Posts Tagged ‘gynecomastia’

Man Boobs (“Gynecomastia”): What You Need to Know

March 30, 2019

Andrew Siegel MD  3/30/19

In females, the breasts (mammary glands) contribute to the alluring female form and allow ready access for the hungry infant, oddly an erogenous zone as well as a feeding zone. 

Breast_anatomy_normal_scheme

1. chest wall  2. pectoral muscles  3. glandular tissue (lobules)  4. nipple  5. areola  6. ducts  7. fatty tissue  8. skin

Image above: by Original author: Patrick J. Lynch. Reworked by Morgoth666 to add numbered legend arrows. – Patrick J. Lynch, medical illustrator, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=2676813  

But men, too, have breasts, areolas and nipples, yet male breasts lack glandular tissue (lobules) and have ducts that are blind-ending and incapable of lactation and providing nutrition to the infant.  This begs the question of why men even have breasts in the first place.  Furthermore, as desirable to the female form as breasts are, enlarged male breasts are viewed by most as unsightly and unattractive. 

So why do men have breasts?

Both genders start out initially as female.  In the absence of the male hormone testosterone (T), the fetus remains female (the default human model), and only in the presence of T does the fetus develops into a male.  However, breasts, areolas and nipples in their rudimentary form are present before T shapes cells into male organs. So, men have breasts, areolas and nipples because they were already present before maleness set in. Consider them nature’s evolutionary bonus!

What are sex hormones?

The main male sex hormone is T and the main female sex hormone estrogen (E).  However, males have some E and females have some T. T takes on two pathways in the body: Much of T is converted to dihydrotestosterone (DHT), the more potent and activated form. Some T is converted to E by virtue of the enzyme aromatase.

What are man boobs?

Man boobs—a.k.a. gynecomastia in medical speak—are a benign proliferation of glandular breast tissue. Gynecomastia is the most common breast condition in men. True gynecomastia—several centimeters or more of dense, firm, rubbery glandular tissue surrounding the areola—is distinguished from pseudo-gynecomastia, in which breast enlargement occurs due to fat deposition, without the presence of glandular tissue. Gynecomastia most commonly involves both breasts, although on occasion it can occur on just one side.

Under what circumstances do man breasts, which are supposed to be rudimentary and undeveloped, grow substantially?

Gynecomastia is seen in three distinct populations: newborns, adolescents and adults.  Breast tissue proliferation is present in the vast majority of newborns because of residual maternal female hormone E in the body, which is depleted in a matter of a few weeks, making the situation self-limited.  Gynecomastia is also seen during puberty in about 50% of adolescent boys, due to a delayed T surge relative to E activity, with spontaneous resolution in most.  However, at this sensitive age, the presence of man boobs on prominent display in the middle-school locker room negatively impacts self-image and self-esteem and can be devastating psychologically and emotionally.  The third population that develops man boobs is aging men, present to some extent in more than 50% after age 50, typically due to weight gain, decreased T levels, increased E levels, and altered T/E ratios.

Adolescent_with_Gynecomastia

Adolescent gynecomastia

Image above: David Andrew Copeland, Dr. Mordcai Blau http://www.gynecomastia-md.com [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/)]

It is vital to make sure that male breast enlargement is not due to male breast cancer, which can occur on rare occasions. Cancer most often causes a hard mass within the breast tissue of one breast, sometimes with skin dimpling, and at times, lymph node enlargement –as opposed to gynecomastia that causes none of the aforementioned signs.

How is the extent of gynecomastia graded?

Grade I: minimal breast growth without drooping (ptosis in medical speak)

Grade II: moderate growth without drooping

Grade III: severe enlargement with drooping

Grade IV: severe enlargement with significant drooping

What is the main factor that underlies male breast growth? 

In both sexes, the main driving factor for breast development is hormonal—E activity and the ratio between E and T.  This explains normal female breast development at puberty (surge of E) as well as newborn, adolescent, and senior gynecomastia, which are associated with increased levels of E and altered ratio of E/T.

What medical issues give rise to gynecomastia?

