Gynecomastia overview: Difference between revisions
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{{Gynecomastia}} | {{Gynecomastia}} | ||
{{CMG}}; {{AE}} | {{CMG}}; {{AE}} {{HS}} | ||
==Overview== | ==Overview== | ||
Gynecomastia is a benign male breast enlargement. Gynecomastia occurs due to increase [[estrogen]] to [[androgen]] ratio. Increased [[estrogen]] to [[androgen]] ratio can be [[physiological]], such as seen during [[infancy]], [[puberty]] and old age or [[Pathological|pathologica]]<nowiki/>l, which is due to [[obesity]], [[steroid]] use, [[pharmacologic]] agents, medical conditions including chronic liver and [[renal]] failure or [[Hypogonadism|hypogonadism.]] However, most cases of the [[gynecomastia]] are [[idiopathic]] and [[asymptomatic]]. The diagnosis is primarily clinical. Other modalities used to diagnose [[gynecomastia]] include laboratory investigations such as blood [[hormone]] levels, [[renal function tests]] and [[liver function tests]] and imaging such as [[ultrasound]] or [[mammography]]. The treatment is usually supportive. [[Anti-estrogen therapy|Antiestrogens]] and surgical intervention can be considered in certain cases depending on physician and patient preference. | |||
==Historical Perspective== | ==Historical Perspective== | ||
Gynecomastia is derived from Greek words | Gynecomastia is derived from Greek words, gyne which means woman and mastos which means breast. The term was originally coined by Galen, a Greek [[physician]]. Gynecomastia has been a known concept since the days of Aristotle (384–322 BC). The surgical management was initially discussed by Paulus, a Greek physician and later modified by Al-Zahrawi or Albucasis, an Andalusian surgeon. | ||
==Classification== | ==Classification== | ||
Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology | Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and [[etiology]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
The main [[pathophysiology]] behind gynecomastia is | The main [[pathophysiology]] behind [[gynecomastia]] is increased [[estrogen]] to [[androgen]] ratio which can occur through multiple mechanisms. These mechanisms can be [[physiological]], [[pathological]] or [[medications|pharmacological]]. | ||
==Causes== | ==Causes== | ||
Common known causes of gynecomastia include [[physiological]], use of [[medications]] and [[Pathological|pathologica]]<nowiki/>l | Common known causes of [[gynecomastia]] include [[physiological]] hormonal changes, use of [[medications]] and [[Pathological|pathologica]]<nowiki/>l entities such as [[cirrhosis]], [[hyperthyroidism]], [[Testicular tumor|testicular tumors]] and [[hypogonadism]]. Less common causes include [[androgen insensitivity syndrome]], [[Kallmann syndrome]], defects of [[testosterone]] pathway and tumors. | ||
==Differentiating gynecomastia from other diseases== | ==Differentiating gynecomastia from other diseases== | ||
Gynecomastia must be differentiated from pseudo gynecomastia | [[Gynecomastia]] must be differentiated from other diseases that cause [[breast]] enlargement in men. These diseases include pseudo [[gynecomastia]], [[Breast cancer|breast cancer]], [[breast abscess]], and [[lipoma]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Gynecomastia has the highest [[prevalence]] in elderly and [[neonatal]] age. Gynecomastia has trimodal age distribution with no racial preference. | Gynecomastia has the highest [[prevalence]] in elderly and [[neonatal]] age. [[Gynecomastia]] has trimodal age distribution with no racial preference. | ||
==Risk Factors== | ==Risk Factors== | ||
Common risk factors in the development of gynecomastia include the use of [[medications]], [[cirrhosis]], and [[hyperthyroidism]]. The less common risk factors include [[aromatase]] overexpression, [[androgen insensitivity syndrome]] and [[testosterone]] pathway defects. | Common risk factors in the development of gynecomastia include the use of [[medications]], [[cirrhosis]], and [[hyperthyroidism]]. The less common risk factors include [[aromatase]] overexpression, [[androgen insensitivity syndrome]] and [[testosterone]] pathway defects. | ||
==Screening== | ==Screening== | ||
There is insufficient evidence to recommend routine screening for [[gynecomastia]]. | |||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
If left untreated patients with gynecomastia may progress to develop [[Psychological stress|psychosocial stresses]] and rarely [[breast cancer]]. The majority of [[physiological]] gynecomastia is self-limited. [[ | If left untreated patients with [[gynecomastia]] may progress to develop [[Psychological stress|psychosocial stresses]] and rarely [[breast cancer]]. The majority of [[physiological]] [[gynecomastia]] is self-limited. Pathological [[gynecomastia]] has an excellent [[prognosis]] and responds well to treatment. [[Pharmacological]] [[gynecomastia]] responds very well to the cessation of the the offending agent. | ||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Criteria=== | ===Diagnostic Criteria=== | ||
There are no established criteria for the diagnosis of [[gynecomastia]]. [[Gynecomastia]] is diagnosed clinically after a thorough history and physical examination. Laboratory investigations, imaging and exclusion of other conditions like pseudogynecomastia and [[breast cancer]], is also helpful in the diagnosis of [[gynecomastia]]. | |||
===History and Symptoms=== | ===History and Symptoms=== | ||
