Gynecomastia

Gynecomastia means a benign (non-cancer) growth of true breast gland tissue in a boy or a man. It happens when the balance between estrogen (which stimulates breast tissue) and androgens like testosterone (which block breast growth) shifts toward estrogen effect. The tissue that grows is a rubbery, firm disc right under the nipple (subareolar). It can affect one breast or both. It can be tender at first. It can happen at any age: in newborns (from mom’s hormones), during puberty (from normal hormone swings), and in older men (from lower testosterone and higher aromatase activity in fat). Many cases are harmless and go away on their own, but some are caused by medicines, health conditions, or tumors that change hormones. Gynecomastia is different from pseudogynecomastia, which is just fat on the chest without gland tissue.

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Other names

• Male breast enlargement (glandular)

• Benign proliferation of male breast gland tissue

• Pubertal gynecomastia (when it happens in adolescence)

• Physiologic gynecomastia (normal life stages)

• Senescent gynecomastia (older age)

• Neonatal gynecomastia (newborns)

• Subareolar glandular disc in males
  (Note: “pseudogynecomastia” is fat only, not true gynecomastia.)

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Types

1. Physiologic gynecomastia
   Normal life stages. Newborns (maternal hormones), puberty (temporary hormone swings), and older men (age-related hormone changes). Often painless or mildly tender. Often resolves on its own.

2. Pathologic gynecomastia
   Due to an illness or a hormone-active tumor. For example, testicular, adrenal, or hCG-secreting tumors, severe liver or kidney disease, or thyroid problems.

3. Drug-induced gynecomastia
   Caused by medicines or substances that raise estrogen effect, lower testosterone, or block androgen action. Common, and often improves after the drug is stopped.

4. Unilateral vs bilateral
   One side or both sides. Either can be normal, but rapid, hard, or oddly shaped one-sided growth needs careful check to rule out cancer.

5. Acute tender vs chronic fibrotic
   Early growth is often sore and rubbery (more active tissue). Long-standing tissue becomes less tender and more fibrous (scar-like), and is less likely to shrink.

6. True gynecomastia vs pseudogynecomastia
   True = gland tissue under the nipple. Pseudo = only fat. Doctors can tell by feel and ultrasound.

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Causes

1. Puberty hormone swings
   In early to mid-puberty, estrogen effect may briefly exceed testosterone action. A small, tender disc under the nipple is common and usually fades within 6–18 months.

2. Newborn exposure to maternal hormones
   Many male newborns have temporary breast swelling from mom’s estrogens. It goes away in a few weeks.

3. Aging and lower testosterone
   Testosterone slowly falls with age. Fat tissue increases aromatase activity (more conversion of androgens to estrogens). This shifts the balance toward estrogen effect.

4. Obesity (increased aromatase in fat)
   Extra fat converts more androgens into estrogens. This increases local breast stimulation.

5. Primary hypogonadism (testes problem)
   Testes make less testosterone (e.g., after mumps orchitis, trauma, radiation, chemotherapy). Low T allows estrogen effects to dominate.

6. Klinefelter syndrome (47,XXY)
   A genetic condition causing small testes, low testosterone, infertility, and a higher risk of gynecomastia and certain tumors.

7. Secondary hypogonadism (pituitary/hypothalamus)
   Pituitary or hypothalamic problems cause low LH/FSH and low testosterone (e.g., pituitary tumors, prolactinoma, systemic illness).

8. Hyperthyroidism (thyrotoxicosis)
   High thyroid hormones increase SHBG and change androgen–estrogen balance, raising free estrogen effect.

9. Chronic liver disease (cirrhosis)
   The liver clears hormones poorly. Estrogen levels rise. Alcohol itself also affects testicular function and liver metabolism.

10. Chronic kidney disease (uremia)
    Uremia and dialysis can disrupt gonadal hormones and increase prolactin, shifting the balance.

11. hCG-secreting tumors
    Some testicular or mediastinal germ cell tumors make hCG, which stimulates testicular estrogen production.

12. Testicular tumors (Leydig/Sertoli/germ cell)
    These may secrete hormones or change the androgen–estrogen balance.

13. Adrenal tumors or adrenal enzyme changes
    Rare tumors or enzyme defects can overproduce estrogen precursors.

14. Medications: spironolactone
    Common cause. It blocks androgen receptors and increases estrogen effect.

15. Medications: antiandrogens/5-α-reductase inhibitors
    Drugs like bicalutamide or finasteride/dutasteride reduce androgen action and can cause breast tissue growth.

