What is Bilateral Gynaecomastia? What are its Diagnosis and Treatments

Gynaecomastia is a prevalent medical condition that impacts men and boys, characterised by the non-cancerous enlargement of male breast tissue. Typically, it presents bilaterally, affecting both sides of the breasts. This article delves into the various facets of bilateral gynaecomastia, covering its responsible factors, diverse types, gynaecomastia stages, and available options for diagnosis and treatment.

What is Bilateral Gynaecomastia?

Gynaecomastia entails the non-malignant enlargement of male breast tissue. While it can occur unilaterally, affecting one breast, bilateral gynaecomastia is more common, involving the enlargement of both breasts. This medical condition is caused by the glandular component of the breast proliferating, which increases the size of the breast. Bilateral gynecomastia is characterised by development that is sometimes asymmetrical, yet it always involves extra tissue on both sides.

In many cases, individuals may self-diagnose bilateral gynaecomastia by feeling a button-sized growth beneath the nipple. Additionally, the condition may present with puffy nipples, even in cases where breast growth is mild. Symptoms for both unilateral and bilateral gynaecomastia generally mirror each other. Individuals may encounter tenderness in one or both breasts, accompanied by psychological discomfort.

Factors Leading to Bilateral Gynaecomastia

Understanding the causes of gynaecomastia is crucial for comprehending the origins of this condition.

Natural Hormone Changes:

The human body, assigned male at birth, predominantly produces testosterone, the quintessential sex hormone. Small amounts of estrogen are also synthesised. Gynaecomastia can ensue when testosterone levels decrease relative to estrogen or when estrogen levels become disproportionately elevated. Natural hormonal fluctuations play a pivotal role in this delicate balance.

Medications:

Various medications contribute to gynaecomastia by interfering with the delicate hormonal equilibrium. Medications implicated include anti-androgens (e.g., flutamide, finasteride), anabolic steroids, certain antiretrovirals, ADHD medications containing amphetamines, anti-anxiety drugs, tricyclic antidepressants, select antibiotics, opioids, chemotherapy agents, and specific heart and stomach medications.

Recreational Substances:

Substance abuse, encompassing alcohol and illicit drugs like anabolic steroids, amphetamines, marijuana, and heroin, can significantly impact hormone levels, potentially leading to gynaecomastia.

Health Conditions:

Underlying health conditions that disrupt hormonal balance are linked to gynaecomastia.

• Hypogonadism: Conditions reducing testosterone production, such as Klinefelter syndrome and pituitary insufficiency.
• Ageing: Hormonal changes associated with ageing, particularly in overweight individuals.
• Tumours: Certain tumours affecting the testes, adrenal glands, or pituitary gland can influence hormone production.
• Hyperthyroidism: Excessive thyroxine production by the thyroid gland.
• Kidney Failure: Hormonal fluctuations in response to dialysis treatment.
• Liver Failure and Cirrhosis: Changes in hormone levels linked to liver issues.
• Malnutrition and Starvation: Insufficient nutrition leads to testosterone decline while estrogen levels remain constant.

Herbal Products:

• Some herbal products, notably those containing tea tree or lavender oil, have been associated with gynaecomastia. The compounds in these oils may mimic estrogen or affect testosterone levels.

Types of Bilateral Gynaecomastia

Gynaecomastia is a condition that doesn't have a uniform presentation, and its manifestations can vary in type based on the characteristics of breast tissue growth. The two main categories include:

• Fatty Gynaecomastia: This type results from excessive weight gain, leading to the accumulation of fat cells around the breast area. Inactivity, alcohol consumption, and unhealthy dietary habits contribute to the development of fatty gynaecomastia.
• Glandular Gynaecomastia: This variant emerges from elevated estrogen production in males. Individuals with glandular gynaecomastia typically experience substantial growth of breast tissue, and this type is more frequently observed in the elderly.