The hallmark of gynecomastia is breast enlargement.The majority of patients with gynecomastia are [[asymptomatic]]. | The hallmark of [[gynecomastia]] is [[breast]] enlargement. The majority of patients with [[gynecomastia]] are [[asymptomatic]]. Pain is the most common symptom of [[gynecomastia]]. Less common symptoms depend on the underlying cause. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Common physical examination findings of [[gynecomastia]] include [[breast]] enlargement with or without [[tenderness]]. Patients with [[gynecomastia]] are otherwise [[asymptomatic]]. | |||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
Gynecomastia which is recent in onset and tender on the examination should have serum concentrations of [[Human chorionic gonadotropin|human chorionic gonadotropin (hCG)]], [[LH]], [[testosterone]], and [[estradiol]] measured. | [[Gynecomastia]] is diagnosed clinically after a thorough history and physical examination. [[Gynecomastia]] which is recent in onset and tender on the examination should have serum concentrations of [[Human chorionic gonadotropin|human chorionic gonadotropin (hCG)]], [[LH]], [[testosterone]], and [[estradiol]] measured. The hormonal levels may vary depending on the underlying cause. | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
There are no [[ECG]] findings associated with gynecomastia. | There are no [[ECG]] findings associated with [[gynecomastia]]. | ||
===X-ray=== | ===X-ray=== | ||
[[ | There are no [[x-ray]] findings associated with [[gynecomastia]]. | ||
===CT scan=== | ===CT scan=== | ||
[[CT scan]] | There are no [[X-ray|CT scan]] findings associated with [[gynecomastia]]. | ||
===MRI=== | ===MRI=== | ||
[[MRI]] | There are no [[MRI]] findings associated with [[gynecomastia]]. | ||
===Ultrasound=== | ===Ultrasound=== | ||
[[Ultrasound]] can be done in gynecomastia when physical findings | [[Gynecomastia]] is diagnosed clinically after a thorough history and physical examination. [[Ultrasound]] can be done in patients with [[gynecomastia]] when physical findings raise suspicion of a [[lump]], [[abscess]] or [[breast cancer]]. | ||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
[[Mammogram]] can be done in gynecomastia when physical findings of a patient raise suspicion of breast cancer. | [[Gynecomastia]] is diagnosed clinically after a thorough history and physical examination. [[Mammogram]] can be done in [[gynecomastia]] when physical findings of a patient raise suspicion of breast cancer. | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
Other diagnostic study in the work up for gynecomastia include biopsy, which helps to confirm the [[diagnosis]] of [[breast cancer]]. | [[Gynecomastia]] is diagnosed clinically after a thorough history and physical examination. Laboratory investigations and imaging studies can be helpful in the diagnosis of [[gynecomastia]]. Other diagnostic study in the work up for [[gynecomastia]] include [[biopsy]], which helps to confirm the [[diagnosis]] of [[breast cancer]]. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
Gynecomastia is usually a self-limited condition, reassurance and follow- | [[Gynecomastia]] is usually a self-limited condition, reassurance and follow-ups are recommended. Causative medications should be withheld and any underlying condition leading to [[gynecomastia]] should be throughly investigated and treated. [[Pharmacologic|Pharmacologic therapy]] is beneficial for the first several months until [[fibrous tissue]] replaces the [[glandular tissue]]. [[Pharmacologic]] options include [[Selective estrogen receptor modulator|SERMs]], [[androgens]] and [[aromatase inhibitors]]. | ||
===Surgery=== | ===Surgery=== | ||
Surgery is not the first-line treatment option for patients with gynecomastia.Surgery is usually reserved for patients with either [[psychological]] stresses, extensive gynecomastia or failure of medical treatment. The type of surgical technique depends on the extent of gynecomastia. | [[Surgery]] is not the first-line treatment option for patients with [[gynecomastia]]. Surgery is usually reserved for patients with either [[psychological]] stresses, extensive [[gynecomastia]] or failure of medical treatment. The type of surgical technique depends on the extent of gynecomastia. | ||
===Primary Prevention=== | ===Primary Prevention=== | ||
There are no established methods for the [[primary prevention]] of gynecomastia. | There are no established methods for the [[primary prevention]] of gynecomastia. | ||
Latest revision as of 14:13, 16 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]
Overview
Gynecomastia is a benign male breast enlargement. Gynecomastia occurs due to increase estrogen to androgen ratio. Increased estrogen to androgen ratio can be physiological, such as seen during infancy, puberty and old age or pathological, which is due to obesity, steroid use, pharmacologic agents, medical conditions including chronic liver and renal failure or hypogonadism. However, most cases of the gynecomastia are idiopathic and asymptomatic. The diagnosis is primarily clinical. Other modalities used to diagnose gynecomastia include laboratory investigations such as blood hormone levels, renal function tests and liver function tests and imaging such as ultrasound or mammography. The treatment is usually supportive. Antiestrogens and surgical intervention can be considered in certain cases depending on physician and patient preference.