There are 4 scenarios that can cause gynecomastia: conditions that cause excess E; conditions that cause low T; chronic medical conditions; and certain medications.

Thyroid disorders, e.g., hyperthyroidism, often increase sex hormone binding globulin (SHBG)—the protein that binds T and E—altering E/T ratio (since T is bound tighter than E), often giving rise to breast enlargement.  Certain tumors of the testes (Leydig, Sertoli cell and occasionally germ cell tumors that secrete human chorionic gonadotropin [HCG]) as well as some adrenal tumors can cause gynecomastia.  Carrying excessive weight and fat – particularly visceral abdominal fat (“beer belly”) – is a major risk factor for gynecomastia, as visceral fat contains an abundance of hormones including  aromatase, the enzyme that converts T to E. Men with large bellies consequently are often found to have low T and high E that can result in “emasculation,” with loss of sex drive, diminished erections, loss of penile length and the presence of man boobs.

Central_Obesity_008

Gynecomastia due to central obesity

Attribution: commons.wikimedia.org/wiki/File:Central_Obesity_008.jpg

Dysfunction of the testes, hypothalamus and pituitary can give rise to low T and promote gynecomastia.

Chronic medical conditions—including kidney disease and cirrhosis—often cause gynecomastia along with many other symptoms.

Numerous medications may give rise to male breast enlargement: HCG, estrogens, human growth hormone, anabolic steroids, finasteride and dutasteride, androgen deprivation therapy medications, spironolactone, cimetidine, proton pump inhibitors, digoxin, verapamil, alcohol, and opioids.

How is gynecomastia evaluated?

Visual inspection is used to determine the extent of enlargement and drooping and physical examination to ensure the absence of an underlying breast mass. It is important to do laboratory testing, including liver, kidney and thyroid function tests as well as total T, free T, SHBG, E, luteinizing hormone (LH), prolactin, HCG.

How is gynecomastia treated?

If a specific underlying medical condition or hormonal abnormality is identified, it needs to be addressed. If the gynecomastia is drug induced, the culprit medication needs to be stopped. If due to obesity, commonsense solutions are weight loss and exercise.

The goal of medical therapy is to modulate the E/T ratio and this can be done with the use of medications including clomiphene (selective estrogen receptor modulator—SERM); tamoxifen (SERM plus blocks action of E on breast tissue); danazol (androgen receptor agonist); anastrozole (aromatase enzyme inhibitor), depending on the specific circumstance.

At times, surgery may be the only solution for gynecomastia. In general, liposuction of excessive fatty and glandular tissue is used successfully for mild-moderate gynecomastia whereas liposuction with excision of excessive skin or surgical excision (reduction mammoplasty) is used for severe gynecomastia with drooping.

GynecomastiaFrontalAsymSevere

Before and after surgical treatment

Attribution of image above: JMZ1122 Dr. Mordcai Blau http://www.gynecomastia-md.com [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

Dr. Siegel’s newest book: PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

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Preview of Prostate Cancer 20/20

Video trailer for Prostate Cancer 20/20

Dr. Siegel is the author of 4 other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

 

 

 

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Obesity and Urology

April 5, 2013

Andrew Siegel, M.D.  Blog #101

A whopping two-thirds of adults in the USA are either overweight or obese.   In 1960 the obesity rate was 13%; currently it is 36%. Our physical activities have diminished, our stress levels and our portion sizes have increased, and our derrières have expanded accordingly.  There are an increasing abundance of readily available, unhealthy, processed, cheap foods.  These factors in sum have contributed to our weight gain and to a very negative impact on our overall health.  In addition to the more obvious increased risk for high cholesterol, high blood pressure, heart disease, stroke, and diabetes, weight gain and obesity are also associated with an increased incidence of gallstones, arthritis and other joint problems, sleep apnea and other breathing problems, as well as certain cancers. There are many other less obvious effects that obesity has, negatively impacting every system in our body.

