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| | __NOTOC__ |
| | {| class="infobox" style="float:right;" |
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| | |[[File:Siren.gif|link=Gynecomastia resident survival guide|41x41px]]|| <br> || <br> |
| | | [[Gynecomastia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| {{DiseaseDisorder infobox | | {{DiseaseDisorder infobox |
| | Name = {{PAGENAME}} | | | Name = {{PAGENAME}} |
| | Image = Gynecomastia_001.jpg | | | Image = Gynecomastia_12.jpg |
| | Caption = An obese teenage male with Gynecomastia. | | | Caption = An obese teenage male with Gynecomastia, Source: Libre Pathology <ref>www.librepathology.com</ref> |
| | DiseasesDB = 19601
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| | ICD10 = {{ICD10|N|62||n|60}}
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| | ICD9 = {{ICD9|611.1}}
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| | OMIM =
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| | MedlinePlus = 003165
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| | eMedicineSubj = med
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| | eMedicineTopic = 934
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| }} | | }} |
| {{SI}} | | {{Gynecomastia}} |
| '''Editor-in-Chief:''' Jay Pensler, M.D., Northwestern University Feinberg School of Medicine [mailto:JPensler@aol.com]
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| {{Editor Join}} | | {{CMG}}; {{AE}} {{HS}}, {{DAMI}} |
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| ==Overview==
| | {{SK}} Gynecomazia, Hypertrophy of male breast, Mammary enlargement in male |
| '''Gynecomastia''', or '''gynaecomastia''', [[International Phonetic Alphabet|pronounced]] {{IPA|[ˈgaɪ.nə.kəʊˌmæs.ti.ə]}} is the development of abnormally large [[mammary gland|mammary glands]] in [[males]] resulting in breast enlargement, which can sometimes cause secretion of milk.<ref>{{cite web | url = http://www.kmle.com/search.php?Search=gynecomastia | title = ''KMLE American Heritage Medical Dictionary definition of gynecomastia'' | author = [http://www.kmle.com The American Heritage Stedman's Medical Dictionary]}}</ref> The term comes from the [[Greek language|Greek]] ''gyne'' meaning "woman" and ''mastos'' meaning "breast". The condition can occur physiologically in [[neonate]]s, in adolescents,adults and in the elderly. In adolescent boys the condition is a source of distress, but for the large majority of boys whose pubertal gynecomastia is not due to [[obesity]], the breast development shrinks or disappears within a couple of years <ref>[http://www.keepkidshealthy.com/adolescent/adolescentproblems/gynecomastia.html Adolescent gynecomastia]</ref>. The common type of gynecomastia in males undergoing pueberty is idiopathic in nature.It is important to note that several causes of gynecomastia have significant sequela and need to be ruled out ethier by history and or laboratory examinations prior to treatment of the disorder.The most common presentation of gynecomastia is idiopathic in nature. It is important to note that pituitary and adrenal tumors can result in gynecomastia. In addition several other endocrinological disorders such as klinefelters syndrome can be associated with gynecomastia and should be ruled out in pre pubertal individuals.Male breast cancer although rare needs to be considered in the differential diagnosis, particularly in cases that are of rapid onset and are unilateral in nature.Several types of exogenously injested substances , most notably steroids, can result in gynecomastia. Breast prominence can result from [[Organ hypertrophy|hypertrophy]] of breast tissue, chest [[adipose tissue]] and skin, and is typically in combination.Two types of tissue : glandular ,breast tissue , and fat ,adipose cells,compose the tissue in the breast. Optimal treatment needs to be directed at correction of the glandular and fatty tissue along with the skin envelope in each patient.As the relative volumes of the aforementioned components of the breast differ from individual to individual and patient specific treament plan needs to be established in all cases.The treatment plan in addition to correction of the obvious physical manifestations of the disease may need to be combined with anappropriate medical workup to establish and if necessary treat any concomitant disorder. <ref>{{cite journal| last=Braunstein| first=GD| title=Gynecomastia| journal=N Engl J Med| year=1993| month=Feb 18| volume=328| issue=7| pages=490-5| id=PMID 8421478}}</ref> or sometimes ''lipomastia''<ref>{{cite web
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| | last = Allee
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| | first = Mark R
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| | title = Gynecomastia
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| | publisher = WebMD, Inc. (emedicine.com)
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| | date = 2006-11-15
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| | url = http://www.emedicine.com/med/topic934.htm
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| | accessdate = 2007-05-20 }}</ref>.
