Gynecomastia resident survival guide: Difference between revisions

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{{WikiDoc CMG}}; {{AE}} {{IF}}
{{WikiDoc CMG}}; {{AE}} {{IF}}
{{SK}} [[Gynecomastia management]], [[Gynecomastia work-up]], [[Approach to gynecomastia]]
==Overview==
==Overview==
Gynecomastia is a benign male breast enlargement. It can be [[physiological]], such as in [[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.]] The diagnosis is primarily clinical.Laboratory investigations done are blood [[hormone]] levels, [[renal function tests]] and [[liver function tests]] and imaging such as [[ultrasound]] or [[mammography]]. Treatment is aimed at treating the underlying condition.[[Pharmacologic]] options include [[Selective estrogen receptor modulator|SERMs]], [[androgens]] and [[aromatase inhibitors]]. Surgery is usually reserved for patients with either [[psychological]] stresses, extensive [[gynecomastia]] or failure of medical treatment.
Gynecomastia is a benign male breast enlargement. It can be [[physiological]], occuring with [[infancy]], [[puberty]] and old age. Gynecomastia can also be [[Pathological|pathologica]]<nowiki/>l, arising with [[obesity]], [[steroid]] use, [[pharmacologic]] agents, medical conditions including chronic liver and [[renal]] failure or [[Hypogonadism|hypogonadism.]] The diagnosis is primarily clinical. Laboratory investigations typically performed are blood [[hormone]] levels, [[renal function tests]] and [[liver function tests]]. [[Ultrasound]] or [[mammography]] imaging modalities are also common in diagnosis. Treatment is aimed at resolution of the underlying condition. [[Pharmacologic]] options include [[Selective estrogen receptor modulator|SERMs]], [[androgens]] and [[aromatase inhibitors]]. Surgery is usually reserved for patients with either [[psychological]] stresses, extensive [[gynecomastia]] or failure of medical treatment.


==Causes==
==Causes==
Line 30: Line 33:


===Common Causes===
===Common Causes===
<ref name="pmid17881754">{{cite journal| author=Braunstein GD| title=Clinical practice. Gynecomastia. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 12 | pages= 1229-37 | pmid=17881754 | doi=10.1056/NEJMcp070677 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17881754  }}</ref> <ref name="pmid17881754">{{cite journal |vauthors=Braunstein GD |title=Clinical practice. Gynecomastia |journal=N. Engl. J. Med. |volume=357 |issue=12 |pages=1229–37 |year=2007 |pmid=17881754 |doi=10.1056/NEJMcp070677 |url=}}</ref> <ref name="pmid25905330">{{cite journal |vauthors=De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng JCM |title= |journal= |volume= |issue= |pages= |year= |pmid=25905330 |doi= |url=}}</ref> <ref name="pmid12736278">{{cite journal |vauthors=Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K, Bryant M, Bulun SE |title=Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene |journal=N. Engl. J. Med. |volume=348 |issue=19 |pages=1855–65 |year=2003 |pmid=12736278 |doi=10.1056/NEJMoa021559 |url=}}</ref><ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref><ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
*Drugs:
*Drugs:
** Block synthesis of [[testosterone]]- [[Ketoconazole]], [[Spironolactone]], [[Metronidazole]], [[Etomidate]], [[Finasteride]]
** Block synthesis of [[testosterone]]- [[Ketoconazole]], [[Spironolactone]], [[Metronidazole]], [[Etomidate]], [[Finasteride]]
Line 42: Line 46:
** Testicular damage- [[Busulfan]], [[Nitrosourea]], [[Vincristine]], [[Ethanol]]
** Testicular damage- [[Busulfan]], [[Nitrosourea]], [[Vincristine]], [[Ethanol]]
**[[Gynecomastia causes#Causes in Alphabetical Order|Other drugs]]
**[[Gynecomastia causes#Causes in Alphabetical Order|Other drugs]]
*[[Idiopathic]]<ref name="pmid17881754">{{cite journal| author=Braunstein GD| title=Clinical practice. Gynecomastia. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 12 | pages= 1229-37 | pmid=17881754 | doi=10.1056/NEJMcp070677 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17881754  }}</ref>
*[[Idiopathic]]
*[[Physiologic]]:<ref name="pmid17881754">{{cite journal |vauthors=Braunstein GD |title=Clinical practice. Gynecomastia |journal=N. Engl. J. Med. |volume=357 |issue=12 |pages=1229–37 |year=2007 |pmid=17881754 |doi=10.1056/NEJMcp070677 |url=}}</ref>
*[[Physiologic]]:
**[[Adolescence]]
**[[Adolescence]]
**[[Aging]]
**[[Aging]]
**I[[Infancy|nfancy]]
**I[[Infancy|nfancy]]
*[[Pathological|Pathologic:]]<ref name="pmid25905330">{{cite journal |vauthors=De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng JCM |title= |journal= |volume= |issue= |pages= |year= |pmid=25905330 |doi= |url=}}</ref>
*[[Pathological|Pathologic:]]
**[[Cirrhosis of liver]]
**[[Cirrhosis of liver]]
**[[Chronic kidney disease|Chronic kidney disease]]
**[[Chronic kidney disease|Chronic kidney disease]]
Line 71: Line 75:


