Although prolactin (PRL) receptors are present in male breast tissue, hyperprolactinemia may lead to gynecomastia through effects on the hypothalamus, causing central hypogonadism.2,10,11 Activation of PRL also leads to decreased androgen and increased estrogen and progesterone receptors in breast cancer cells. E2 levels rise more rapidly than T during early puberty, which leads to an elevated estrogen/androgen ratio.4,7 In most pre-adolescent males, breast enlargement regresses concomitant with pubertal progression and the rise in T levels and so only small numbers of patients have persistent gynecomastia, and the condition usually spontaneously regresses within two years of onset. However, both conditions involve changes in breast tissue, and having gynecomastia does not increase a man’s risk of developing breast cancer. It is the benign enlargement of male or female breast tissue together, which occurs due to hormonal imbalances or other medical conditions. This review covers the causes, evaluation, and treatment of gynaecomastia and the risk factors for and evaluation and treatment of breast cancer in males. Ashkenazi Jews have a higher prevalence of BRCA1 and BRCA2 and an increased risk of male breast cancer than the general population.13 Male carriers of BRCA2 have a cumulative risk for breast cancer of 7% by age 80. Men over the age of 50 are at higher risk of male breast and prostate cancer, due to declining testosterone levels. These steroids increase testosterone levels, which can convert to estrogen in excess, causing breast tissue to develop. When estrogen levels increase or androgen levels decrease, men may experience breast tissue growth. Men with gynecomastia have about a fivefold greater risk of developing male breast cancer when compared with the general population. Gynaecomastia, or the enlargement of male breast tissue, is a condition that can occur at any age due to various factors. It was also successfully used to reduce the estrogen excess and breast enlargement in a patient with familial aromatase excess, a patient with Sertoli cell tumor, and two hypogonadal males with gynecomastia that had been induced by testosterone therapy. In several studies, prophylactic RT was found to be effective in preventing gynecomastia and mastodynia in patients with prostate cancer.2,11 However, although the high radiation doses may improve pain, they are less effective in reducing the volume of the tissue. In one study of the use of Tmx, 69% of prostate cancer patients in the high-dose bicalutamide (150 mg/day) group had gynecomastia, but this was reduced to only 9% in the group receiving both bicalutamide and Tmx (10-20 mg/day).30,31,32 Tmx must be continued throughout the anti-androgen therapy, since its effects do not persist after it has been discontinued. Anti-estrogens–In recent years, anti-estrogens have been increasingly used to decrease the stimulatory effects of estrogen on the male breast. Dehydrotestosterone (DHT) is a non-aromatizable androgen that has been approved for the treatment of gynecomastia in some countries and was found to be effective in uncontrolled studies.17,18 Danazole is a weak androgen that inhibits the secretion of LH and FSH from the pituitary. Malnourishment can cause gynecomastia due to decreased gonadotropin and T levels, coupled with normal production of estrogens (and their precursors) from the adrenal glands. Spironolactone is also used to treat cirrhotic patients, which can exacerbate the condition.11,15 Alcohol use can also disrupt the hypothalamic–pituitary–testicular axis, causing a decrease in serum T levels. Interestingly, more than half of the patients with persistent pubertal gynecomastia have a family history of the condition. Certain health conditions disturb the production of hormones, thus increasing the chance of developing Gynaecomastia. Anastrozole also reduced anti-androgen related gynecomastia, but was less effective than Tmx. Complications of the surgery may include contour irregularity, hematoma/seroma, numbness of the nipple and areolar areas, the shedding of tissue due to loss of blood supply, breast asymmetry, nipple necrosis or flattening and hypertrophic or broad scars. Histological analysis of the gynecomastia tissue is recommended because unexpected findings such as spindle-cell hemangioendothelioma and papilloma occur in 3% of cases. Hormonal conditions can be tricky to find and complicated to treat. If you feel uncomfortable about the look and size of your breasts (chest), reach out to your healthcare provider. If gynecomastia is causing you distress and/or you have other new symptoms, talk to your healthcare provider. If you have gynecomastia due to obesity (pseudogynecomastia), weight loss may decrease it. Cordova and Moschella proposed a morphological classification of gynecomastia based on the evaluation of the relationship between the nipple-areola complex and the inframammary fold, which makes it possible to establish an algorithm for the most suitable intervention. Medical treatment can therefore be beneficial if implemented during the early proliferative phase, before the glandular structure has been replaced by stromal hyalinization and fibrosis. In the later stages (after 12m), there is marked stromal fibrosis, a slight increase in the number of ducts, but little to no epithelial proliferation and no inflammatory response. Table 3 lists differences in the presentation of gynaecomastia and malignancy. Germ cell tumours produce intratesticular human chorionic gonadotrophin, which can cause dysfunction of Leydig cells and reduced testosterone production. Renal failure has many effects on hormone and drug metabolism. The mechanisms are thought to be similar to those governing gynaecomastia during puberty. Cosmetics, creams, and lotions may contain oestrogens or compounds with oestrogen effects. Oestradiol and oestrone can be interconverted in peripheral tissues (fig 1). Yes, several medications can cause gynecomastia as a side effect. In some cases, more testosterone can help with gynecomastia if it’s caused by low testosterone. Testicular tumors, such as Leydig cell and Sertoli cell tumors, can lead to increased estrogen production. Conditions such as hypogonadism or hyperthyroidism can disrupt the balance of testosterone and estrogen. Certain drugs, including antidepressants, anti-anxiety medications, and steroids, can cause gynecomastia. The lump may move easily within the breast tissue and may be tender to touch. Gynecomastia most often happens due to an imbalance of hormones — specifically testosterone and estrogen. Obesity can also cause an increase in breast size due to excess adipose (fat) tissue. Certain medications and medical conditions can also cause it. Regular self-examinations can help identify any changes in breast tissue early on.