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| == Differential Diagnosis of Causes of Gynecomastia == | | ==[[Gynecomastia overview|Overview]]== |
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| In alphabetical order. <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>
| | ==[[Gynecomastia historical perspective|Historical Perspective]]== |
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| * [[Acromegaly]]
| | ==[[Gynecomastia classification|Classification]]== |
| * [[Adrenal Cancer]]
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| * [[Androgen-insensitivity Syndrome]]
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| * [[Breast Cancer]]
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| * [[Carcinoid]]
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| * [[Chromophobe adenoma]]
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| * [[Chronic Liver Disease]]
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| * [[Chronic Renal Insufficiency|Chronic renal insufficiency]]
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| * [[Cirrhosis]]
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| * [[Congenital anorchia]]
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| * [[Extragonadal germ cell tumors]]
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| * Familial gynecomastia
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| * [[Five alpha-reductase deficiency Syndrome]]
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| * [[Hemochromatosis]]
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| * [[Hepatitis]]
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| * [[Hepatocellular carcinoma]]
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| * [[Hypogonadism]]
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| * [[Hypopituitarism]]
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| * [[Hypothyroidism]]
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| * Idiopathic
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| * [[Kallman Syndrome]]
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| * [[Kidney Carcinoma]]
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| * [[Klinefelter Syndrome]]
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| * [[Liver cancer]]
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| * Local irradiation
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| * [[Lung cancer]]
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| * Medications/drugs:
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| *:* [[Alcohol]]
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| *:* [[Anabolic]]s
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| *:* [[Chemotherapeutic]]s
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| *:* [[Chlorpromazine]]
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| *:* [[Cimetidine]]
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| *:* [[Clomiphene]]
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| *:* [[Diazepam]]
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| *:* [[Digoxin]]
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| *:* [[Estrogen]]s
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| *:* [[Etomidate]]
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| *:* [[Finasteride]]
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| *:* [[Heroin]]
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| *:* [[Human chorionic gonadotropin]] ([[HCG]])
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| *:* [[Isoniazid]]
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| *:* [[Ketoconazole]]
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| *:* [[Marijuana]]
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| *:* [[Methadone]]
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| *:* [[Methyldopa]]
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| *:* [[Metoclopramide]]
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| *:* [[Metronidazole]]
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| *:* [[Nifedipine]]
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| *:* [[Omeprazole]]
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| *:* [[Penicillamine]]
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| *:* [[Phenothiazine]]
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| *:* [[Spironolactone]]
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| *:* [[Steroid]]s
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| *:* [[Tamoxifen]]
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| *:* [[Tricyclic antidepressants]]
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| *:* [[Verapamil]]
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| * Persistent postpubertal/elderly gynecomastia
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| * Physiologic gynecomastia of puberty
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| * Re-feeding after starvation
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| * [[Stomach cancer]]
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| * [[Testicular cancer]]
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| * Testicular trauma
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| * [[Thyroid Disease]]
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| * [[Torsion of testes]]
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| * Viral [[orchitis]]
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| Physiologic gynecomastia occurs in neonates, at or before [[puberty]] and with [[Senescence|aging]]. Many cases of gynecomastia are [[idiopathic]], meaning they have no clear cause.
| | ==[[Gynecomastia pathophysiology|Pathophysiology]]== |
| Potential pathologic causes of gynecomastia are: medications including hormones, increased serum [[estrogen]], decreased [[testosterone]] production, [[androgen]] receptor defects, chronic kidney disease, chronic liver disease, [[HIV]],<ref>{{cite journal| last=Peyriere| first=H| coauthors=et al| title=Report of gynecomastia in five male patients during antiretroviral therapy for HIV infection| journal=AIDS| year=1999| month=Oct 22| volume=13| issue=15| pages=2167-9| id=PMID 10546872}}</ref> and other chronic illness. Gynecomastia as a result of spinal cord injury and refeeding after starvation has been reported.<ref>{{cite journal| last=Heruti| first=RJ| coauthors=et al| title=Gynecomastia following spinal cord disorder|journal=Arch Phys Med Rehabil| year=1997| month=May |volume=78| issue=5| pages=534-7| id=PMID 9161376}}</ref> In 25% of cases, the cause of the gynecomastia is not known.
