Gynecomastia, or as it’s more informally known, gyno, is nature’s equivalent of using a Sharpie to deface a pretty painting. Not only do these “man boobs” mar what might otherwise be an impressive male physique, they also cause damage to a man’s confidence and self-esteem.
Imagine (or maybe you don’t have to imagine) taking your shirt off in front of the mirror and seeing a “puffiness” around your nipples. If you’re like most men, you blast through the different stages of grief over the span of about 30 seconds. You start with denial, shoot right through to anger, progress real quick to the bargaining, and then settle right down into a deep depression.
You skip the acceptance phase, though, because no man who doesn’t harbor a secret desire to go to a sex change clinic ever gets comfortable with the idea that they’re suddenly going through the same thing their mother or sister went through when they were about 13, albeit while experiencing a decidedly different set of emotions.
It’s weird that most men don’t know much about gyno, especially when you consider that, depending on a variety of factors, it affects between 32 and 65% of all men at some point in their lives.
What Exactly Is Gyno, Anyway?
Most people think gyno is just fat that’s been so rude as to form around a man’s pecs. Now it is true that there’s a condition called “pseudogynecomastia” that’s generally associated with obese men. It involves the simple deposition of fat around the chest, but true gynecomastia is entirely different.
Real gyno is characterized by the presence of a firm, rubbery mass that extends concentrically and symmetrically from the nipple and, as it progresses, is accompanied by the proliferation of glandural tissue. It almost always occurs bilaterally.
In its early stages, it may or may not be apparent to onlookers, unless you’re otherwise lean. If left unchecked, though, the glandural tissue continues to grow and eventually assumes the consistency of a piece of gristle, whereupon it’s usually painfully apparent to even the most casual observer.
The cause of gyno is well known: It’s simply a disruption of the balance of the testosterone and estrogen ratio. Anything that causes an elevation in the amount of circulating estrogen or a decrease in circulating androgen (e.g., testosterone) can escalate the estrogen to androgen ratio and induce gyno.
It’s easier to understand if you realize that the development of male breast tissue is exactly the same, biochemically and physiologically, as the development of female breast tissue.
Several things can trigger gyno, some natural and some unnatural.
The Three Ages of Gyno
There are three times in a man’s life when he’s most susceptible to developing gyno. These periods constitute a “trimodal age distribution.”
The first peak incidence occurs to both boys and girls in the neonatal or infancy stage. This is due to high levels of estradiol floating around the mother’s veins, in addition to the conversion of the hormone DHEA and DHEA-S04 to estrone and estradiol by the placenta, both of which stimulate the development of breast tissue.
Mercifully, to what might otherwise be horrified fathers, this condition usually regresses rather than progresses within a few weeks after birth.
The second peak, occurs, cruelly, when boys are starting to grapple with puberty and trying to process their impending masculinity. It usually begins between the ages of 10-12 and peaks at 13-14. Unlike most cases of adult gyno, pubertal gyno can be asymmetrical and occur unilaterally.
Again, it’s caused by a decreased androgen to estrogen ratio, along with a probably genetically determined increase in aromatase (an enzyme that converts testosterone to estrogen) activity in skin fibroblasts (cells that make up connective tissue).
There are estimates that gyno affects between 4 and 69% of all adolescents. The Grand Canyon like variance is because clinicians have widely divergent views about what constitutes actually gyno, along with varying diagnostic skills between different physicians.
Most of the time, pubertal gyno resolves itself within 18 months. However, some 20% have residual gyno at the age of 20.
The third peak hits older males between 50 and 80 and there are several possible causes. Older males are usually fatter males, and fatty tissue converts androgen to estrogens. Secondly, levels of steroid hormone binding globulin (SHBG) increase with age, and SHBG chemically ties up testosterone, thereby upsetting the estrogen to androgen ratio.
Lastly, there are a lot of meds that cause gyno and old coots use a lot of them. In fact, it’s thought that up to 80% of gyno in old guys is directly attributable to their prescription drugs.
All that being said, there are all kinds of things that can cause gyno to develop in men of all ages who don’t fall into that trimodal age distribution.
Other Causes of Gyno
A lot of steroids aromatize to estrogen, thus offsetting the estrogen to androgen ratio and initiating breast development.
Steroid-using athletes can avoid gyno by not choosing steroids that aromatize (testosterone and Anadrol, for example) and using the very few steroids that don’t. Alternately, they can add about 20 mg. of an anti-estrogen like Nolvadex (tamoxifen) per day to their stack.
Starvation and Refeeding
When someone is suffering from malnutrition, or possibly even severe dieting, their testosterone levels drop while estrogen production continues unabated. When re-feeding occurs, however, testosterone production soars, and consequently, because of aromatization, so does estrogen, again offsetting the E to A ratio. This type of gyno is often described as a “second puberty.”
George Costanza was right to be alarmed when he saw his dad without a shirt. There’s a familial type of gyno where affected members have increased levels of aromatase activity.