Abdominal obesity—an accumulation of fat in our midsections—not only is unattractive from a cosmetic standpoint, but can have dire metabolic consequences that can affect the quality and quantity of our lives.  It is important to understand that fat is not merely the presence of excessive padding and insulation that signifies excessive intake of energy—but a metabolically active endocrine “organ” that does way more than just protrude from our abdomens, producing hormones and other chemical mediators that can have many detrimental effects on all systems of our body.  So, fat is not just fat. Today’s blog will focus on the harmful ramifications of weight gain and obesity on urological health. As a urologist, on a daily basis I sadly bear witness to the adverse effects and ill consequences of America’s bulging waistline.

Overactive bladder (OAB) is a common condition that causes urinary urgency, frequency, the need to run to the bathroom in a hurry, and at times urinary leakage before arrival at the bathroom. There is a clear-cut association between weight gain and the presence of OAB.   Similar to the way obesity taxes the joints, particularly the knees, so it burdens and puts pressure on pelvic organs including the urinary bladder.

Stress urinary incontinence (SUI) is a frequent ailment in adult women in which there is leakage of urine associated with a sudden increase in abdominal pressure, such as with sneezing, coughing, lifting, laughing, jumping, and any kind of strenuous exercise. Although the major risk factor is pregnancy, labor, and delivery, weight gain is clearly associated with exacerbating the problem.

Pelvic organ prolapse (POP) is a prevalent issue in adult women in which one or more of the pelvic organs—including the bladder, uterus, or rectum—drop down into the space of the vagina and possibly outside the vagina.  Similar in respect to stress urinary incontinence in that the major risk factor is pregnancy, labor and delivery, it is most certainly associated with weight gain and obesity, which have a negative effect on tissue strength and integrity.

Kidney stones are a major source of pain and disability and are very much associated with weight gain, obesity, and dietary indiscretion. Excessive protein and salt intake are unequivocal risk factors for the occurrence of kidney stones.   Uric acid stones, in particular, occur more commonly in overweight and obese people.  Beyond a certain weight limitation, “larger” patients cannot be treated with the standard, non-invasive shock wave lithotripsy to break up a kidney stone and urologists must, therefore, resort to more antiquated, more invasive, more risky measures.

Hypogonadism, a condition in which there are insufficient levels of the male sex hormone testosterone, is an increasingly prevalent condition that is associated with a host of negative effects. Obesity has a pivotal role in the process leading to low testosterone. One’s waist circumference is a reasonable proxy for low testosterone. Fat has an abundance of the hormone aromatase, which functions to convert testosterone to the female sex hormone estrogen.  The consequence of too much conversion of testosterone to estrogen is the potential for gynecomastia, a.k.a. “man boobs.”  Too much estrogen slows testosterone production and with less testosterone more abdominal obesity occurs and even more estrogen is made, a vicious cycle of emasculation and loss of libido.

Erectile dysfunction is a very prevalent condition associated with aging and numerous other risk factors. Weight gain and obesity are major contributors to poor quality rigidity and durability of erections.   This goes way beyond simply low testosterone levels.  Erections in essence are all about sufficient blood flow to the penis. Obesity contributes to problems with penile blood flow that can interfere in a major way with sexual function.   Additionally, as the abdominal fat pad grows, the penis seemingly shrinks and it is estimated that for every 35 pounds of weight gain, there is a 1-inch loss in apparent penile length. In fact, penile shrinkage is a very common complaint among my obese patients.

Prostate cancer is the most common cancer in men.  Like all cancers, prostate cancer is caused by mutations that occur during the process of cellular division.   Prostate cancer has a multifactorial basis, with both genetic and environmental factors at play. There is a clear association between a Western diet and the occurrence of prostate cancer.   This has been witnessed in Asian men, who have a relatively low incidence of prostate cancer in Asia, but after migrating to the USA and assuming a Western diet and lifestyle, have an incidence of prostate cancer that approaches that of Caucasians.

The obese patient presents a real challenge to the urological surgeon in terms of care both during and after an operation.  Surgery on overweight patients is more complex and takes longer as it is much more difficult to achieve proper exposure of the anatomical site being operated upon.  Surgery on obese patients has a higher complication rate with increased respiratory and wound problems. Anesthesiologists have more difficulty placing the breathing tube through a thick, obese neck, and greater difficulty with regional anesthesia as well, because of fatty tissue obscuring the landmarks to place the needle access for spinal anesthesia.