16. Medications: some antipsychotics and antidepressants
    Risperidone and others can raise prolactin, reduce gonadal hormones, and trigger gynecomastia.

17. Medications: cimetidine, ketoconazole, digoxin, some HIV meds
    These can lower testosterone, block androgen synthesis, or act like estrogens.

18. Anabolic steroid cycles and withdrawal
    Using and then stopping anabolic steroids can lead to relative estrogen excess and breast growth (aromatization to estradiol).

19. Alcohol and recreational drugs (e.g., cannabis—evidence mixed)
    Alcohol harms testes and liver. Cannabis data are mixed, but many clinicians consider it a possible contributor.

20. Malnutrition and refeeding
    During starvation, testosterone falls. During refeeding, estrogen effect may temporarily rise, causing breast tissue growth.

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Symptoms and signs

1. Breast enlargement
   A slow or sometimes quick increase in breast size. One or both sides. Often centered under the nipple.

2. Subareolar “rubbery disc”
   A firm, rubbery, round area right under the nipple. This is true gland tissue, not just fat.

3. Breast tenderness or soreness
   Common early on. Pain usually eases as the tissue stabilizes.

4. Nipple sensitivity
   The area may feel more sensitive to touch or clothing.

5. Unilateral or asymmetric change
   One breast may be larger. If it is hard, irregular, or fixed, this needs careful evaluation.

6. Nipple discharge (rare)
   Can occur with high prolactin, certain medicines, or tumors. Bloody discharge is concerning and needs urgent check.

7. Skin or nipple changes
   Dimpling, nipple retraction, or skin thickening is unusual and may suggest cancer. Needs prompt imaging.

8. Lumps in the testicles
   A testicular mass with breast growth raises concern for a hormone-secreting tumor.

9. Low libido or erectile problems
   A sign of low testosterone in some men with gynecomastia.

10. Infertility or small testes
    Suggests hypogonadism or Klinefelter syndrome.

11. Loss of body hair or shaving frequency
    Another gentle clue to low androgen effect.

12. Thyroid symptoms
    Weight loss, tremor, palpitations, heat intolerance can point toward hyperthyroidism.

13. Liver disease clues
    Jaundice, easy bruising, abdominal swelling may signal cirrhosis.

14. Kidney disease clues
    Fatigue, swelling, and known CKD may be present.

15. Emotional distress and body image concerns
    Anxiety, embarrassment, and social withdrawal are common and deserve care and support.

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Diagnostic tests

(Grouped as Physical Exam, Manual Tests, Lab/Path, Electrodiagnostic, Imaging. Doctors choose based on your history and exam. Not everyone needs every test.)

A) Physical Exam

1. General inspection of the chest
   The doctor looks for symmetry, size, skin changes, and nipple changes. True gynecomastia is centered under the nipple. Pseudogynecomastia looks more like soft fat spread over the chest.

2. Breast palpation (feel) for a subareolar disc
   The doctor gently presses around the nipple to feel a firm, rubbery disc. Hard, irregular, or fixed masses away from the nipple raise concern for cancer and need imaging.

3. Nipple discharge check
   The clinician lightly compresses to see if fluid appears. Milk-like discharge suggests prolactin-related issues; bloody discharge is uncommon and needs urgent imaging and referral.

4. Testicular exam
   The doctor checks size, texture, and any masses. Small, firm testes suggest Klinefelter or hypogonadism. A testicular lump needs ultrasound.

5. Thyroid, liver, and general exam
   Fast heart rate or tremor may suggest hyperthyroidism. Jaundice or liver stigmata suggest cirrhosis. Body hair pattern and muscle bulk help assess androgen status.

B) Manual Tests / Bedside Maneuvers

6. Two-finger “roll” test
   The doctor traps tissue between two fingers and rolls it under the nipple. A distinct, rubbery disc supports true gynecomastia; soft, diffuse tissue suggests fat.

7. Pinch test for fat vs gland
   Pinching away from the nipple helps tell if the tissue is mostly fat. Lack of a central disc points to pseudogynecomastia.

