European Journal of Cardiovascular Medicine

Gynaecomastia is defined as the benign proliferation of glandular breast tissue in males, resulting from an imbalance between estrogenic stimulation and androgenic inhibition at the breast tissue level [1]. Clinically, it presents as a palpable, firm, concentric mass beneath the nipple–areolar complex and must be distinguished from pseudo gynaecomastia, which represents adipose tissue deposition without true glandular proliferation. The condition demonstrates a classical trimodal age distribution, occurring in neonatal, pubertal, and elderly populations due to physiological hormonal fluctuations [1].

Globally, pubertal gynaecomastia is the most common form, affecting up to 60–70% of adolescent boys, with spontaneous regression in the majority within 1–2 years [2]. However, persistent or progressive cases warrant further evaluation to exclude pathological causes such as endocrine disorders, systemic illnesses, or drug-induced etiologies. Common pharmacological agents implicated include spironolactone, cimetidine, and anabolic-androgenic steroids (AAS) [3].

In the Indian context, the clinical profile of gynaecomastia is influenced by unique sociocultural and lifestyle factors. Increasing urbanisation, dietary transitions, rising obesity, and widespread use of unregulated gym supplements have contributed to changing patterns of presentation [3]. Additionally, social stigma and embarrassment often lead to delayed healthcare seeking, particularly among adolescents and young adults, thereby increasing the likelihood of fibrotic disease at presentation.

Given the limited Indian data on comprehensive clinical profiling and treatment outcomes, this study aims to evaluate the demographic characteristics, etiological spectrum, and effectiveness of various management modalities in patients presenting with gynaecomastia at a tertiary care centre.

Study Design and Setting - A hospital-based cross-sectional study conducted over 24 months in a tertiary care centre in Bangalore Study Population-100 male patients presenting with breast enlargement were included during the study period Inclusion Criteria -Males with clinically or ultrasonographically confirmed glandular enlargement Exclusion Criteria • Lipomastia • Suspected malignancy • Non-consenting individuals Data Collection tools- • Clinical history: duration, pain, drug intake, lifestyle • Physical examination: Simon’s grading • Laboratory tests: Testosterone, Estradiol, LH, FSH, Prolactin (selected cases) Management Protocol • Observation • Pharmacotherapy (Tamoxifen 10–20 mg/day) • Surgery (Liposuction + Subcutaneous mastectomy) Statistical Analysis Data were analysed using descriptive statistics. Results are presented as percentages and proportions.

A total of 100 male patients with clinically confirmed gynaecomastia were included in the study. Statistical analysis was performed using chi-square tests to assess associations between categorical variables. A p-value of <0.05 was considered statistically significant.

Demographic Profile

The study population showed a predominance of younger individuals, with adolescents          (13–20 years) constituting the largest group (52%), followed by young adults (21–40 years) at 34%. The association between age group and type of presentation (physiological vs pathological) was statistically significant (χ² = 9.82, p = 0.02), indicating higher physiological cases in adolescents.

Table 1: Age Distribution of the study population

Clinical Presentation

Bilateral breast enlargement was the most common presentation, observed in 68% of patients, while 32% had unilateral involvement. Among unilateral cases, a slight predominance of left-sided involvement was noted. The majority of patients (70%) were asymptomatic and presented primarily due to cosmetic concerns, whereas 30% reported mastalgia or tenderness, particularly in the early (florid) phase of the disease.

No statistically significant association was observed between laterality and symptom presence (χ² = 1.12, p = 0.28). However, mastalgia was significantly more common in early-stage disease (Grade I/IIa) compared to advanced stages (χ² = 6.45, p = 0.01).

Table 2: Clinical Characteristics

Severity Grading

Grade IIa gynaecomastia was the most common (42%), followed by Grade I 30%) and Grade IIb (21%). Advanced disease (Grade III) was observed in 7% of cases. A statistically significant association was found between duration of symptoms (>12 months) and higher grades               (χ² = 11.36, p = 0.01).

Etiological Profile

Idiopathic gynaecomastia constituted the majority (62%), followed by physiological pubertal cases (22%). Drug-induced gynaecomastia, primarily associated with anabolic steroid or supplement use, accounted for 8% of cases. Systemic illnesses such as chronic liver disease and chronic kidney disease contributed to 5%, while endocrine disorders (e.g., hypogonadism, hyperprolactinemia) were identified in 3% of patients.

Table 3: Simon’s Grading

A significant association was noted between anabolic steroid use and occurrence in the 21–40 age group (χ² = 7.21, p = 0.02).

Table 4: Etiology

Treatment Outcomes

Management strategies varied based on disease stage and patient preference. Conservative management (observation) was employed in 25% of patients, mainly adolescents with early-stage disease, of whom 72% showed spontaneous regression during follow-up. Pharmacological therapy using tamoxifen was administered in 15% of patients, particularly those with pain and early disease; it was effective in relieving mastalgia but showed limited efficacy in reducing established glandular tissue. Surgical management was the most commonly employed modality (60%), especially in patients with long-standing or higher-grade disease. The combined approach of liposuction and subcutaneous mastectomy yielded excellent cosmetic results, with 92% of patients reporting high satisfaction at follow-up.

Tamoxifen showed significant relief in mastalgia (p = 0.01), but not in reduction of gland size (p = 0.18). Surgical management demonstrated the highest satisfaction rate (92%), which was statistically significant when compared to non-surgical methods (χ² = 14.52, p < 0.001).