Bottom Line: Fat puts one at risk…for many very unfortunate potentialities.  Maintaining a healthy weight is an important priority for overall health, as well as our urological health.  The good news is that a lifestyle “remake” is typically the first line of treatment for many of the problems that I have just delved into and has the capacity of mitigating, if not reversing, some of them.  This involves the adoption of healthy eating habits, weight loss to achieve a healthy weight, and exercising on a regular basis.   

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

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Man-Oh-Pause: When Things Are Not So Good Under The Hood

September 1, 2012

Blog #73     Andrew Siegel, M.D.

 

“T”  (an abbreviation for testosterone) has become a very commonly used and in vogue term. Many of my patients come into the office specifically asking for their T levels to be checked.  The pharmaceutical industry has been responsible for direct-to-consumer advertising of testosterone replacement products, a practice that has promoted this recent grass-roots awareness of testosterone issues, a subject that was previously the domain of urologists and endocrinologists.

T is that all-important male hormone that goes way beyond male sexuality.  Testosterone has moved to the endocrine vanguard and is now regarded as a key factor in men’s health. Current evidence suggests that a man’s testosterone level might serve a function as a good indicator/marker of general male health.

Aside for contributing to libido, masculinity and sexual function, T is responsible for the physical changes that commence at the time of puberty, including pubic, axillary and facial hair, deepening voice, prominent Adam’s apple and increased bone and muscle mass.  Additionally, T contributes to our mood, bone and muscle strength, red blood cell count, energy, and general mojo.  Most testosterone is manufactured in the testicles, although a small percentage is made by the adrenal glands.

There is a gradual decline in T that occurs with the aging process—approximately a 1% decline each year after age 30.  This will occur in most men, but will not always be symptomatic.  40% of American men aged 45 or older have low or low range T.  Low T is associated with metabolic syndrome and diabetes, bone mineral loss, and altered sexual function.  Specifically, symptoms of low T may include one or more of the following:  fatigue; irritability; depression; decreased libido; erectile dysfunction; impaired orgasmic function; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; abnormal lipid profiles. Essentially, low T can accelerate the aging process.

Belly fat is literally the enemy of masculinity and a testosterone-choker that can push you in the direction of the female gender.  Perhaps when you are standing naked in the shower and you gaze down towards your feet, all you see is the protuberant roundness of your large midriff, obscuring the sight of your manhood.  Perhaps you’re wondering where your penis is hiding.  In most cases, the abundant pubic fat pad that occurs coincident with weight gain obscures the penis—the “turtle effect.”  If your belly blocks your view of your penis, your pubic fat pad makes your penis difficult to locate, your breasts have filled out, and your libido and erections are sub-par, it may just really be time to rethink your lifestyle habits!

Abdominal obesity—an accumulation of fat in our midsections—not only is unattractive from a cosmetic standpoint, but can have dire metabolic consequences that can affect the quality and quantity of our lives. Obesity has a pivotal role in the process leading to low T and waist circumference is a reasonable proxy for low T. Fat is not just fat—it is a metabolically active endocrine organ that does way more than just protrude from our abdomens.  Fat has an abundance of the hormone aromatase, which functions to convert T to the female sex hormone estrogen (E).  The consequence of too much conversion of T to E is the potential for gynecomastia, aka man boobs.  Too much E slows T production, and with less T, more abdominal obesity occurs and even more E is made, a vicious cycle (literally a vicious circus) of male castration and emasculation.

Obesity can steal away your masculinity, male athletic form and body composition, mojo, strength, and also one of your most precious resources—the ability to obtain and maintain a good quality erection.  Remember the days when you could achieve a majestic, heaven-pointing erection simply by seeing an attractive woman or thinking some vague sexual thought?  Chances were that you were young, physically active, and had a svelte build with a hard abdomen. If those days are mere memories, it is probable that you are now carrying extra pounds, have a soft and protuberant belly, and are not physically active.  When you’re soft in the middle, the consequence is that you will probably be soft down below. The good news is that by losing the abdominal fat, the unfortunate consequences of low T can often be reversed.