8. Confrontation visual fields (screen for pituitary mass)
   A simple bedside check for visual field cuts, which can occur in large pituitary tumors that also cause hormonal problems.

C) Laboratory / Pathological Tests

9. Morning total testosterone
   A key first test. Low levels suggest hypogonadism. Repeat if borderline or if you were ill or sleep-deprived.

10. LH and FSH
    High LH/FSH with low testosterone = primary testicular failure. Low or normal LH/FSH with low testosterone = secondary (pituitary/hypothalamic) cause.

11. Estradiol (E2)
    High estradiol suggests increased production or decreased clearance (e.g., tumors or liver disease).

12. Prolactin
    High prolactin can lower gonadotropins and testosterone, contributing to gynecomastia.

13. β-hCG
    Elevated levels may point to germ cell tumors (testis or mediastinum) that stimulate estrogen production.

14. Thyroid tests (TSH and free T4)
    Detect hyperthyroidism, which shifts the balance toward estrogen effect.

15. Liver function tests (AST/ALT, bilirubin, albumin, INR)
    Abnormal results suggest cirrhosis or chronic liver disease, which alter hormone metabolism.

16. Renal function (creatinine, eGFR) ± electrolytes
    Assesses kidney disease, which can disturb hormones and prolactin clearance.

(Additional tests sometimes used: SHBG, DHEA-S, sex chromosome analysis for Klinefelter, tumor markers like AFP/LDH, or selective drug levels—ordered case-by-case.)

D) Electrodiagnostic

17. Electrocardiogram (ECG)
    Not for gynecomastia itself, but useful if hyperthyroidism is suspected (to check rhythm), or before/while using certain medicines that can affect the heart. It helps with safe overall care.

E) Imaging Tests

18. Breast ultrasound
    First-line imaging in many men. It distinguishes solid gland tissue from fat and can spot suspicious masses or cysts. It guides biopsies when needed.

19. Diagnostic mammography
    Used if exam or ultrasound suggests cancer (e.g., hard mass, nipple retraction, bloody discharge, skin changes). Patterns help separate gynecomastia from malignancy.

20. Testicular ultrasound
    Ordered when the exam or lab tests (like high β-hCG) suggest a testicular tumor. It is sensitive for small intratesticular masses.

Non-drug care

Below are 10 core non-pharmacological measures that are reasonable, safe, and often recommended while diagnostic work proceeds or as adjuncts to medical/surgical therapy. (High-quality randomized trials are limited; guidance is primarily based on expert reviews and clinical guidelines.)

1. Education & reassurance – Explain the diagnosis, inherited nature (when present), and treatment paths; this reduces anxiety and improves adherence. NCBI+1

2. Psychosocial support – Validate body-image concerns; consider counseling if distress, bullying, or avoidance behaviors occur; this reduces depression/anxiety risk. PubMed Central

3. Observation with scheduled follow-ups – Even in hereditary cases, short observation is sometimes used while labs/genetics finalize; structured reviews track growth, pain, and breast size. andrologyacademy.net

4. Compression garments – Soft, age-appropriate compression shirts can reduce visibility and tenderness during activity. PubMed Central

5. Pain-minimizing habits – Avoid nipple trauma (backpack straps, contact sports without protection); use gentle fabrics to reduce tenderness. NCBI

6. Healthy weight & fitness – While gland tissue doesn’t melt with exercise, keeping body fat in a healthy range reduces pseudogynecomastia and improves self-image. NCBI

7. Trigger review – Eliminate exogenous estrogen/phytoestrogen exposures (unregulated supplements, certain essential oils) and discuss any medications with endocrine effects. NCBI

8. School accommodations – Allow flexible clothing for PE, seating away from teasing hotspots; reduces psychosocial harm. PubMed Central

9. Photo/measurement tracking – Periodic, respectful measurements help detect real change and guide decisions. andrologyacademy.net

10. Family genetic counseling (when AEXS/FMPP confirmed) – Explains inheritance, testing options for siblings, and future reproductive implications. PubMed+1

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Medicines

Safety first: Pediatric dosing and timing are specialist decisions. The summaries below reflect common practice in the literature; always manage through a pediatric endocrinologist.

