Physiological gynecomastia

Physiological gynecomastia: that which appears during physiological periods such as pregnancy, puberty, old age, etc. The latter is related to an increase in estrogens due to the decrease in sex hormone binding globulin. It is estimated that up to 70% of men over the age of 70 have gynecomastia.

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Gynecomastia

The cases that require surgery correspond to young subjects with physiological gynecomastia that does not remit in a reasonable period of time and that cause a profound psychological disorder in the patient.

The causes of gynecomastia are multiple and include:

1.- Physiological gynecomastia: that which appears during physiological periods such as pregnancy, puberty, old age, etc. The latter is related to an increase in estrogens due to the decrease in sex hormone binding globulin. It is estimated that up to 70% of men over the age of 70 have gynecomastia.

2.- Pathological processes: tumors (testicular, hepatic, adrenal), drugs (antidepressants, antihypertensives), liver cirrhosis, etc.

3.- Drugs: anabolic steroids, trenbolone acetate, methyltestosterone, etc.

Etiology

The most common causes are pathologies of the endocrine system, consumption of drugs and use of anabolic steroids.

Pathological gynecomastia has been described as a result of different diseases, mainly hormonal disorders. These include tumors, hyperthyroidism, cirrhosis, hypogonadism or drug use.

Drugs have been involved in the development of gynecomastia since the eighteenth century. It has been reported that some medications such as digoxin, morphine and spironolactone can produce gynecomastia at the doses used in clinical practice.

Radiological contrast dyes and antibiotics such as erythromycin have also been described as causative agents.

However, other drugs such as antiandrogens and antiestrogens such as flutamide and tamoxifen are used in the treatment of advanced breast cancer in men. These treatments cause feminization and should not be confused with drug-induced gynecomastia.

Gynaecomastia is defined as an increase of the glandular component of the breast in males. It is a benign condition that is present in 20–40% of the male population and occurs at all ages. Although it is often asymptomatic, gynaecomastia can be associated with psychosocial morbidity and even gynecomastia-specific depression.20,21 In severe cases, it can result in functional impairment (e.g., difficulty with running or playing sports) and negative body image which may impose a significant burden on quality of life.22 Although treatment is not always necessary, many men request surgical correction because of physical discomfort or psychosocial distress related to the condition.

Most of the cases that require surgery correspond to young subjects with physiological gynecomastia that does not remit in a reasonable period of time and that cause a profound psychological disorder in the patient.

On the other hand, some cases of pseudogynecomastia may respond well to liposuction alone. In some situations, the remodeling of the glandular tissue and the implantation are necessary.

The purpose of this chapter is to present the different surgical options available to correct gynecomastia, considering not only its etiology but also the evolution and volume of breast tissue.

The word gynecomastia is derived from the Greek words “gyne” (woman) and “mastos” (breast). Gynecomastia is the development of a breast with feminine characteristics in the male. It can appear physiologically during different stages of life or be secondary to a pathological process or pharmacological therapy.

It usually presents as a small “bud” under the nipple that may increase in size until it reaches its maximum dimensions. Its degree of extension varies from an increase in volume of only one side to both breasts, and even symmetrically. The development of gynecomastia enforces the female characters in the male, however, it is not associated with increased femininity.1

Background

Gynecomastia has been reported since antiquity and Hippocrates was the first to describe it. Galenus proposed that it was caused by an imbalance between male and female hormones.

The term gynecomastia was introduced by Virchow in 1863 and he suggested that increased levels of estrogen were responsible for this disorder; however, he did not describe any method for determining this hormonal imbalance.2

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