How To Turn On Your Testosterone Boosters: 

  • A healthy lifestyle, including good eating habits, maintaining a healthy weight, engaging in exercise, obtaining adequate sleep, moderation with respect to alcohol intake, avoiding tobacco, and stress reduction are the initial approaches to treating low T engendered by abdominal obesity.  Insufficient sleep can lower T.  Excessive alcohol increases the conversion of T to E.  Maintaining an active sex life can help maintain T.
  • It is of paramount importance to lose the abdominal fat, with the caveat that a sufficient caloric intake of quality food and nutrients is necessary to prevent the body going into “starvation mode,” which can substantially decrease T production.
  • In terms of exercise, a healthy balance of aerobic, resistance, and core training is best, but in particular, vigorous resistance exercise is crucial.  This will help the flabby abdomen disappear and build lean muscle mass, which in turn will increase metabolic rate.

If lifestyle modification fails to improve the symptoms of low T and T remains measurably low via a simple blood test, a trial of T replacement under the supervision of your doctor can provide a meaningful improvement of your quality of life.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

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Male Obesity Causes Low Testosterone With Potentially Dire Medical Consequences

July 30, 2011

Testosterone (T) is an important male sexual hormone that promotes the physical changes that commence at the time of puberty including pubic, axillary and facial hair, deepening voice, prominent Adam’s apple and increased bone and muscle mass.  Throughout adulthood, testosterone helps maintain libido, masculinity, sexuality, and youthful vigor and vitality.  The lion’s share of testosterone is manufactured in the testicles, although a small percentage is made by the adrenal glands.

There is a gradual decline in T that occurs with the aging process—approximately a 1% decrease each year after age 30. The decline will occur in most men, but will not always be symptomatic. Symptoms of low T may include one or more of the following:  fatigue, irritability, depression, decreased libido, erectile dysfunction, ejaculatory dysfunction, decreased energy and sense of well-being, loss of muscle and bone mass, increased body fat, abnormal lipid profiles. Essentially, low T can accelerate the aging process.

Obesity can have a pivotal role in the process leading to low T. Fat is not just fat—it is a metabolically active endocrine organ that does not just protrude from our abdomens in an inert state.  Fat produces pro-inflammatory factors, hormones and immune cells—including cytokines—which function to inhibit T production in the testicles and the release of hypothalamus and pituitary hormones that govern the release of T.  Low T is present in about half of obese men.   Fat has an abundance of the hormone aromatase, which functions to convert T to the female hormone estrogen (E).  The consequence of too much conversion of T to E is the potential for gynecomastia, aka breast enlargement or alternatively, man boobs.

There is a strong relationship between low T and metabolic syndrome.  Metabolic Syndrome is defined as having three or more of the following: high blood glucose levels; abdominal obesity; high fats (triglycerides); low levels of the “good” cholesterol (HDL); and high blood pressure. If we have a substantial amount of belly fat, then by definition we have insulin-resistance, a condition in which our pancreas works overtime in order to make more and more insulin to get glucose into our cells.  This is a precursor to diabetes, cardiovascular disease and all the havoc they can wreak.  Those with metabolic syndrome have a much-increased risk of cardiovascular disease and type 2 diabetes.

Bottom line:  Abdominal obesity—an accumulation of fat in our midsections—not only is unattractive from a cosmetic standpoint, but can have dire metabolic consequences that can unequivocally affect the quality and quantity of our lives. Obesity in males often promotes low levels of the all-important male hormone testosterone, which can have a number of detrimental effects on our sexuality, bone and muscle health, energy, well-being, etc.  The good news is that by losing the abdominal fat, all of the potentially bad consequences can be reversed.

Andrew Siegel, M.D.

http://www.PromiscuousEating.com for information on Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship With Food

http://www.youtube.com/incontinencedoc for educational videos on low T and a variety of other urological and wellness subjects