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Home > The Breast > I am a man I think I am developing breasts

I am a man but I think I may be developing breasts what do I do?

 

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I am a man but I think I may be developing breasts – what do I do?

Professor Philip J Drew
BSc MBBS MD(Hons) MS FRCS (Eng) FRCS (Glasg) FRCS (Ed) FRCS (Gen)
Professor / Consultant Breast Surgeon

There are two main reasons why a man may develop a lump in the breast. Very rarely this can be a sign of breast cancer but much more frequently it is due to a condition known as GYNAECOMASTIA. Either way all breast changes in a man or woman should be investigated appropriately.

Unlike in women breast cancer in men is rare. However the signs are similar to those in women i.e. a lump in one breast, distortion of nipple away from the centre, skin tethering, bloody nipple discharge, palpable lymph nodes in the armpit etc. A family history of breast cancer is important both in female and male relatives but is not essential. It is managed in a similar fashion to female breast cancer.

Gynaecomastia (male breast growth) is much more common. Indeed in some groups the presence of some breast growth is more common than not. Particularly in young teenage boys the presence of some breast growth and even nipple discharge is very common but usually resolves spontaneously before the age of 18 years. Significant breast growth should be investigated as a small percentage can be due to an underlying hormonal abnormality or genetic issue. There are surgical treatments available if the gynaecomastia is causing significant problems but it is generally best to wait until it resolves spontaneously and thus to treat only severe or persistent cases. The latter group is known as persistent pubertal gynaecomastia and represents only about 10% of those teenage boys who initially developed gynaecomastia.

Gynaecomastia developing as a new finding in young men should always be investigated. Various testicular problems and other hormonal imbalances – either from a disease process such as liver, thyroid or kidney disease or from the use of substances such as anabolic steroids or other prescribed medication can manifest as gynaecomastia in the young adult although as with pubertal gynaecomastia a cause is not always found. There is also a known benign genetic predisposition in some families.

In the male over 45 years of age gynaecomastia once again becomes more common. This is probably due to the reduction in testosterone that occurs at around 1% a year after the age of 35 although obesity, medication – especially for prostate problems and other diseases can also play a role. In some cases testosterone can fall to such a low level that testosterone replacement may be a consideration. Whilst still rare breast cancer is also more common in elderly men and those taking the drug Finesteride for benign prostatic hypertrophy should be particularly aware of any changes in the breast as there is some evidence that breast cancer increases with this group of drugs.

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Symptoms and Signs

Gynaecomastia may occur in either one or both breasts and is often worse on one side. It tends to develop as a smooth mobile tender lump directly behind the nipple area. Unlike the rest of the breast tissue it is not compressible between the fingers. Psuedogynaecomastia or lipomastia is a condition related to obesity where there is excess fat deposition in the breast but no excess glandular tissue.

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Investigation

A full history will be taken to include family history of both breast cancer and gynaecomastia as well as details of other illnesses and operations such as hernia repair and prescribed and non-prescribed medication and supplements.

In the teenager the diagnosis of pubertal gynaecomastia can usually be made clinically with further investigation reserved for persistent or severe cases.

In the young adult male with new gynaecomastia imaging with ultrasound and / or mammography may be advised and a needle biopsy preformed if there is any doubt. Blood tests will include screening for testicular tumours and other endocrine abnormalities including tests for testicular function, prolactin (a hormone produced by the pituitary gland), thyroid function, liver and kidney function.

In the middle aged and elderly male imaging is more important and blood tests are as comprehensive but are also guided by the history with particular attention paid to any causative medication.

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Management

Young teenagers with mild gynaecomastia are best advised to address any other issues such as obesity and wait to allow the problem to resolve spontaneously. More significant breast growth can be addressed surgically once it can be shown there is no underlying cause.

In the young the elasticity of the skin allows for liposuction of the breast to produce an excellent result over time. However the glandular element behind the nipple is resistant to treatment by liposuction. Traditionally this has been removed by cutting around the nipple. Clearly this can cause problems with very visible permanent scarring. I have therefore developed and published on a technique where the glandular element is removed using a vacuum assisted biopsy device placed remotely through the armpit skin. This leaves no scar visible on the nipple or breast and only a 3mm scar in the armpit. (1)

Where there is significant excess skin a combination of procedures may be required. In the young it is possible to reduce the skin by performing sequential “doughnut” type removals of skin from around the nipple thus leaving only a scar around the edge of the nipple.

In the more mature patient often reassurance and advice on lifestyle or medication can be all that is needed. If this is not enough there are some non-surgical approaches but the medication involved carries significant risks without guaranteed benefit and these will be discussed with the patient so they can make an informed decision.

For those men with significant breast growth with excess skin it may be that a more formal breast reduction type technique is required. There are several different methods available which each leave different scars and can be selected after discussion with the clinician and depending on the desires of the patient as regards final outcome.

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Summary

In teenagers and elderly men gynaecomastia is common whereas male breast cancer is rare. However all breast lumps in adult males require investigation and also significant breast growth in teenagers due to the risk of significant underlying conditions.

The investigation and treatment of gynaecomastia requires a specialist with a particular interest if appropriate medical and surgical treatment options are to be offered.

Where surgery is required in mild gynaecomastia it is possible to remove the glandular element using a biopsy device combined with liposuction leaving no visible scar on the breast.

References

1) Minimally Invasive Surgery for Gynaecomastia. Annals of the Royal College of Surgeons 2010 Apr;92(3):198-200. 

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