===Genetic Causes===
===Genetic Causes===
*[[Familial|Familial prepubertal gynecomastia]]<ref name="pmid12736278">{{cite journal |vauthors=Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K, Bryant M, Bulun SE |title=Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene |journal=N. Engl. J. Med. |volume=348 |issue=19 |pages=1855–65 |year=2003 |pmid=12736278 |doi=10.1056/NEJMoa021559 |url=}}</ref>
*[[Familial|Familial prepubertal gynecomastia]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[gynecomastia]] according to the Endocrine Society and European Association of Andrology.<ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <ref name="pmiddoi.org/10.1210/jc.2010-1720">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi.org/10.1210/jc.2010-1720 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref>  
Shown below is an algorithm summarizing the diagnosis of [[gynecomastia]] according to the Endocrine Society and European Association of Andrology.<ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <ref name="pmiddoi.org/10.1210/jc.2010-1720">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi.org/10.1210/jc.2010-1720 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref><br>
 
'''Abbreviations:'''
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Gynecomastia (Breast tissue enlargement)}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Gynecomastia (Breast tissue enlargement)}}
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----
----
❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor
❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor
----
</div>}}
</div>}}
{{familytree/end}}
{{familytree/end}}




Shown below is an algorithm summarizing the treatment of [[gynecomastia]] according to the Endocrine Society and European Association of Andrology. <ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <ref name="pmiddoi.org/10.1210/jc.2010-1720">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi.org/10.1210/jc.2010-1720 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref>  
Shown below is an algorithm summarizing the treatment of [[gynecomastia]] according to the Endocrine Society and European Association of Andrology. <ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <ref name="pmiddoi.org/10.1210/jc.2010-1720">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi.org/10.1210/jc.2010-1720 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10 }} </ref>  <ref name="pmid11569940">{{cite journal| author=Gruntmanis U, Braunstein GD| title=Treatment of gynecomastia. | journal=Curr Opin Investig Drugs | year= 2001 | volume= 2 | issue= 5 | pages= 643-9 | pmid=11569940 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11569940 }} </ref>


