Different Grades of Gynaecomastia Explained

Quick Summary

Gynaecomastia can look different from one man to another. For some, it may be a small lump underneath the nipple. For others, the chest may become much larger, with loose or sagging skin.

This is why gynaecomastia is divided into different grades. Knowing your grade can help you understand how severe it is, whether it may go away on its own, and which treatments may be suitable for you.

 

What Is Gynaecomastia?

Gynaecomastia is the enlargement of breast tissue in males. It is usually linked to a change in the balance between oestrogen and testosterone.

It is also important to know what differentiates true gynaecomastia and pseudogynaecomastia.

True gynaecomastia develops firm glandular tissue under the nipple. pseudogynaecomastia, sometimes called “fake gynaecomastia” is caused by excess fat around the chest.

This difference is important to understand because the two conditions can need different approaches. Losing weight or having liposuction may help with excess chest fat, while firm glandular tissue may need to be surgically removed.

Related read: Gynaecomastia London

 

Why Do Grades Matter?

The grade is not just a label. It can give you and your clinician a better idea of what treatment may be needed.

For example, mild gynaecomastia may only need monitoring, especially in teenagers. More severe cases with loose skin are more likely to need surgery.

Knowing the grade also helps the surgeon decide how much tissue needs to be removed, whether the skin may tighten naturally and how complex the treatment may need to be.

 

The Different Grades of Gynaecomastia

Simon classification

The Simon Classification is one of the main systems used to describe gynaecomastia. It looks at the amount of breast enlargement and whether there is excess skin.

Grade	What It Looks Like	Excess Skin
Grade I	A small, firm area under the nipple	None
Grade IIa	Moderate breast enlargement	None
Grade IIb	Moderate enlargement with some early loose skin	Mild
Grade III	Larger breasts with more noticeable breast shape	Significant loose or sagging skin

The exact grading can vary between systems, but the basic idea is the same. The higher the grade, the more breast tissue and excess skin tends to be.

 

Rohrich classification

The Rohrich classification also looks at which causes the chest enlargement, such as the glandular tissue or fat, as well as how much the skin is sagging.

 

Beldholm 2024 classification

Dr. Bernard Beldholm’s 2024 system is a newer approach based on this surgical experience. It looks at several factors to give a more detailed picture of the condition.

It:

• Covers both true and pseudogynaecomastia recognising that both can affect confidence.
• Considers skin sagging, which can help guide treatment.
• Looks at the amount of fat and glandular tissue in the chest.
• Links each grade to possible treatments to help surgeons plan the most suitable approach.

 

Types of Gynaecomastia

Gynaecomastia can develop for different reasons. Some cases are a normal part of hormonal changes, while others may be linked to a health condition or extra body fat.

 

 

Physiological gynaecomastia

This is the normal type of gynaecomastia caused by changes in hormone levels. It can happen at different stages of life.

• Puberty: it can affect up to two-thirds of boys and usually goes away on its own within 6 to 24 months.
• Ageing: as men get older, testosterone levels can drop, while the effect of oestrogen may become stronger.

 

Pathological gynaecomastia

This type is linked to an underlying health problem that affects hormone levels or how the body processes them.

Possible causes include:

• Hormonal conditions (low testosterone or hypogonadism, an overactive thyroid, a certain hormone producing tumours)
• Long-term health conditions (liver disease, kidney failure, severe malnutrition)
• Genetic conditions (Klinefelter syndrome)

 

Pseudogynaecomastia

It is sometimes called fake gynaecomastia. It is caused by extra fat around the chest rather than an increase in breast gland tissue. It is more common in men who are overweight or obese.

Related read: What Is Gynaecomastia in Men? Causes & Treatment

 

What Causes Gynaecomastia?

In many cases, gynaecomastia develops because of a change in the balance between oestrogen and testosterone. This can happen naturally at different stages of life, but certain medicines, health conditions and substances can also play a role.

 

Hormonal changes

Gynaecomastia can develop when oestrogen increases and testosterone levels drop. This is why it is commonly seen during puberty and later in life.