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| Medications cause 10-20% of cases of gynecomastia in post-adolescent adults. These include [[cimetidine]], [[omeprazole]], [[spironolactone]], [[imatinib|imatinib mesylate]], [[finasteride]] and certain [[antipsychotic]]s. Some act directly on the breast tissue, while others lead to increased secretion of [[prolactin]] from the [[pituitary]] by blocking the actions of [[dopamine]] (prolactin-inhibiting factor/PIF) on the [[lactotrope]] cell groups in the [[anterior pituitary]]. [[Androstenedione]], used as a performance enhancing food supplement, can lead to breast enlargement by excess [[estrogen]] activity. Medications used in the treatment of [[prostate cancer]], such as [[antiandrogens]] and [[Gonadotropin-releasing hormone analog|GnRH analogs]] can also cause gynecomastia. [[Marijuana]] use is also thought by some to be a possible cause; however, published data is contradictory.<ref>{{cite journal |author=Thompson D, Carter J |title=Drug-induced gynecomastia |journal=Pharmacotherapy |volume=13 |issue=1 |pages=37-45 |year= |id=PMID 8094898}}</ref>
| | ==[[Gynecomastia causes|Causes]]== |
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| Increased estrogen levels can also occur in certain testicular [[tumors]], and in [[hyperthyroidism]]. Certain adrenal tumors cause elevated levels of [[androstenedione]] which is converted by the [[enzyme]] [[aromatase]] into [[estrone]], a form of estrogen. Other tumors that secrete [[hCG]] can increase estrogen. A decrease in estrogen clearance can occur in liver disease, and this may be the mechanism of gynecomastia in liver [[cirrhosis]]. [[Obesity]] tends to increase estrogen levels.<ref>{{cite journal| last=Glass |first=AR| title=Gynecomastia| journal=Endocrinol Metab Clin North Am| year=1994| month=Dec| volume=23| issue=4| pages=825-37| id=PMID 7705322}}</ref><ref>{{cite journal| last=Braunstein| first=GD| title=Aromatase and Gynecomastia| journal=Endocr Relat Cancer| year=1999| month= Jun| volume=6| issue=2| pages=315-24| id=PMID 10731125}}</ref>
| | ==[[Gynecomastia differential diagnosis|Differentiating Gynecomastia from Other Diseases]]== |
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| Decreased [[testosterone]] production can occur in congenital or acquired testicular failure, for example in [[genetic disorder]]s such as [[Klinefelter Syndrome]]. Diseases of the [[hypothalamus]] or [[pituitary]] can also lead to low testosterone. Abuse of anabolic androgenic steroids (AAS) has a similar effect. Mutations to androgen receptors, such as those found in [[Kennedy disease]] can also cause gynecomastia.
| | ==[[Gynecomastia epidemiology and demographics|Epidemiology and Demographics]]== |
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| Although stopping these medications can lead to regression of the gynecomastia, surgery is sometimes necessary to eliminate the condition.
| | ==[[Gynecomastia risk factors|Risk Factors]]== |
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| Repeated topical application of products containing [[Lavender oil|lavender]] and [[tea tree oil]]s among other unidentified ingredients to three prepubescent males coincided with gynecomastia; it has been theorised that this could be due to their estrogenic and antiandrogenic activity. However, other circumstances around the study are not clear, and the sample size was insignificant so serious scientific conclusions cannot be drawn.<ref>{{cite journal |author=Henley D, Lipson N, Korach K, Bloch C |title=Prepubertal gynecomastia linked to lavender and tea tree oils |journal=N Engl J Med |volume=356 |issue=5 |pages=479-85 |year=2007 |id=PMID 17267908}}</ref>
| | ==[[Gynecomastia screening|Screening]]== |
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| ==Pathophysiology and Etiology== | | ==[[Gynecomastia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| There are three broad causes of gnyecomastia:
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| === Decreased Testosterone ===
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| * [[Androgen-insensitivity syndrome]]
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| * [[Congenital anorchia]]
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| * [[Five alpha-reductase deficiency]]
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| * [[Hypopituitarism]]
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| * [[Kallman Syndrome]]
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| * [[Klinefelter Syndrome]]
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| * [[Renal Failure]]
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| * Testicular trauma
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| * Torsion of the testes
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| * Viral [[orchitis]]
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| === Increased Estrogens === | | ==Diagnosis== |
| * [[Adrenal cancer]]
| | [[Gynecomastia history and symptoms|History and Symptoms]] | [[Gynecomastia physical examination|Physical Examination]] | [[Gynecomastia laboratory findings|Laboratory Findings]] | [[Gynecomastia electrocardiogram|Electrocardiogram]] | [[Gynecomastia chest x ray|Chest X Ray]] | [[Gynecomastia CT|CT]] | [[Gynecomastia MRI|MRI]] | [[Gynecomastia ultrasound|Ultrasound]] | [[Gynecomastia other imaging findings|Other Imaging Findings]] | [[Gynecomastia other diagnostic studies|Other Diagnostic Studies]] |
| * Chronic liver disease
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| * [[Extragonadal germ cell tumors]]
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| * Familial gynecomastia
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| * [[Hyperthyroidism]]
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| * [[Kidney carcinoma]]
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| * [[Liver cancer]]
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| * [[Lung carcinoma]]
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| * Malnutrition