{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | A01 |A01= • Discontinue the causative drug<br>• Treat the underlying cause<br> }}  
{{familytree | | | | | | | | | A01 |A01= • Discontinue the causative drug<br>• Treat the underlying cause<ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <br> }}  
{{familytree | | | | | | | | | |!| | | | }}  
{{familytree | | | | | | | | | |!| | | | }}  
{{familytree | | | | | | | | | A01 |A01= Observe for 3 months }}
{{familytree | | | | | | | | | A01 |A01= Observe for 3 months }}
Line 138: Line 141:
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|.| | | | | | }}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|.| | | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | | | }}  
{{familytree | |!| | | |!| | | |!| | | |!| | | | | | | }}  
{{familytree | D01 | | D02 | | D03 | | D04 | |D01= [[Androgens]] and [[testosterone]]<br>• [[Hypogonadism]]<br>|D02= [[Aromatase inhibitors]] in [[prostate cancer]]<br>• [[Anastrazole]] <br>|D03=[[Selective estrogen receptor modulators]] (SERMs)<br>•[[Tamoxifen]] (10-20 mg once daily for 3-9 months) <br> •[[Raloxifene]] (60 mg once daily for 3-9 months) <br>|D04=Surgery if:<br> • Persistent for > 12 months<br> • [[Fibrotic]] gynecomastia<br> • Failure of medical therapy<br>}}
{{familytree | D01 | | D02 | | D03 | | D04 | |D01= [[Androgens]] and [[testosterone]]<br>• [[Hypogonadism]]<br>|D02= [[Aromatase inhibitors]] in [[prostate cancer]]<br>• [[Anastrazole]] <br>|D03=[[Selective estrogen receptor modulators]] (SERMs)<ref name="pmid12907471">{{cite journal| author=Khan HN, Blamey RW| title=Endocrine treatment of physiological gynaecomastia. | journal=BMJ | year= 2003 | volume= 327 | issue= 7410 | pages= 301-2 | pmid=12907471 | doi=10.1136/bmj.327.7410.301 | pmc=1126712 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12907471  }} </ref><br>•[[Tamoxifen]] (10-20 mg once daily for 3-9 months) <br> •[[Raloxifene]] (60 mg once daily for 3-9 months) <br>|D04=Surgery if:<br> • Persistent for > 12 months<br> • [[Fibrotic]] gynecomastia<br> • Failure of medical therapy<br>}}
{{familytree/end}}
{{familytree/end}}


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* Always evaluate for [[physiological]] causes.
* Always evaluate for [[physiological]] causes.
* Evaluate for drugs causing [[gynecomastia]].
* Evaluate for drugs causing [[gynecomastia]].
* Correct underlying causes first. <ref name="pmid19880691">{{cite journal| author=Johnson RE, Murad MH| title=Gynecomastia: pathophysiology, evaluation, and management. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 11 | pages= 1010-5 | pmid=19880691 | doi=10.1016/S0025-6196(11)60671-X | pmc=2770912 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19880691  }} </ref>
* Correct underlying causes first. <ref name="pmid11569940">{{cite journal| author=Gruntmanis U, Braunstein GD| title=Treatment of gynecomastia. | journal=Curr Opin Investig Drugs | year= 2001 | volume= 2 | issue= 5 | pages= 643-9 | pmid=11569940 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11569940  }} </ref> <ref name="pmid19880691">{{cite journal| author=Johnson RE, Murad MH| title=Gynecomastia: pathophysiology, evaluation, and management. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 11 | pages= 1010-5 | pmid=19880691 | doi=10.1016/S0025-6196(11)60671-X | pmc=2770912 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19880691  }} </ref>


==Don'ts==
==Don'ts==
* Do not treat the [[gynecomastia]] without evaluating for an underlying cause.
* Do not treat the [[gynecomastia]] without evaluating for an underlying cause. <ref name="pmid19880691">{{cite journal| author=Johnson RE, Murad MH| title=Gynecomastia: pathophysiology, evaluation, and management. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 11 | pages= 1010-5 | pmid=19880691 | doi=10.1016/S0025-6196(11)60671-X | pmc=2770912 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19880691  }} </ref>


==References==
==References==
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Latest revision as of 20:11, 15 January 2021

Gynecomastia
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]

Synonyms and keywords: Gynecomastia management, Gynecomastia work-up, Approach to gynecomastia

Overview

Gynecomastia is a benign male breast enlargement. It can be physiological, occuring with infancy, puberty and old age. Gynecomastia can also be pathological, arising with obesity, steroid use, pharmacologic agents, medical conditions including chronic liver and renal failure or hypogonadism. The diagnosis is primarily clinical. Laboratory investigations typically performed are blood hormone levels, renal function tests and liver function tests. Ultrasound or mammography imaging modalities are also common in diagnosis. Treatment is aimed at resolution of the underlying condition. Pharmacologic options include SERMs, androgens and aromatase inhibitors. Surgery is usually reserved for patients with either psychological stresses, extensive gynecomastia or failure of medical treatment.

Causes

Life-threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of gynecomastia.

Common Causes

[1] [1] [2] [3][4][5]

Less Common Causes

To review a complete list of gynecomastia causes, click here.