There’s a lot of increased aromatase activity in fatty tissue, so carrying a lot of fat is thought to be causative of gyno. Oddly enough, though, most obese men supposedly don’t have elevated estrogen levels. Niewoehner and Nuttall, though, found a correlation between body mass index (BMI) and the percentage of men with gyno.
While an overactive thyroid appears to induce gyno through several mechanisms, the predominant one appears to be through increased aromatase activity. (The aromatase enzyme binds more tightly to androgens than estrogen, thus potentially upsetting the E to A ratio, yet again.)
Men who, for whatever reason, are low in testosterone because of some disruption of the hypogonadal axis are more susceptible to gyno. As testosterone levels go down and luteinizing hormone levels go up, more estrogen is produced, along with more aromatization of testosterone to estrogen.
Any kind of physical injury to the testicles, be it from horse kicks, sitting on the bicycle seat and missing, or overzealous lovers, can quite understandably affect testosterone production and upset the A to E ratio.
Any number of diseases, ranging from kidney disease, HIV, recurrent urinary tract infection, or neuropathic bladder can lead to gynecomastia.
Male Breast Cancer
While exceedingly rare, male breast cancer has been associated with gyno. Risk factors for this kind of cancer include alcohol intake, obesity, testicular disorders, radiation to the chest, liver damage, and exogenous estrogen exposure.
Symptoms that may indicate breast cancer include skin dimpling around the nipple, nipple retraction or discharge, and swollen lymph nodes, and while patients with run of the mill gyno often experience tenderness in the breast area, it’s unusual with breast cancer patients.
Also be aware that while not entirely impossible, gyno doesn’t “turn into” male breast cancer. Breast cancer, however, can sometimes look like gyno.
It’s estimated that approximately 20% of gyno cases are directly attributable to prescription drugs. Some of these drugs have estrogen-like qualities, some increase the production of estrogen, and some, like testosterone and other androgens, are precursors.
Here’s a list of classes of drugs, along with a couple of examples of drugs implicated with gyno:
- Hormones: Steroids, GH
- Anti-Androgens: Finasteride, Dutasteride
- Antibiotics: Metronidazole, Ketoconazole
- Anti-Ulcer Drugs: Cimetidine, Omeprazole
- Cancer Chemotherapeutic Agents: Methotrexate, Vinca alkylating agents
- Cardiovascular Drugs: Captopril, Diltiazem, Nifedipine
- Psychoactive Drugs: Diazepam, Tricyclic antidepressants
- Recreational Drugs: Alcohol, Amphetamines, Heroin, Marijuana (weak association), Methadone
These are chemicals in the environment that mimic estrogen. Culprits include heavy metals, synthetic chemicals like DES and DDT, and industrial chemicals like phthalates. The variety of these continue to grow in number, and accumulate in more tissues, with each passing year.
Since they mimic estrogen, they can, like other causes of gyno, upset the A to E ratio. They’re found in foods, adhesives, fire retardants, detergents, drinking water, perfumes, waxes, household cleaning products, lubricants… virtually everywhere.
Furthermore, there’s plenty of evidence that these chemicals are a part of all of us. Researchers found that 75% of the samples taken from 400 adults contained significant levels of industrial xenoestrogens.
It’d be wise to take some measures to avoid exposure to them in general.
You raised an eyebrow at this one, didn’t you? To be honest, there’s only one study that associated consumption of low-fat milk with increased estrogen, but I think it’s worth noting, nonetheless.
Scientists fed whole milk and low-fat milk to subjects and those in the low-fat group had higher levels of “conjugated estrogens” in their blood, which are the most bio-available form of estrogen and the type found in birth control pills. It was theorized that the milk fat inhibited the enzymes needed to deconjugate the estrogen.
These are plant estrogens that, when consumed in sufficient amounts, can offset the A to E ratio. Examples include the isoflavones found in soy, chickpeas, mung beans, and alfalfa; the coumestans found in alfalfa, clover, and soy sprouts,; and the lignans found in linseed, grains, and vegetables.
There is some controversy, however, as to how potentially damaging these phytoestrogens can be. While they definitely act as weak estrogens, you’d most likely have to ingest a lot of them to develop gyno.
Miscellaneous Weird Things
Cases of gyno have been ascribed to inadvertent exposure to estrogens contained in skin creams or anti-balding creams, or the transference of estrogens to children from women who use transdermal estrogens but fail to wash their hands afterwards.
Sexual intercourse with a woman who uses vaginal estrogen creams can also put a male at risk. Several outbreaks of gyno among children have been associated with estrogens fed to livestock whose meat or milk was then ingested by children.
There’s one case in the literature where a man developed gyno from drinking 3 quarts of soymilk a day. When he stopped, the gyno resolved itself. One decidedly weird guy developed gyno because he had a penchant for drinking the urine of women.
Gyno is also known as the “embalmers curse” as some of the chemicals used in mortuary practice are highly estrogenic. The use of lavender and tea oils has also been implicated.
Treating Gyno with Natural Products
A number of natural plant compounds have been found to have anti-estrogenic properties and as such may prevent or even treat gyno. Many of them, including some exotic fatty acids and various peptides extracted from bacterium, aren’t available for consumer usage.
