and pseudogynecomastia. These two health conditions can be differentiated through medical consultation, blood tests and radiologic imaging. Gynecomastia Gynecomastia is the most common breast disease in males. It is defined as the enlargement of breast issue that characteristically presents with a rubbery or a firm palpable tissue, which extends symmetrically outward from the nipple area. Under microscopic analysis, this is a benign condition with growth of male glandular breast tissue. It occurs symmetrically in both breasts. Prevalence According to research studies, the prevalence of gynecomastia varies from 30-60%. During an entire lifetime, there are three age groups wherein this occurence is most commonly observed. First is during the infancy period, because during pregnancy, the placenta converts maternal hormones into estrogenic substances. These hormones cross the placenta and enter the baby’s circulation that stimulates the enlargement of the male breast tissue. Second, it is commonly observed during puberty (10-14 years old) because of hormonal changes that happens during this period of rapid growth. Lastly, it occurs in the advanced age group (50-80 years old), which can be attributable to excessive fat tissue formation. This excess fat tissue becomes converted into estrogen, which stimulates breast glandular enlargement in males. Pathophysiology Gynecomastia is generally caused by a hormonal imbalance among males, wherein there is a predominance of estrogen secretion as a result of excessive estrogen production or a decrease in androgenic hormone synthesis. Estrogen is an important hormone that stimulates the proliferation of the breast tissue. It causes further development within the breast ducts, causing it to enlarge and branch diffusely. Estrogen also increases the vascularity of breast tissue. This hormonal imbalance can be caused by a lot of factors such as puberty, the use of estrogenic medications, liver disease, kidney disease, hyperthyroidism, tumors that produce estrogen and prolactin. It can also be caused by an increased activity of aromatase, the enzyme important for estrogen synthesis. Diagnosis Patients with gynecomastia usually present with bilateral breast involvement. However, there are cases wherein breast enlargement is not symmetrical or may be found only in one breast. Breast palpation usually reveals a palpable, firm, movable ovoid mound of tissue that is noted just directly underneath the nipple-areolar region. There are no palpable nodules underneath the areola itself. Breast ultrasound or mammography can be done to differentiate it from other breast conditions. If the results of breast imaging tests are inconclusive, breast biopsy can be done to confirm the diagnosis. Once diagnosis is confirmed, the patient undergoes blood tests to look for secondary causes of hormonal imbalance. Treatment If gynecomastia was secondary to medical condition, then the primary medical condition should be treated first. Medications and supplements that elaborate estrogen synthesis should be discontinued. Patients are then asked to follow up from 6 months to a year. If there is no resolution of symptoms, medications such as estrogen receptor blockers may be offered. However, for those patients, who find the symptoms psychologically disturbing, surgical removal of the enlarged breast tissue may be offered. This treatment is called subcutaneous mastectomy. Pseudogynecomastia Pseudogynecomastia, also known as lipomastia, is also a common breast condition that is frequently observed among obese males. It is characterized by excessive fat deposition on both breasts. Under microscopic analysis, it is also a benign condition that lacks proliferation of male glandular breast tissue. It also occurs symmetrically on both breasts. Prevalence Unlike gynecomastia, epidemiologic data on the prevalence and incidence of pseudogynecomastia is unknown. However, because there has been an increase in the prevalence of obesity among males, the incidence of pseudogynecomastia is also projected to increase. Since there is proportional and symmetrical fat deposition in all body parts, patients with excess chest fat generally do not seek medical consultation unless symptoms become cosmetically disturbing. Pathophysiology Pseudogynecomastia develops due to excessive adipose tissue. The enzyme aromatase is found in fat cells. It functions to catalyze the conversion of estrogen precursors into estrogen. In patients who are obese, there is increase in the expression of the aromatase enzyme in fat tissue. Because of this, there is increased conversion of estrogen precursors to estrogen. The increased availability of estrogen stimulates extra glandular growth of the male breast tissue, which results to pseudogynecomastia. Diagnosis In contrast to gynecomastia, there is no palpable mass on the breast tissue in patients with pseudogynecomastia. Underneath the nipple-areolar complex, soft fatty tissue may be palpated. During palpation of the breast in patients with excess chest fat, there is no resistance as seen in patients with gynecomastia. Breast imaging modalities, such as breast ultrasound and mammography are routinely done to exclude the possibility of malignant diseases of the breast. Hormonal testing is not routinely done unless the diagnosis remains unclear. Treatment Unlike gynecomastia, treatment is not usually indicated for patients with excessive fat tissue on the chest. However, they are generally advised to adapt lifestyle changes that promote weight loss in order to improve overall health and to decrease risk factors for developing cardiovascular diseases. Summary Gynecomastia and pseudogynecomastia are the two most common causes of benign breast enlargement among men. Gynecomastia is usually a result of excessive estrogenic stimulation of the breast tissue, while pseudogynecomastia is excessive fat deposition within the chest as a consequence of obesity. Between these two conditions, gynecomastia is treated as a disease and mechanism that causes hormonal imbalance is usually addressed. On the other hand, pseudogynecomastia spontaneously resolves through an effective weight loss regimen. Source