Genetic Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of gynecomastia according to the Endocrine Society and European Association of Andrology.[6] [7]
Abbreviations:

 
 
 
 
 
 
 
 
Gynecomastia (Breast tissue enlargement)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Newborn
 
Physiological; resolves within 4 weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drugs (see list above)
 
Discontinue implicated drug
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pseudogynecomastia
 
Weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Features of malignancy
 
Mammography; Breast USG; Biopsy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Testicular mass
 
Testicular USG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
True Gynecomastia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Testosterone
• Estradiol(E2)
• Luteinizing hormone (LH)
• Prolactin • Follicle Stimulating Hormone (FSH)
• Beta- hCG
 
 
 
 
• Thyroid function tests
• Liver function tests
• Renal function tests
 
If deranged,correct underlying disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Low testosterone
• High LH
 
• Low testosterone
• Low LH
 
• High Estradiol
• Low LH
 
• High Prolactin
 
• High beta-hCG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary hypogonadism
 
Secondary hypogonadism
 
Testicular USG
 
MRI head for
• Pituitary adenoma
• Empty sella
• Panhypopituitarism
 
 
Testicular USG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sertoli or Leydig cell tumor
 
Evaluate for
•Adrenal neoplasm
• Exogenous estrogen use
• Obesity (excess aromatase)
 
 
Germ cell tumor
 
If normal; evaluate for
• Extragonadal germ cell tumor
• Non-trophoblastic beta hCG secreting tumors

Treatment

Evaluation of Gynecomastia

❑ Obtain a detailed history
❑ Examine the breasts to rule out malignancy
❑ Stop drugs that may cause gynecomastia

Obtain laboratory tests

❑ Testosterone
❑ Estradiol
❑ Beta hCG
❑ Luteinizing hormone (LH)
❑ Follicle Stimulating Hormone (FSH)
❑ Prolactin

Treat underlying disorders

❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor


Shown below is an algorithm summarizing the treatment of gynecomastia according to the Endocrine Society and European Association of Andrology. [6] [7] [8]

 
 
 
 
 
 
 
 
• Discontinue the causative drug
• Treat the underlying cause[6]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observe for 3 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If pain/tenderness; proceed with medical therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Androgens and testosterone
• Hypogonadism
 
Aromatase inhibitors in prostate cancer
• Anastrazole
 
Selective estrogen receptor modulators (SERMs)[9]
•Tamoxifen (10-20 mg once daily for 3-9 months)
•Raloxifene (60 mg once daily for 3-9 months)
 
Surgery if:
• Persistent for > 12 months
• Fibrotic gynecomastia
• Failure of medical therapy
 

Do's

Don'ts

References

  1. ↑ 1.0 1.1 Braunstein GD (2007). "Clinical practice. Gynecomastia". N Engl J Med. 357 (12): 1229–37. doi:10.1056/NEJMcp070677. PMID 17881754.
  2. ↑ De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng J. PMID 25905330. Vancouver style error: initials (help); Missing or empty |title= (help)
  3. ↑ Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K, Bryant M, Bulun SE (2003). "Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene". N. Engl. J. Med. 348 (19): 1855–65. doi:10.1056/NEJMoa021559. PMID 12736278.
  4. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  5. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  6. ↑ 6.0 6.1 6.2 Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G; et al. (2019). "EAA clinical practice guidelines-gynecomastia evaluation and management". Andrology. 7 (6): 778–793. doi:10.1111/andr.12636. PMID 31099174.
  7. ↑ 7.0 7.1 Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID doi.org/10.1210/jc.2010-1720 Check |pmid= value (help).
  8. ↑ 8.0 8.1 Gruntmanis U, Braunstein GD (2001). "Treatment of gynecomastia". Curr Opin Investig Drugs. 2 (5): 643–9. PMID 11569940.
  9. ↑ Khan HN, Blamey RW (2003). "Endocrine treatment of physiological gynaecomastia". BMJ. 327 (7410): 301–2. doi:10.1136/bmj.327.7410.301. PMC 1126712. PMID 12907471.
  10. ↑ 10.0 10.1 Johnson RE, Murad MH (2009). "Gynecomastia: pathophysiology, evaluation, and management". Mayo Clin Proc. 84 (11): 1010–5. doi:10.1016/S0025-6196(11)60671-X. PMC 2770912. PMID 19880691.
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