However, standbys like chrysin (extracted from passion flower, honey, or bee spit) and maca (from a Peruvian plant) have been found to be moderately effective, while the polyphenol resveratrol (Rez-V™), in particular, was reported to strongly inhibit aromatase.
Treating Gyno With Prescription Drugs
Often, gyno can resolve itself through diet and exercise, but in cases where it’s severe or of recent onset (less than 6 months), chemical intervention may be required. This is generally done using one of three different classes of drugs:
Androgens (testosterone, DHT, danazol)
If the case of gyno is already fairly far along in its development, testosterone usually doesn’t work very well because it can aromatize and exacerbate the condition.
Clinicians have had good results with DHT, though, especially in cases of pubertal gyno that haven’t resolved because DHT doesn’t aromatize. Of the androgens, however, danazol seems to have the best success rate. Even so, it only resolved 23% of cases (as opposed to 12% with placebo).
Anti-Estrogens (clomiphene, tamoxifen)
The use of 100 mg. a day of clomiphene has had a 64% response rate, whereas tamoxifen has had, depending on which study you believe, either a 78% success rate or a 90% success rate.
There’s always a chance of reoccurrence when choosing these drugs as a treatment, but the risk of side effects is low.
Aromatase Inhibitors (letrozole, anastrozole)
Theoretically, at least, this class of drugs should work great in resolving gyno, but the research just hasn’t confirmed their efficacy yet.
It’s important to note, though, that none of these drugs will do very much if the gyno has advanced to the point where the tissues have become fibrotic. In that case, surgery may be the best option.
Surgical Treatment of Gyno
Surgeons have been tackling gynecomastia for a long time. We can trace the first description of surgical intervention to Paulus Aegineta back in 1538. Back then, it was likely the only treatment. Today, it’s the final option.
It’s usually reserved for patients with long-standing gyno who are experiencing psychological stress because of the social stigma involved.
Surgery isn’t recommended for gyno-plagued adolescents, though, as there’s always the risk that the tissue could grow back. Surgeons usually recommend waiting until the patient’s testes have reached adult size before agreeing to the surgical option.
I actually was allowed to witness one of these surgeries. What the doctor does is in effect a sub-Q mastectomy where they remove all the breast tissue through an incision while of course sparing the skin, areola, and nipple.
Any fibrotic tissue is, of course, removed too. (In the surgery I witnessed, removing this tissue reminded me of the rubbery, elastic gristle you sometimes pull out of a bad cut of steak with your teeth.)
Afterwards, the surgeon performs liposuction to remove any residual fatty tissue to ensure a smooth contour. While this surgery is minimally invasive and there are usually few complications, they do occur.
Problems like irregularity in the contour of the pec, hematomas, lasting numbness in the nipple and areolar areas, asymmetry between the two pecs, and even nipple necrosis or flattening are possible.
It should also be stated that up to 50% of the patients find the results cosmetically unsatisfactory, which points to the necessity of finding a surgeon who’s had plenty of experience with this type of surgery.
Barring complications, most patients can start training and living a normal life as soon as the incisions have healed.
Don’t Freak Out
If you ever find yourself afflicted with this condition, try to take some solace in the fact that the gyno is extremely common, no matter what your age, and that it’s your body’s way of telling you that your androgen to estrogen ratio is screwed up so you can take steps to remedy the situation.
It usually subsides on its own with a little help from a smart diet and exercise, but if that doesn’t work, you’ve got lots of outs.
- Marcy J. Balunas, Bin Su, […], and A. Douglas Kinghorn. “Natural Products as Aromatase Inhibitors,” Anticancer Agenets Med Chem, 2008, Aug. 8(6):646-682.
- Glenn Braunstein, Chairman1, James Klinenberg, Chair in Medicine2. “Environmental Gynecomastia,” Endocrine Practice: May 2008, Vol. 14, No. 4, pp. 409-411.
- Neslihan Cuhaci, Sefika Burcak Polat, Berna Evranos, Reyhan Ersoy, and Bekir Cakir. “Gynecomastia: Clinical evaluation and management,” Indian J Endocrinol Metab. 2014 Mar-Apr; 18(2): 150–158.
- Karin B. Michels, et al, “Urinary excretion of sex steroid hormone metabolites after consumption of cow milk: a randomized crossover intervention trial,” American Journal of Clinical Nutrition, Volume 109, Issue 2, February 2019.
- Niewoehner CB, Nuttal FQ. “Gynecomastia in a hospitalized male population.” Am J. Med., 1984 Oct;77(4):633-8.
- Frank Q. Nuttall. “Gynecomastia as a Physical Finding in Normal Men,” The Journal of Clinical Endocrinology & Metabolism, Volume 48, Issue 2, 1 February 1979, Pages 338–340.
- Ronald S. Swerdloff, MD; Chiu Ming Ng. “Gynecomastia: Etiology, Diagnosis, and Treatment,” NCBI Bookshelf, July 7, 2019.