The clinical practice article, a regular NEJM feature that focuses on a case history highlighting a common clinical problem, was authored by Glenn D. Braunstein, M.D., chair of the Department of Medicine at Cedars-Sinai Medical Center and an expert in gynecomastia and other hormone-related diseases.
"Nearly half of all men will experience breast tissue growth during their lifetimes, but many are unaware of it or are too embarrassed to even discuss the problem with their doctor," said Braunstein. "Raising awareness of the condition - its causes, symptoms, treatments - may help more boys and men with gynecomastia be correctly diagnosed, and reassure them that they are not alone in experiencing this."
Gynecomastia is characterized by the presence of a rubbery or firm mass extending concentrically from the nipples. About half the time, it is detected in both breasts. Other, different conditions present with similar symptoms: pseudogynecomastia, which is fat deposition without glandular proliferation, and is increasing along with the incidence of obesity in American men; and carcinoma of the breast, which is much less common. Breast cancer in men is usually not symmetrical to the nipple, is generally found only on one side, and may be associated with skin dimpling or nipple discharge. Several other conditions may also lead to breast enlargement in men, including neurofibromas, hematomas, and dermatoid cysts, but they are rare.
Gynecomastia can be physiologic (occurring normally during infancy, puberty and older age), or pathologic (due to drugs or disorders such as androgen deficiency, testicular tumors, hyperthyroidism, and chronic kidney disease). In adult men, 50 percent of cases are due to persistent pubertal gynecomastia or medication side effects, and an additional 25 percent have no known cause.
The condition is most common during the normal hormone fluctuations of adolescence - nearly 65 percent of boys age 13 and 14 experience breast enlargement to some degree - but it usually resolves without intervention in late puberty. In adults and older men, gynecomastia can be the result of low testosterone or other hormone imbalances, medications, other illnesses, or an increase in body fat, which converts male hormones to estrogens. It also can be a side effect of hormone therapies prescribed to treat prostate cancer. Medications such as the antiestrogen drug tamoxifen, may alleviate the pain and tenderness that can accompany gynecomastia.
"I've seen hundreds of cases of gynecomastia - and in many of those, the men were not even aware that they had it. It's fairly common, and in general, nothing to worry about from a medical standpoint," said Braunstein, who is also holder of the James R. Klinenberg Chair in Medicine at Cedars-Sinai. "If, however, the growth of breast tissue is very recent in onset, or if it is accompanied by pain or tenderness, it should be brought to the attention of your doctor who should take a careful medical history followed by exam and blood tests to rule out hormonal disorders or malignancies."
If no serious disease is found, and the gynecomastia persists for longer than one year or is troublesome to the man who is experiencing it, surgical removal of the breast tissue is an option that usually leads to a good cosmetic result. For patients with asymptomatic gynecomastia who are not particularly bothered by it, no treatment is necessary.
"This information should be reassuring to all men, but especially to adolescent boys and their parents who may be spending time worrying about this," said Braunstein.
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