1) Tamoxifen (SERM) – Why: blocks estrogen receptors in breast tissue to reduce pain/size. Use: Short courses (often 3–6 months) are reported for persistent, painful gynecomastia. Notes in kids: Case series and reviews suggest benefit; RCT evidence in adolescents is limited; monitor mood, thrombotic risk (rare in healthy boys). PubMed Central+2ScienceDirect+2

2) Raloxifene (SERM) – Why: similar receptor blockade; sometimes chosen if tamoxifen not tolerated. Pediatric data are sparse but small series report improvement. Monitor for cramps, rare thrombosis. NCBI

3) Anastrozole (aromatase inhibitor, AI) – Why: lowers conversion of androgens→estrogens. Best fit: AEXS and situations with high aromatase activity; also adjunct in FMPP to counter aromatization of excess androgens. Evidence includes trials/case series; monitor bone health and lipids. PubMed Central+3Oxford Academic+3ScienceDirect+3

4) Letrozole (AI) – Why: stronger estrogen suppression; used in AEXS (including prophylaxis during puberty in affected families) with long-term case follow-up; requires growth/ bone monitoring. Frontiers+1

5) Exemestane (AI, steroidal) – Why: irreversible aromatase inhibitor; considered when others not tolerated; pediatric data limited—specialist use only. NCBI

6) Bicalutamide (antiandrogen) – Why: key in FMPP, blocks androgen receptors; combined with an AI (anastrozole) to blunt estrogen conversion. Shown to slow skeletal advancement and improve clinical course in FMPP. Monitor liver enzymes and for gynecomastia as a side effect in other contexts. PubMed+2PubMed Central+2

7) GnRH agonists (e.g., leuprolide) – Why: If long-standing peripheral precocity (like FMPP) triggers central puberty, a GnRH agonist can suppress the central axis in addition to bicalutamide+AI. They do not treat FMPP alone. PubMed Central

8) Ketoconazole (steroidogenesis inhibitor) – Why: Historically used in refractory FMPP to reduce androgen synthesis; limited by hepatotoxicity and adrenal suppression risks; largely replaced by bicalutamide+AI strategies. ScienceDirect

9) Danazol – Why: weak androgen that suppresses gonadotropins; occasionally reported for gynecomastia but generally avoided in children because of androgenic and metabolic adverse effects. Use only if expert recommends. NCBI

10) Dihydrotestosterone (DHT) gel – Why: topical androgen used in some countries for pubertal gynecomastia; pediatric data limited; not standard in hereditary prepubertal cases. NCBI

(Guidelines emphasize that many boys with typical pubertal gynecomastia don’t need drugs; hereditary prepubertal forms like AEXS/FMPP are the exceptions where AIs and (for FMPP) antiandrogens have the most supportive evidence.) andrologyacademy.net

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Dietary molecular supplements

There are no supplements proven to reverse hereditary prepubertal gynecomastia or to safely “balance hormones” in children. Some plant products (e.g., concentrated phytoestrogens, certain essential oils) may worsen breast tissue via estrogenic effects. Families should avoid unregulated hormonal supplements and discuss any product with the child’s physician. NCBI

If diet is discussed at all, it should focus on general child nutrition (adequate protein, calcium/vitamin D, fruits/vegetables) to support growth and bone health while formal medical therapy addresses estrogen excess. Vitamin D and calcium support bone when AIs are used, but they do not treat gynecomastia itself. Oxford Academic

Immunity-booster / regenerative / stem-cell drugs

There are no immune boosters, regenerative medicines, or stem-cell therapies that are appropriate or evidence-based for hereditary prepubertal gynecomastia. Using such products could delay effective care and expose a child to risk. Management should target the hormonal driver (AIs/antiandrogens) or, if needed, surgery. andrologyacademy.net

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Surgery

Subcutaneous mastectomy (often with liposuction and preservation of the areola-nipple complex) is considered when breast tissue is sizable, fibrotic, symptomatic, or psychosocially severe, and medical therapy is ineffective or contraindicated. In AEXS, recurrence can occur if estrogen excess continues; some families combine surgery with AI therapy through puberty to reduce recurrence. Decisions are case-by-case in a multidisciplinary team. PubMed Central+1

Surgical planning in adolescents prioritizes small, well-hidden incisions and contour symmetry to reduce scarring and improve quality of life. Complication risks (hematoma, contour irregularity, nipple sensation change) are discussed in advance, and most boys go home the same day with compression and activity restrictions for several weeks. emergency.zaslavsky.com.ua+1