Stages of Bilateral Gynaecomastia:

Gynaecomastia is often classified into stages based on the severity of breast enlargement and changes in breast tissue. The gynaecomastia stages include:

• Small Enlargement without Skin Excess: In this initial stage, individuals may notice small breast enlargement not readily visible with clothing. Tissue growth around the areola may be observed, and treatment is often recommended at this stage for optimal results.
• Moderate Enlargement without Skin Excess: This stage involves broader tissue growth, expanding throughout the chest. Although still not highly noticeable under clothing, the chest may feel tight under the nipple area. Gland excision, along with liposuction gynaecomastia surgery, is often recommended at this stage.
• Moderate Enlargement with Minor Skin Excess: Excess skin around the areola can cause drooping in this stage. Breast enlargement is significant, leading to increased chest width.
• Moderate to Severe Enlargement: At this stage, male breasts resemble female breasts, even with loose-fitting clothing. The sagging of the breasts is noticeable, requiring liposuction with gland excision for treatment of gynaecomastia.

Diagnosis and Treatment of Gynaecomastia

Gynaecomastia, the enlargement of male breast tissue, may be a benign and self-resolving condition, but certain situations warrant further evaluation and tailored treatment. Here, we explore the diagnostic process and options for treatment for gynaecomastia, focusing on medical assessments and interventions.

Diagnosis:

To determine if gynaecomastia is present, a healthcare professional initiates the process with pertinent questions, symptom inquiries, and a thorough medical examination encompassing breast tissue, abdominal region, and genitals.

Clinical Evaluation:

• Patients with macromastia (breast size > 5 cm) or those with tender, progressive, or recent-onset lumps require further assessment.
• Signs of malignancy, such as hard or fixed lymph nodes, trigger the need for comprehensive evaluation.

Laboratory Tests:

• Serum chemistry panel, free or total testosterone, LH, estradiol, and dehydroepiandrosterone sulfate levels are considered.
• Thyroid function tests (TSH and free thyroxine) are included in the diagnostic process.

Imaging Studies:

• Mammography becomes crucial if clinical examination raises suspicion of breast cancer, followed by fine-needle aspiration or breast biopsy as needed.
• Testicular ultrasonography is recommended when elevated estradiol levels and clinical findings hint at a testicular neoplasm.
• Breast ultrasonography, though with a low positive predictive value in males, may be considered.
• CT scans, often revealing gynaecomastia, contribute to a comprehensive diagnostic approach.

Biopsies:

• Tissue biopsies, involving the removal of a small tissue piece for laboratory analysis may be conducted for precise diagnosis.

Treatment for Gyno

Gynecomastia frequently goes away on its own, especially throughout puberty. However, based on the underlying causes of gynaecomastia, certain treatments can be necessary.

Pubertal Gynaecomastia: Teens who are developing gynecomastia as a result of normal hormonal fluctuations might not need any form of assistance. Regular checkups every 3 to 6 months monitor spontaneous resolution, common within two years.

Medication: Adults with persistent gynaecomastia may benefit from medications like tamoxifen, raloxifene, or aromatase inhibitors, although not specifically approved for gynaecomastia.

Surgical Options: Surgical intervention becomes an option for individuals with enduring gynaecomastia causing distress or discomfort.

• Liposuction: This gynaecomastia surgery involves the removal of excess fatty tissue using a cannula (a thin tube) inserted through small incisions. Liposuction is particularly effective for treating fatty gynaecomastia.
• Gland Excision: In cases where glandular tissue is the primary concern, surgical excision of the gland may be performed. This involves making an incision to remove excess glandular tissue and reshape the chest.

Conclusion

Bilateral gynaecomastia develops as the enlargement of both male breasts is primarily attributed to hormonal imbalances. Precision in diagnosis involves a multifaceted process, including physical examination, medical history assessment, and pertinent tests. Treatment methods encompass addressing the root causes of gynaecomastia, implementing medication, and, when necessary, opting for surgical interventions tailored to individual requirements. Consistent follow-ups and consultations with healthcare professionals are instrumental in effectively managing gynaecomastia, fostering both physical and psychological well-being.