Historical Perspective
Gynecomastia is derived from Greek words, gyne which means woman and mastos which means breast. The term was originally coined by Galen, a Greek physician. Gynecomastia has been a known concept since the days of Aristotle (384–322 BC). The surgical management was initially discussed by Paulus, a Greek physician and later modified by Al-Zahrawi or Albucasis, an Andalusian surgeon.
Classification
Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology.
Pathophysiology
The main pathophysiology behind gynecomastia is increased estrogen to androgen ratio which can occur through multiple mechanisms. These mechanisms can be physiological, pathological or pharmacological.
Causes
Common known causes of gynecomastia include physiological hormonal changes, use of medications and pathological entities such as cirrhosis, hyperthyroidism, testicular tumors and hypogonadism. Less common causes include androgen insensitivity syndrome, Kallmann syndrome, defects of testosterone pathway and tumors.
Differentiating gynecomastia from other diseases
Gynecomastia must be differentiated from other diseases that cause breast enlargement in men. These diseases include pseudo gynecomastia, breast cancer, breast abscess, and lipoma.
Epidemiology and Demographics
Gynecomastia has the highest prevalence in elderly and neonatal age. Gynecomastia has trimodal age distribution with no racial preference.
Risk Factors
Common risk factors in the development of gynecomastia include the use of medications, cirrhosis, and hyperthyroidism. The less common risk factors include aromatase overexpression, androgen insensitivity syndrome and testosterone pathway defects.
Screening
There is insufficient evidence to recommend routine screening for gynecomastia.
Natural History, Complications, and Prognosis
If left untreated patients with gynecomastia may progress to develop psychosocial stresses and rarely breast cancer. The majority of physiological gynecomastia is self-limited. Pathological gynecomastia has an excellent prognosis and responds well to treatment. Pharmacological gynecomastia responds very well to the cessation of the the offending agent.
Diagnosis
Diagnostic Criteria
There are no established criteria for the diagnosis of gynecomastia. Gynecomastia is diagnosed clinically after a thorough history and physical examination. Laboratory investigations, imaging and exclusion of other conditions like pseudogynecomastia and breast cancer, is also helpful in the diagnosis of gynecomastia.
History and Symptoms
The hallmark of gynecomastia is breast enlargement. The majority of patients with gynecomastia are asymptomatic. Pain is the most common symptom of gynecomastia. Less common symptoms depend on the underlying cause.
Physical Examination
Common physical examination findings of gynecomastia include breast enlargement with or without tenderness. Patients with gynecomastia are otherwise asymptomatic.
Laboratory Findings
Gynecomastia is diagnosed clinically after a thorough history and physical examination. Gynecomastia which is recent in onset and tender on the examination should have serum concentrations of human chorionic gonadotropin (hCG), LH, testosterone, and estradiol measured. The hormonal levels may vary depending on the underlying cause.
Electrocardiogram
There are no ECG findings associated with gynecomastia.
X-ray
There are no x-ray findings associated with gynecomastia.
CT scan
There are no CT scan findings associated with gynecomastia.
MRI
There are no MRI findings associated with gynecomastia.
Ultrasound
Gynecomastia is diagnosed clinically after a thorough history and physical examination. Ultrasound can be done in patients with gynecomastia when physical findings raise suspicion of a lump, abscess or breast cancer.
Other Imaging Findings
Gynecomastia is diagnosed clinically after a thorough history and physical examination. Mammogram can be done in gynecomastia when physical findings of a patient raise suspicion of breast cancer.
Other Diagnostic Studies
Gynecomastia is diagnosed clinically after a thorough history and physical examination. Laboratory investigations and imaging studies can be helpful in the diagnosis of gynecomastia. Other diagnostic study in the work up for gynecomastia include biopsy, which helps to confirm the diagnosis of breast cancer.
Treatment
Medical Therapy
Gynecomastia is usually a self-limited condition, reassurance and follow-ups are recommended. Causative medications should be withheld and any underlying condition leading to gynecomastia should be throughly investigated and treated. Pharmacologic therapy is beneficial for the first several months until fibrous tissue replaces the glandular tissue. Pharmacologic options include SERMs, androgens and aromatase inhibitors.
Surgery
Surgery is not the first-line treatment option for patients with gynecomastia. Surgery is usually reserved for patients with either psychological stresses, extensive gynecomastia or failure of medical treatment. The type of surgical technique depends on the extent of gynecomastia.
Primary Prevention
There are no established methods for the primary prevention of gynecomastia.
Secondary Prevention
There are no established methods for the secondary prevention of gynecomastia.