 

Medicines and substances

Substances like anabolic steroids, cannabis and excessive alcohol can also be linked with breast enlargement.

 

Other health conditions

Gynaecomastia can be linked with health problems affecting hormones. These include:

• Liver disease
• Thyroid disorders
• Kidney disease
• Obesity
• Conditions that affect testosterone production

Related read: What Causes Gynaecomastia? Hormones, Drugs & Risks

 

What Does Gynaecomastia Feel Like?

The symptoms can vary, but you may notice:

• A firm rubbery area underneath the nipple
• Enlargement on one or both sides
• Tenderness or discomfort especially when the condition first develops
• One side looking larger than the other

 

Gynaecomastia During Puberty

Pubertal gynaecomastia develops between the ages of 10 and 14 as hormone levels change. In many cases, it settles naturally within 6 to 24 months.

But if it continues for a long time, the tissue can become more fibrous and less likely to respond to medication.

You should seek medical advice if enlargement persists and if you notice:

• A hard, irregular or fixed lump
• Nipple discharge
• Skin changes
• Rapid breast enlargement
• Breast enlargement before puberty

 

Treatment Options by Grade

Treatment depends on your grade, how long you have had the condition, the amount of glandular tissue and fat, your skin quality and what you want to achieve.

Grade	What It Means	Possible Treatment Options
Grade I	Small amounts of breast tissue usually with little or no excess skin.	Observation, especially during puberty. Weight loss and lifestyle changes if needed. Reducing alcohol Stopping anabolic steroids or cannabis. Medication (tamoxifen) may be considered in some cases.
Grade II	More noticeable breast enlargement, often caused by a mix of fat and glandular tissue. Some skin looseness may also be present.	Liposuction can remove excess fat. Gland excision may be needed if there is firm glandular tissue. For grade IIb, combination of liposuction and gland excision may be recommended.
Grade III	Larger amounts of breast tissue with significant loose or drooping skin.	Gland excision Liposuction Excess skin removal Chest reshaping Nipple repositioning for severe cases

Related read: Tamoxifen for Gynaecomastia: Benefits, Risks & Results

 

Surgery vs Non-Surgical Treatment

Surgery is more likely to be considered when the condition has been present for a long time, there is significant excess skin, and medical treatment has not worked or the condition is having a major effect on your quality of life.

Non-surgical options also have their limits.

• Weight loss: can reduce excess fat but it would not remove firm glandular tissue.
• Medication: more likely to help during the early stages of gynaecomastia. But once the tissue becomes firm and fibrous, medication is less likely to make a significant difference.
• Compression garments can make the chest look flatter while you are wearing them, but they do not treat the underlying tissue.

 

How Is the Right Treatment Chosen?

Your treatment plan will usually depend on three main things:

• Your grade: higher grades may need more involved surgery
• Skin elasticity: loose skin may need to be removed
• Your goals: helps guide the surgical technique

 

Conclusion

Gynaecomastia is common and treatable, and there is no need to feel embarrassed about asking for help.

Getting assessed earlier can be useful because there may be more treatment options while the condition is still developing. Once the tissue becomes more fibrous or excess skin develops, treatment can become more complex.

Early treatment may also help reduce the impact gynaecomastia can have on your confidence and quality of life.

If you are concerned about changes to your chest, your first step can be speaking to your GP. They can assess what is causing the enlargement, check for any underlying medical conditions and recommend if you need further assessment by a specialist.

 

FAQs

• What are the grades of gynaecomastia?

The Simon classification has Grades I as mild, II as moderate, and III involves more breast tissue and loose, sagging skin.

• Can gynaecomastia go away on its own?

Yes, especially during puberty. It often settles within 6 to 24 months. But long-term gynaecomastia is less likely to go away without proper treatment.

• Which grade needs surgery?

Grade IIb and Grade III are more likely to need surgery, especially when there is loose skin or firm breast tissue present.

• Is gynaecomastia caused by hormones?

In some cases, yes. It can happen when the balance between oestrogen and testosterone changes. This can happen during puberty and ageing, or because of certain medications, health conditions or substance use.