This article explains the relationship between low testosterone and the presence of gynecomastia. It also provides information on diagnosis and treatment options.
Most men believe that hormones are the purview of women. Every month they have their menstruation, and their hormones go up and suddenly they are very irritable. What most men do not understand is that their bodies are also under the control of these hormones, though more subtly. Sex hormones are what shape our body as we go through adolescence. Females have estrogens, and males have testosterone and androgens. If the body is functioning normally, these hormones are kept in a balance which allows the body to look gender-appropriate. But what is the relationship between low testosterone and male breasts?
If the balance of these hormones is disrupted then the body begins to respond in ways that some people are not quite comfortable with. In women this can mean becoming hairy or developing deeper voices. In men this could mean developing higher pitched voices, losing their armpit and pubic hair, or developing gynecomastia.
This article will define gynecomastia, what causes it and how it is diagnosed. It will also show the treatments available to treat a condition which causes a lot of mental anguish.
Gynecomastia and Hormonal Imbalances
Medically, gynecomastia is defined as the enlargement of one or both breasts occurring in adult males. It is usually on both sides, and appears similar to the breast enlargement that adolescent females experience. If diagnosed it must be differentiated form malignant masses found in the male breast.
The causes are usually an imbalance in the male hormones, also called androgens and feminizing hormones like estrogen, or the use of certain medications. If the enlargement occurs on one side only, or in part of the breast then a biopsy is recommended as this is probably a malignant mass.
The male breast just like the female breast is under the influence of hormones. Gynecomastia results when there is an imbalance between estrogens which stimulate breast tissue to grow and androgens which suppress these effects. These imbalances occur under normal and abnormal situations in the body.
In infancy and around puberty, an enlargement of the breasts in a male child is normal, or what is medically termed as physiologic gynecomastia. The enlargement is usually temporary, and symmetrical.
Males who are likely to be affected by this are newborns, those going through puberty, the very old, or any male who has elevated levels of estrogen in his system. Elevated levels of estrogen occur in multiple disorders, the most important of which is liver cirrhosis. This is because the liver metabolizes estrogen, but when it is cirrhotic it is dysfunctional and thus it cannot metabolize estrogen effectively.
In newborns, gynecomastia is caused by the estrogens that linger from the placenta. These estrogens were produced by the mother and now affect the newborn male child. In Puberty, gynecomastia is a result of greater amounts of a type of estrogen called estradiol, in comparison to testosterone.
For elderly males, gynecomastia occurs because the estrogen being produced by the adrenal glands next to the kidney increases. This is because the adrenal glands are not producing a sufficient amount of the male hormones (androgens). Thus with elevated estrogens and diminished androgens, the breasts are stimulated to grow.
There are drugs such as alcohol, heroin or anabolic steroids like those used by weight lifters, which have been known to encourage the development of gynecomastia. Occasionally gynecomastia occurs as art of a congenital disease known as Klinefelter syndrome, or if a male has a mass in his testis such as a Leydig cell tumor. Tumors in the liver, lungs and other body organs can produce hormones which encourage the breast tissue to multiply.
Conditions which predispose one to gynecomastia:
- Leydig cell tumors
- Seroli cell tumors
- Tumors of the adrenal cortex
- Lung carcinomas
- Liver carcinomas
- Disorders of the endocrine system
- Liver diseases such as cirrhosis
- Alterations in the nutritive functions of the body
- Deficiencies in the production of androgens
- Old age
- Klinefelter’s syndroms
- Testicular failure
- Rosewater-Gwinup-Hamwi familial gynecomastia
- Kallmann syndrome
- Testicular trauma
- Radiation exposure
- Kidney diseases, such as renal failure
What Happens In Gynecomastia?
In gynecomastia, the breast tissue grows larger and becomes longer, this causes a change in the skin which also stretches to accommodate the increase in size of the breast tissue. When it occurs in adolescence, it tends to happen in one breast and is seen around the ages of 12 to 15 years. On the other hand, in the elderly, gynecomastia is usually seen in both breasts.
What are The Signs and Symptoms?
The signs and symptoms listed below are not specific for gynecomastia. Usually they are considered together, in order to pinpoint the cause of a disease. Some of the signs and symptoms, are used to identify the underlying cause of the gynecomastia.
- An increase in the size of the nipples, with possible associated pain and maybe even a discharge from the nipples
- Recent loss of weight
- Frequent tiredness
- Changes in skin color, such as jaundice
- Loss of hair (alopecia)
- A history of a lot of infections
- Frequent fractures due to fragile bones
- Changes in the mood of the individual, and even their ability to function cognitively.
- Presence of tremors in the hands, usually in the fingers
- An inability to stand elevated temperatures
- Loose bowel movements frequently
How is it Diagnosed?
For a doctor to diagnose gynecomastia, a full and through physical examination must be carried out. This will not only identify the problem, but give signs of what the underlying cause is. The physical examination will proceed as follows:
- The doctor will assess the patient’s vital signs
- The doctor will then look at the patient’s general appearance, with a focus on the skin for any color changes. This is because jaundice is usually indicative of a liver problem.
- The doctor also examines the neck, to look for goiters or any enlargement in the anterior neck. This is because a mass in the anterior neck could be a sign of hyperthyroidism.
- The abdomen is also carefully observed. If there is any enlargement, or the veins appear abnormal, this could indicate cirrhosis.
- The physician will also observe the rest of the body, to see if the male patient has developed secondary sexual characteristics, as estrogens tend to feminize and inhibit the development of male secondary sexual characteristics. The testes is checked to see if it is smaller than normal, as this could predispose one to developing this condition.
- The male patient’s breasts are then examined. The examiner will have to palpate them and press them, to check for the presence of a discharge, or if there are any lumps in the breast.
- The doctor also checks the armpits which are medically termed the axilla. This is to see if there are any lymph nodes, usually they do this if they noted any lumps in the breast tissue.
Are There Any Tests To Be Done?
Usually in patients with physiologic gynecomastia, no tests are done after the physical examination. Also in adolescent males with gynecomastia, no more test are required. A follow up after 6 months to observe the progression of the condition is recommended.
However, in certain patients there are findings that usually prompt more testing. These include:
- Breasts which are more than 5 centimeters in size. This is referred to as macromastia.
- If any lumps were identified in the breast tissue, were they painful when touched?
- Also doctors look for any sign that the enlargement may not be gynecomastia, but may be a form of male breast cancer.
The list of tests that can be done:
- A hormone panel, of the testosterone, estrogens and other hormones that affect the breast
- A thyroid hormone panel
- Imaging studies such as a mammography, testicular ultrasound, breast ultrasound or a CT scan of the breasts.
- Blood tests
The following are the protocols for treating gynecomastia:
- Physiologic gynecomastia never requires treatment, and should be allowed to pass as it is transient.
- When it occurs in puberty, it will resolve by itself after about 36 months for most of the patients
- If there is an underlying disorder, it should always be treated as this will resolve the elevations in the estrogens and restore hormonal balance.
- If the treatment of patients with idiopathic forms of this condition, or after treatment of the underlying cause does not resolve the breast enlargement then medical and surgical solutions must be considered.
- The medications that are used to treat gynecomastia include clomiphene and danazol. These medications should be given as early as possible.
- The surgical procedures used to manage gynecomastia are reduction mammoplasty, or plastic surgery or an endoscopic subcutaneous mastectomy.