Gynecomastia

Introduction

[PRAVIN TODO: text needed]

Common Facts

[PRAVIN TODO: text needed]

Historical Perspectives on Gynecomastia

The male chest has historically been linked to qualities of masculinity, virility, and strength. The following is a perspective on the condition of gynecomastia which has been recognized since antiquity. It is included in our website as a matter of interest and to illustrate that men have grappled with this condition for millennia.

“We make men without chests and expect of them virtue and enterprise.” CS Lewis

The quote by CS Lewis in the Abolition of Man Published in 1943 illustrates the cultural importance of a masculine chest. Although I find CS Lewis’ metaphor to be unfair, I would grant that he was probably referencing what is within the chest as opposed to mere appearances.

The earliest descriptions of gynecomastia date back to Aristotle (circa 350 BCE).  The condition is vividly depicted in Egyptian art such as statues of Thutmose IV. The term gynecomastia (gynos: female + mastia: breast)  was first used by Claudius Galenus in the 2nd century who described it as a fatty accumulation on the chest.

It appears that the condition was viewed even by the ancients as problematic and the first attempts at treatment were described centuries later by Paulus of Aegina in the 7th century. Paulus of Aegina actually described the earliest attempts at surgical correction in works titled the Epitome of Medicine. Greek treatises were the foundation of knowledge later refined by Islamic scholars during the Golden Age of Islam. The Islamic physician Al-Zahrawi, considered by some to be the Father of Surgery, described several surgical techniques in Al-Tasrif published around the 11th-century.

“The breast of some males may swell on attaining puberty so as to resemble the female breast, and they remain permanently swollen and ugly. If this is abhorrent, a semicircular incision should be made on the breast like the figure (referencing the illustration in the text), then dissect away all the fatty tissue and pack the wound with a cicatrizing compound and sew the lips together and dress until healed.” From Kitab-Al-Tasrif circa 1000 CE.

Further descriptions of surgical corrections followed by Renaissance surgeons in the 16th-century after which little progress was made until the 20th-century.

In the 1920s, surgical techniques involved complete excision of the chest skin, glandular tissue, and the nipple-areola complex. It was argued that since the nipple-areola complex had no function in males, it should be removed as part of the treatment of gynecomastia. Perhaps due to unsatisfactory results, there was a reluctance to treat gynecomastia at all. In the 1940s, Bernard Simon conducted studies on gynecomastia in the enlisted personnel of the US Navy. He identified that embarrassment of the condition was present in over 60% of sailors with gynecomastia and additionally noted the presence of anxiety and depression due to the condition. Simon pioneered the intr-areolar incision and approach to gland removal. He later went on to describe his eponymous classification system still in use today.

The physiology basis and psychosocial aspects of gynecomastia have been well studied in the 20th-century and surgical correction is now widely accepted.

Psychosocial Impacts of Gynecomastia

In the course of interviewing hundreds of patients, I have noted that insecurity in personal appearance and reluctance to engage in personal relationships are probably the most prevalent concerns.

It has been well established by academic review that gynecomastia has adverse psychosocial impacts on young men aged 12 to 22 years. Some of these adverse effects include anxiety, depression, social appearance anxiety, increased likelihood of teasing, and attacks on personal property (Isik et al, 2025). The earliest study of gynecomastia and its adverse effects was conducted by the US Navy in the 1930s and 63% of subjects reported “embarrassment” as the primary concern (Simon 1973). A separate literature review identified depression, anxiety, low self esteem , and eating disorders as common problems associated with men with gynecomastia (Oretaz et al, 2022). Successful treatment of gynecomastia has been noted to result in improved self esteem and seven separate Quality of Life (QoLs) metrics (McNamara et al, 2022). Interestingly, one review noted improved academic performance after successful treatment of gynecomastia (Isik et al, 2025).

Based on numerous personal interviews and observations of patients who have undergone treatment of gynecomastia, I have noted that correction of gynecomastia is not simply a cosmetic procedure but a surgery that confers numerous psychosocial benefits on the patients. Therefore, it is not simply a vanity concern or procedure.

Grading of the Severity of Gynecomastia

Simon’s Classification (1973)

Simon, B.E., Hoffman, S. and Kahan, S., 1973. Classification and surgical correction of gynecomastia. Plastic and reconstructive surgery, 51(1), pp.48-52.

Video: Simon’s Classification

Alternate grading systems of gynecomastia

Rohrich Classification (2003)

*Ptosis of the chest is graded using the Rignault system. Ptosis of gynecomastia is one criteria used in the Rohrich classification system.

Rohrich classification and management of gynecomastia: Defining the role of ultrasound-assisted liposuction. Plastic and Reconstructive Surgery. 2003 Feb;111(2):909-23; discussion 924-5.

The most commonly used method to grade the severity of gynecomastia is the Simon’s classification. I find the Simon’s classification to be the most practical as it is not possible to determine the mass of the gland in grams – as required by the Rohrich system. Furthermore, it is easier to convey Simon’s grades during the consultation and to match the severity to the appropriate treatment. The disadvantage of the Simon’s system is that it is difficult to customize and some patients do not neatly fit into the different grades.

Definition

Gynecomastia is defined as the benign (non-cancerous) enlargement of male breast tissue due to the proliferation of glandular tissue, ducts, stroma, or fat.

Johnson RE, Murad MH. Mayo Clin Proc. Gynecomastia: Pathophysiology, Evaluation, and Management. 2009 Nov;84(11):1010–1015.

Pseudogynecomastia

Pseudogynecomastia aka adipomastia or lipomastia is simply an accumulation of adipose tissue on the chest and has no glandular component. It is usually associated with obesity.

Physiologic gynecomastia (normal development) vs Pathologic gynecomastia (a disease condition)

Physiologic Gynecomastia is a benign proliferation of breast tissue that normally occurs during pubescence. It is a condition and not a disease and therefore its treatment is elective. Generally, gynecomastia that has been present for greater than 12-months and stable does not require further evaluation.

Pathologic Gynecomastia, on the other hand, is related to an underlying disease condition such as male breast cancer, testicular tumors, liver disease, or hormone secreting tumors. Additionally, pathologic gynecomastia may be related to medication use. Pathologic gynecomastia requires a different evaluation from physiologic gynecomastia involving a multidisciplinary team. One should consider the diagnosis of pathologic gynecomastia if gynecomastia develops rapidly; is associated with other symptoms; or there is a strong family history of breast cancer.

In addition to a thorough history and physical exam, diagnostic studies for the evaluation of pathologic gynecomastia may include laboratory investigations. These laboratory studies may include the following: testosterone (T), estradiol (E2), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), follicular stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactin, human chorionic gonadotropin (hCG), alpha-fetal protein (AFP), liver and renal function tests (Kanakis et al. EAA Clinical Practice Guidelines –Gynecomastia Evaluation and Management. Andrology. 2019 Nov;7(6):778-793).