Diagnosis
The treatment for gynecomastia is guided by the grade of gynecomastia and the patients’s desired outcome. Most plastic surgeons in Canada use either the Webster or Simon classification system.
The Webster classification system divides gynecomastia into three englarement grades:
Grade I
Small enlargement of the gland without excess skin
Grade II
Moderate enlargement of the gland without excess skin
Grade III
Marked enlargement of the gland with excess skin
The Simon classification system divides into Grade 1 -3 with Grade 2 being a little more in depth.
Grade I
Small enlargement of the gland without excess skin
Grade II
a) Moderate enlargement of the gland, no excess skin
b) Moderate enlargement of the gland, some excess skin
Grade III
Marked enlargement of the gland with excess skin
Beginning The Journey
When we assess a patient with gynecomastia, a comprehensive medical history and physical examination will be performed. The following aspects of the patient’s medical history are what we commonly consider:
1
Personal History: We will inquire about your age, gender, and any noticeable changes in glandular tissue size and shape. We will also ask about the duration of gynecomastia symptoms and whether the condition is stable, worsening, or improving over time.
2
Symptoms: Any associated symptoms, such as breast tenderness, pain, discharge from the nipples, or changes in nipple appearance.
3
Medications: Any current medications, including prescription drugs, over-the-counter medications, and herbal supplements. Some medications can contribute to gynecomastia as a side effect or by altering hormone levels. It is important to provide a complete list of all medications being taken.
4
Substance Use: Any use of substances known to be associated with gynecomastia, such as anabolic steroids, marijuana, alcohol, or illicit drugs.
5
Family History: Any family history of gynecomastia or other conditions that could be related, such as breast cancer.
6
Psychological Impact: Any psychological distress or impact on self-esteem caused by gynecomastia.
Following the history, a physical examination will be performed. The examination typically involves the following steps:
7
Visual Inspection: Looking for any visible enlargement or swelling of the glandular tissue, noting the size, symmetry, and contour of the chest. This includes with and without a T Shirt on. The skin is also evaluated for judging it’s quality, amount and changes, such as redness or dimpling.
8
Palpation: Feeling for the amount, density and location of glandular tissue versus fat.
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Nipple Evaluation: The nipples and areolas are assessed for any changes in size, shape, or color.
Finally, some cases require a Testicular Examination. Since certain hormonal disorders can cause gynecomastia, if we suspect this may be a case that is pathological in origin, we may perform a testicular examination to assess the size, consistency, and any tenderness or masses in the testicles. This is infrequently performed since most cases are physiologic in nature.
In general, a complete history and physical is enough to work up a patient who presents to us. Should we suspect non physiologic cause, we may order further investigations, such as blood tests, hormone level assessments, imaging studies (e.g., ultrasound, mammogram), or a biopsy, to determine the underlying cause or rule out any other potential conditions.