Table 5: Treatment Outcomes

Overall, statistically significant associations were observed between age and etiology, duration and severity, and treatment modality with patient satisfaction, reinforcing the importance of stage-based management in gynaecomastia.

Figure 1   Patient treated by Observation (Grade 1 Bilateral)

BEFORE                                                                                     AFTER

Figure 2  Patient treated by Surgery (Grade 3 , Bilateral)

BEFORE                                                                                     AFTER

Figure 3 Patient treated by Surgery (Grade 2 A , Unilateral )

BEFORE                                                                                     AFTER

This study provides a comprehensive overview of the clinical profile and management outcomes of gynaecomastia in an Indian tertiary care setting. The findings demonstrate a clear predominance among adolescents (52%) and young adults (34%), supporting the well-established trimodal age distribution described in global literature, with a notable skew toward younger populations in India [1,4]. Unlike Western studies, where senile gynaecomastia constitutes a significant proportion, our data indicate that sociocultural factors and delayed healthcare-seeking behaviour contribute to a higher burden in younger age groups. [5,6]

The predominance of idiopathic cases (62%) in our cohort is consistent with previous Indian and international studies [7,8,9]. However, it is important to recognise that “idiopathic” often reflects limitations in identifying subtle endocrine or environmental contributors. Increasing exposure to endocrine-disrupting chemicals and dietary phytoestrogens may play a role, although these factors remain underexplored in Indian populations. Additionally, 22% of cases were attributed to pubertal gynaecomastia, which aligns with physiological hormonal fluctuations characterised by transient estrogen predominance during adolescence [1].

A key emerging trend observed in this study is the contribution of drug-induced gynaecomastia (8%), particularly associated with anabolic-androgenic steroid (AAS) use and unregulated nutritional supplements. Similar observations have been reported in recent surgical and endocrine literature, highlighting the role of exogenous androgens that undergo peripheral aromatization to estrogens [10,11]. This is especially relevant in urban India, where increasing gym culture and easy access to over-the-counter supplements have created a new at-risk population. Clinicians must therefore maintain a high index of suspicion and obtain a detailed drug history in young, muscular individuals presenting with rapid-onset breast enlargement.

Clinically, bilateral involvement (68%) and predominance of Grade I and II disease reflect early-stage presentation in a majority of patients. However, despite relatively low grades, psychosocial distress was disproportionately high, particularly among adolescents. Previous studies have emphasized the psychological burden of gynaecomastia, including reduced self-esteem, social withdrawal, and body image dissatisfaction [6]. In the Indian sociocultural context, stigma associated with feminization of the male chest further amplifies this distress, often delaying presentation until symptoms interfere with social or professional milestones such as marriage or employment.

The distinction between florid and fibrotic phases is crucial in determining therapeutic outcomes. In the florid phase, characterized by ductal epithelial proliferation and stromal edema, medical therapy such as tamoxifen has demonstrated efficacy in reducing pain and halting progression [11,12]. Our findings corroborate this, with significant relief of mastalgia observed; however, reduction in gland size was limited once fibrosis had set in. This underscores the importance of early diagnosis and timely initiation of pharmacotherapy in selected patients.

Surgical management emerged as the most definitive and satisfactory treatment modality, with 92% patient satisfaction. The combined approach of liposuction and subcutaneous mastectomy has become the gold standard, offering superior cosmetic outcomes compared to traditional excision alone [12]. Liposuction allows for contouring of the chest wall and removal of adipose tissue, while direct excision addresses dense glandular components. This dual technique minimises complications such as contour irregularities and “saucer deformity,” which were more common with older methods. Grade III cases requiring skin excision highlight the need for individualised surgical planning based on severity and skin redundancy.

An important consideration in the Indian setting is the perception of gynaecomastia surgery as a purely cosmetic procedure. Our findings challenge this notion, demonstrating significant psychological benefits post-surgery, including improved self-confidence and social functioning. This aligns with emerging perspectives that classify such interventions as reconstructive rather than cosmetic, particularly when psychosocial morbidity is substantial.

The study has certain limitations. Being a single-center study with a relatively small sample size, the findings may not be generalizable to the broader population. Hormonal evaluation was not performed in all patients, potentially underestimating endocrine causes. Additionally, long-term follow-up data on recurrence and sustained patient satisfaction were limited.

Future research should focus on multicentric studies with larger cohorts, evaluation of environmental and dietary risk factors, and long-term outcomes of different treatment modalities. Regulatory oversight of nutritional supplements and increased public awareness are also essential to address preventable causes of gynaecomastia in India.

Gynaecomastia in Indian males predominantly affects adolescents and young adults, with the majority of cases being idiopathic or physiological in origin. The condition often presents late due to sociocultural stigma, leading to progression from the florid to the fibrotic stage, which limits the effectiveness of medical therapy. Early identification and appropriate classification are essential for optimal management. Observation remains suitable for transient pubertal cases, while pharmacotherapy with selective estrogen receptor modulators is beneficial in early symptomatic stages. However, surgical intervention—particularly the combination of liposuction and subcutaneous mastectomy—offers the most definitive and satisfactory outcomes in long-standing or high-grade disease. Importantly, the psychosocial burden associated with gynaecomastia warrants equal attention, and management should incorporate psychological support alongside physical treatment. Future strategies should emphasize early awareness, regulation of exogenous risk factors such as anabolic supplements, and multicentric research to better understand the evolving epidemiology in the Indian population.

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