TYPES, GRADES AND STAGES OF GYNECOMASTIA
Gynecomastia is the medical word used to describe abnormal enlargement of the male breast. In most men for most of their life, higher levels of testosterone and lower levels of estrogen mean that breast tissue stays small and unnoticeable. If anything causes the balance of hormones to change, the male breast tissue will respond (just as in women) and grow. Gynecomastia is very common at certain stages in life, and up to 70% of teenagers have some degree of gynecomastia during puberty. This is because the huge hormonal changes can mean that for a while estrogen levels are relatively high, and this causes the breast tissue to grow. Some other common causes of gynecomastia are listed below:
- Hormone level changes during puberty or older age
- Side-effects of prescribed medicines including ulcer treatments and some anti-depressants
- Recreational drugs including steroids (for bodybuilding) and marijuana
- Liver or kidney disease
- Rare genetic conditions
- Tumours which produce hormones
Gynecomastia is also much more common in overweight or obese men. Most men need no other treatment than weight loss, exercise, time and possibly a change of medication.
Different types of gynecomastia
There are several different ways of discussing different gynecomastia types: it may be one- or two-sided, true or pseudogynecomastia, and the swelling can range in size.
Gynecomastia usually affects both sides, but one-sided or unilateral gynecomastia can occur. It is common for one side to start growing before the other, and for one side to be slightly larger than the other.
True gynecomastia – where the breast tissue is enlarged – is also different from pseudogynecomastia. Pseudogynecomastia is the condition where a man appears to have breast tissue, or man boobs, but the swelling is caused entirely by fatty tissue. The breast itself remains the normal size. This is much more common in men who are overweight or obese.
Naturally, gynecomastia does not simply appear overnight, and different stages of gynecomastia can therefore be seen as the breast tissue grows. For bilateral true gynecomastia, the American College of Plastic Surgeons has defined 4 different grades of gynecomastia. These are important as they allow doctors to communicate with each other and document the growth or progression of the gynecomastia. However, gynecomastia type or grade does not always match up with how concerned a man may be about his man boobs. Grade one is described as mild, but some men may find even this degree of gynecomastia extremely embarrassing or distressing. Conversely, other men may find they can live quite happily with gynecomastia described as stage three or four.
- Grade One – Mild enlargement of the breast bud concentrated behind the areola
- Grade Two – Breast growth spreading beyond the areola with edges that blend with the chest wall
- Grade Three – Breast growth spreading beyond the areola, with clear edges and redundant skin
- Grade Four – Marked breast enlargement with redundant skin and feminisation of the breast
In these descriptions, the areola is the area that is pink in colour including and surrounding the nipple.
When thinking about the different stages or types of gynecomastia, grade one is the first that men will notice. It may be preceded by some itching around the nipple area, or ‘jutting out’ of the nipple, but this is the first noticeable change most men see. Grade one gynecomastia can be felt as a firm or rubbery nodule behind the nipple. This does not spread beyond the edges of the pink ‘areola’ on the chest wall. It is usually found on both sides, and there may be some discomfort, but is not usually acutely painful. Many men may be happy to live with this degree of gynecomastia, although for some it may be very distressing. If the cause of breast enlargement continues, the gynecomastia may progress through to other grades, although for some men grade one is as large as the swelling becomes. Doctors may be reluctant to consider treatment for grade one gynecomastia and simply suggest diet and exercise if this is needed. Many surgeons would advise against surgery as the swelling is small so the possible benefits are limited.
Grade two describes where the breast tissue continues to grow and spreads beyond the pink areola. The swelling on the chest wall will become more noticeable. The edges of the gynecomastia remain indistinct, blending in with the rest of the chest wall. This grade is described as anywhere between mild and severe depending on the amount of growth. Treatment may be possible for this grade of swelling. Each man’s gynecomastia is different, and it’s important to discuss the best options with a doctor or surgeon who is experienced in treating the condition.
Grade three describes gynecomastia which is more obvious. Here the edges of the breast become clear, with a distinct ‘angle’ in the skin at the start of the breast enlargement. In addition, in grade three there will be some redundant skin. This means that if the man chooses to have surgery to get rid of his gynecomastia, he may need to have this skin removed to provide the best cosmetic outcome. This makes the operation a longer and more technical procedure, but may provide the best long-term results.
Grade four is the highest grade of gynecomastia. Here, as well as all the features described above, the breast is ‘markedly’ enlarged and there is feminisation of the breast. This may mean that the breast starts to ‘sag’ or that there are changes to the nipple making it appear more female. Surgery for this grade of gynecomastia will almost always involve removal of some redundant skin to achieve good aesthetic results. Treatments other than surgery are unlikely to provide a good result with this amount of breast enlargement.
It is important to realise that not all gynecomastia continues to grow. We don’t really understand why some men will develop larger man boobs than others – in the same way as we don’t really understand why some women have larger breasts than others. A man who has just noticed grade one gynecomastia should remember that for some men this is as large as their boobs get. Only a very few men are unfortunate enough for their breasts to grow as big as grade four. However, any grade or stage of gynecomastia can be embarrassing and upsetting. If a man is worried about gynecomastia, he should go and talk to a doctor to discuss any possible causes, rule out serious conditions and possibly think about treatment to help get rid of the problem.