An enlarged male chest is generally categorized into two distinct conditions: gynecomastia and pseudogynecomastia. True gynecomastia involves the growth of glandular breast tissue, while pseudogynecomastia, also called adipomastia, is solely the accumulation of fatty tissue. Understanding this difference is the first step toward determining the appropriate management.
Physical Differences Between Fatty Tissue and Glandular Growth
Pseudogynecomastia is characterized by soft, uniform fatty tissue distributed across the chest. This tissue feels pliable and does not form a distinct, dense mass beneath the nipple-areola complex. A self-examination involves pinching the tissue on both sides of the areola; if the tissue feels soft and your fingers meet without resistance from a firm core, it is likely fat.
True gynecomastia involves the proliferation of glandular and stromal tissue, which presents as a firm, rubbery, or dense mass. This growth is typically concentrated in a disc-like shape directly underneath the nipple and areola. When palpated, this firm disc can be felt distinct from the surrounding softer fat tissue. Glandular tissue may also be tender or painful, especially if the condition is of recent onset.
Hormonal and Medical Factors Driving True Gynecomastia
The primary cause of true gynecomastia is a hormonal imbalance, specifically an elevated ratio of estrogen to androgen (testosterone) activity. An increase in estrogen or a decrease in testosterone levels stimulates the growth of glandular tissue. This hormonal shift occurs naturally during the newborn period, adolescence, and in older age, particularly after age 50.
In adolescents, pubertal gynecomastia is often transient, resolving spontaneously in up to 90% of cases within one to three years. Beyond these natural life stages, gynecomastia can signal an underlying medical issue, such as liver disease, kidney failure, or thyroid disorders, which alter hormone metabolism. Certain medications are also known to induce glandular growth, including anti-androgens, specific cardiovascular or ulcer medications, and illicit substances like anabolic steroids and marijuana. Tumors of the testes, adrenal glands, or pituitary gland can also cause the condition by altering hormone balance.
The Clinical Diagnostic Process
Diagnosis begins with a thorough medical history, including the duration of the enlargement, any associated pain, and a detailed review of all medications and supplements. The physical examination involves careful palpation of the chest to differentiate the firm, subareolar glandular tissue from the softer, diffuse fatty tissue. The physician also examines the genitals and assesses secondary sex characteristics, looking for signs of hypogonadism or other systemic issues.
Immediate investigation is necessary for “red flag” symptoms, such as rapid, unilateral growth, a fixed or immobile mass, nipple discharge, or skin changes like dimpling. If glandular tissue is confirmed, blood tests are often ordered to check hormone levels (testosterone, estradiol, luteinizing hormone, and prolactin), along with liver and kidney function tests. Imaging, such as an ultrasound or mammogram, may be used if the mass is indeterminate or if malignancy is suspected.
Management and Treatment Options
For pseudogynecomastia, which is solely fat accumulation, the first line of treatment involves lifestyle modifications. A combination of diet modification and exercise is recommended to achieve overall weight loss, which can reduce the size of the chest fat deposits. If men achieve their goal weight but still have stubborn, localized fat, liposuction is an effective surgical option. This procedure removes the excess adipose tissue to create a flatter chest contour.
For true gynecomastia, treatment starts with addressing any underlying medical cause or stopping a causative medication. Pubertal gynecomastia often resolves spontaneously over time, making observation common. If the glandular growth is painful or persistent, medications like selective estrogen receptor modulators (SERMs), such as tamoxifen, may be prescribed. SERMs block the effect of estrogen on the breast tissue, with reported success rates of partial to complete resolution in up to 80% of patients. If the condition is long-standing, severe, or unresponsive to medication, surgical intervention is the most definitive treatment. This typically involves surgical excision to remove the firm glandular tissue, often combined with liposuction for the surrounding fat, achieving a contoured and lasting result.