When Merle Yost was 10, his breasts grew noticeably enlarged. From then on, school could be nightmare. Girls would taunt him by offering their bras, and boys would slap at his chest. Yost eventually underwent breast reduction surgery when he was 33. His condition, called gynecomastia, affects males who have a hormonal imbalance. His situation is hardly unique, but his solution isn't the only one available. This week, the New England Journal of Medicine published an article about treatments for gynecomastia, focusing attention on this common yet rarely discussed condition. U.S. News spoke to the author, Glenn Braunstein, an endocrinologist at Cedars-Sinai Medical Center in Los Angeles.
Who gets gynecomastia?
All males produce some "female" hormone. Sometimes there is an imbalance, and when the imbalance occurs, it produces gynecomastia. Probably about two thirds of boys will develop this. It usually comes toward mid-to-late puberty or at about age 13 or 14. Gynecomastia may cause pain and tenderness when boys put their shirt on and the cloth rubs against the nipple. Another big peak is in older individuals after the age of 50.
How can it be treated?
In boys, it usually lasts for three to six months or less, and then goes away in the vast majority of cases. About 5 percent will have persistent gynecomastia. If it is particularly distressing or painful, the medication tamoxifen can help. Up to 80 percent of individuals will have some improvement using tamoxifen. If that doesn't help, then a plastic surgeon can remove the extra tissue.
What role does obesity play in gynecomastia?
One of the more common causes of breast enlargement is fat accumulation behind the breast. One study showed a direct correlation between [body mass index] and gynecomastia.
Is losing weight recommended?
Yes. There are two good reasons to lose weight. First, it may reduce the fat [in the breast]. Second, it can improve cosmetic results if you end up having a plastic surgical procedure.
I have heard that some men intentionally gain weight to avoid the embarrassment of their breasts.
That would be a very silly thing to do. Gynecomastia really is not a disease. It doesn't make sense to take something that is a benign process and risk developing type 2 diabetes, heart problems, eye problems, joint problems, etc.
I imagine the condition can be rather distressing for boys.
If all of a sudden a boy starts getting breast enlargement, they are afraid to take their shirts off in the locker room and may have fears that they're turning into a girl. I give [the patient] a lot of reassurance that he is not turning into a female.
Can gynecomastia be confused with male breast cancer?
One should be able to differentiate gynecomastia from male breast cancer, which accounts for about 1 percent of all breast cancers. Gynecomastia starts out in the nipple and spreads out. Breast cancer is oftentimes not symmetrical. Gynecomastia, in about half the cases, is on both sides, whereas breast cancer is usually on one side. If there is still a concern, one can get a mammogram.
Gynecomastia can be a symptom of certain cancers and problems involving the testis, thyroid gland, liver, or kidneys. Should parents worry that a teen with gynecomastia has an underlying disease?
Parents should be reassured that two thirds of teenagers will develop gynecomastia without any underlying problem. If the child develops it early—at age 5, 6, or 7—there is more of a concern that there is an underlying disease. When it occurs early, then by all means, the parents need to have the child see a pediatrician.
When is breast reduction surgery a good option?
For somebody who is really emotionally distraught and whom medication has not helped, I think surgery is a good solution. A number of different techniques can be used, and the cosmetic results are pretty good. There are risks to the surgery, of course, but of the people who undergo surgery, the majority is pleased with the results.
How long should boys wait before considering surgery?
After a year and a half, if [the gynecomastia] is still there, it's likely to contain scar tissue and is unlikely to go away spontaneously or to respond to medication. So then you can think about surgery. You want to make sure boys are pretty much through puberty. If you remove breast tissue too early, it may grow back.
Should the surgery be covered by insurance?
No. It's usually not covered by insurance because it is considered cosmetic. The costs of healthcare are so high I would rather see those same dollars go towards better immunization of children, better prenatal care of women rather than going to cosmetic surgery.