What causes gynaecomastia?

History of gynaecomastia

As early as the seventh century when Paulis of Aegina first described surgical excision, men have presented requesting reduction of their gynaecomastia. Various excision techniques have been described over the decades, and more recently liposuction has gained popularity. The optimal form of surgery depends on the classification of gynaecomastia, with the outcome of surgical intervention to restore a normal adult male chest appearance. However, it is the author’s experience that often affected men prefer an adolescent appearance, such is their stigma attached to any form of breast swelling.

What is gynaecomastia?

Gynaecomastia is best described as abnormal breast tissue enlargement in men. It is caused by an imbalance of the oestrogen / androgen ratio either during normal physiological changes such as at birth, puberty or in the seventh decade of life, or due to pathological conditions (See Table 1). However, the most common cause is unknown, accounting for 25% of all cases.

Table 1: Common causes of gynaecomastia

Social Impact of Gynaecomastia

There have been relatively few publications on the psychological aspects of gynaecomastia in men, compared to the variety of surgical techniques. It is the psychological factors that cause men to request surgical treatment for a relatively benign condition. Therefore, it is important to understand these factors to help manage the patients and their expectations.

Nuzzi et al. compared the physical and psychological differences between affected adolescents and healthy adult males, and identified that there was no difference in the severity of gynaecomastia and the psychological scores [5]. Moreover, they confirmed that there was a significant negative impact on psychological scores in adolescents with gynaecomastia.

Wassersug et al. suggested that due to the embarrassment from their breast size, sufferers would refrain from otherwise beneficial exercise [6]. The associated loss of masculinity was the biggest contributing factor to their embarrassment. Recently, media attention has started to focus on male beauty and not just female perfection. This may have had a significant impact on men’s perception of their own bodies and may have led to a rise in fitness trainings. Certainly, male fashion uses slimmer fitting shirts and tops and for those that suffer with gynaecomastia, these items of clothing are impossible to wear, causing further social embarrassment.

We identified that only 6% of men who had corrective surgery scheduled, had the confidence to go topless in front of their friends, clearly demonstrating social inhibition. A common driving factor in men requesting surgery was that their embarrassment was inhibiting their swimming habits, and in particular when taking their own children swimming. Indeed 16% of patients would not go swimming without covering up with a T-shirt, when with their children. Oversized clothing was worn in 45% of patients in an attempt to hide their breasts. Social embarrassment in front of their partners was present in large numbers with 48% of men not able to go topless with their loved ones.

Clearly these statistics demonstrate the severe impact gynaecomastia has on these men’s social lives. Routine dismissal in primary care compounds their lack of self-esteem and this practice must be discouraged with further advice on best management.