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Prevention & everyday tips

• You can’t prevent inherited conditions like AEXS or FMPP, but you can:

1. Seek early endocrine evaluation if breast tissue appears before puberty. andrologyacademy.net

2. Avoid exogenous estrogens/phytoestrogens and unregulated “hormone” supplements. NCBI

3. Keep routine growth tracking and get a bone-age x-ray if advised. NCBI

4. Maintain adequate calcium/vitamin D and weight-bearing activity—especially if on aromatase inhibitors. Oxford Academic

5. Use compression garments and supportive counseling to reduce day-to-day distress. PubMed Central

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When to see a doctor

See a pediatric endocrinologist promptly if:
• Breast enlargement starts before normal puberty (before testicular volume ~4 mL), grows rapidly, or is asymmetric with pain/tenderness.
• There are signs of very early puberty (rapid growth, pubic hair, acne, body odor) before age 9.
• A family history of AEXS/FMPP or short adult height with early growth spurt exists.
These patterns merit targeted labs, bone age, and genetics. For emergencies (e.g., sudden breast mass with skin changes), seek care immediately to rule out other causes. NCBI+1

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Food guidance

What to emphasize: balanced meals with lean proteins, whole grains, fruits/vegetables, dairy or fortified alternatives for calcium/vitamin D, and adequate calories for growth—especially important if medical therapy affects appetite or bone. Hydration and regular meals help mood and energy. Oxford Academic

What to avoid: highly processed “supplements” marketed for “hormone balance,” concentrated phytoestrogen extracts, and topical products with estrogenic oils used chronically on the chest. These do not cure gynecomastia and may worsen it; always discuss any supplement with the care team. NCBI

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Frequently asked questions

1) Can this go away by itself?
Typical pubertal gynecomastia often resolves; hereditary prepubertal forms usually persist unless the hormonal source is treated (e.g., AIs for AEXS). andrologyacademy.net+1

2) Is it cancer?
No—this is benign breast gland growth. Cancer is extremely rare in children, but unusual lumps or skin changes should be assessed. NCBI

3) Will medicines stunt growth?
Aromatase inhibitors can slow bone-age advancement in AEXS and are carefully monitored; the goal is to preserve adult height, not reduce it. Oxford Academic+1

4) Are SERMs (tamoxifen/raloxifene) proven?
Good case series and reviews show symptom and size reduction; robust RCT data in adolescents are limited, so therapy is individualized. PubMed Central+1

5) What about FMPP treatment?
Best evidence supports bicalutamide + anastrozole, sometimes plus GnRH agonist if central puberty is activated. PubMed+1

6) Will surgery fix it for good?
Surgery removes existing tissue, but if estrogen excess continues (e.g., untreated AEXS), recurrence can occur; many teams pair surgery with medical control. Frontiers

7) Is there a role for “testosterone boosters” or herbs?
No. Such products can be risky and may worsen estrogen balance via aromatization. Avoid them. NCBI

8) Could weight loss solve it?
Weight management helps fat-related chest fullness, but true gland tissue from estrogen excess won’t melt with exercise alone. NCBI

9) How is AEXS inherited?
Usually autosomal dominant—each child of an affected parent has ~50% chance of inheriting it; genetic counseling helps families plan. PubMed

10) How early can FMPP show up?
As early as infancy to toddler years; children show rapid growth and early virilization; gynecomastia may occur from aromatization. Oxford Academic

11) Are long-term AI data available?
Case series with years of follow-up suggest preserved height potential and gynecomastia control when monitored carefully. Oxford Academic

12) Do we need bone-age x-rays?
Yes, they help track maturation and guide therapy timing. NCBI

13) Is tamoxifen safe for bones in teens?
Small studies did not show major bone harm with short courses, but monitoring is prudent. PubMed Central

14) Can essential oils or lavender products cause gynecomastia?
Some products have estrogenic activity in lab studies and case reports; regular chest application is not advised in boys with gynecomastia. NCBI

15) Who coordinates care?
A pediatric endocrinologist (for diagnostics/medication) and, when needed, a pediatric plastic surgeon (for surgery), with support from primary care and counseling services.

 

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The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: September 22, 2025.

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