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| * Other gastrointestinal (GI) tract carcinoma
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| * [[Stomach cancer]]
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| * [[Testicular cancer]]
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| === Other (physiologic) === | | ==Treatment== |
| * Benign gynecomastia of adolescence
| | [[Gynecomastia medical therapy|Medical Therapy]] | [[Gynecomastia surgery|Surgery]] | [[Gynecomastia primary prevention|Primary Prevention]] | [[Gynecomastia secondary prevention|Secondary Prevention]] | [[Gynecomastia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Gynecomastia future or investigational therapies|Future or Investigational Therapies]] |
| * Drugs
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| * Familial gynecomastia
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| * Gynecomastia in the newborn
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| * Gynecomastia of aging
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| == Diagnosis == | | ==Case study== |
| | | [[Gynecomastia case study one|Case #1]] |
| The condition usually can be diagnosed by examination by a [[physician]]. Occasionally, imaging by [[X-ray]]s or [[ultrasound]] is needed to confirm the [[diagnosis]]. Blood tests are required to see if there is any underlying disease causing the gynecomastia.
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| === History and Symptoms ===
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| * Complete history exam should include the following:
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| *:* Family history
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| *:* Developmental history
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| *:* Associated symptoms
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| *:* Detailed past medical history
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| *:* Careful drug history
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| === Physical Examination ===
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| A thorough exam to exclude other primary causes is in orer.
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| === Laboratory Findings ===
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| * [[Human chorionic gonadotropin]] ([[HCG]])
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| * [[Liver function tests]] ([[LFTs]])
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| * [[Alpha-fetoprotein]] ([[AFP]])
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| * [[Testosterone]]
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| * [[Thyroid stimulating hormone]] ([[TSH]])
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| * [[Blood urea nitrogen]] ([[BUN]])
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| * [[Creatinine]] ([[Cr]])
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| * [[Estradiol]]
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| * [[Dehydroepiandrosterone-sulfate]] ([[DHEA-S]])
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| * [[Prolactin]]
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| * [[Erythrocyte sedimentation rate]] ([[ESR]])
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| === Electrolyte and Biomarker Studies ===
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| === Chest X Ray ===
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| * Chest X-ray can be useful in ruling out [[lung cancer]]
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| === MRI and CT ===
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| * A [[CT scan]] of the head may reveal a [[pituitary tumor]]
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| === Echocardiography or Ultrasound ===
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| * Ultrasound used to differentiate between suspicious lesions and normal glandular tissue
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| === Other Imaging Findings ===
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| * [[Mammogram]] may be indicated if cancer is suspected
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| === Other Diagnostic Studies ===
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| * Karyotype analysis is used to diagnose Klinefelter's syndrome
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| == Treatment ==
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| Treating the underlying cause of the gynecomastia may lead to improvement in the condition. Patients should talk with their doctor about revising any medications that are found to be causing gynecomastia; often, an alternative medication can be found that avoids gynecomastia side-effects, while still treating the primary condition for which the original medication was found not to be suitable due to causing gynecomastia side-effects (e.g., in place of taking spironolactone the alternative eplerenone can be used.) [[Selective estrogen receptor modulator]] medications, such as [[tamoxifen]] and [[clomiphene]], or [[androgen]]s or [[aromatase inhibitor]]s such as [[Letrozole]] are medical treatment options, although they are not universally approved for the treatment of gynecomastia. Endocrinological attention may help during the first 2-3 years. After that window, however, the breast tissue tends to remain and harden, leaving surgery (either [[liposuction]], gland excision, skin sculpture, [[Breast reduction|reduction mammoplasty]], or a combination of these surgical techniques) the only treatment option. Many American insurance companies deny coverage for surgery for gynecomastia treatment on the grounds that it is a cosmetic procedure. [[Radiation therapy]] is sometimes used to prevent gynecomastia in patients with prostate cancer prior to estrogen therapy. Compression garments can camouflage chest deformity and stabilize bouncing tissue bringing emotional relief to some. There are also those who choose to live with the condition.
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| As a summary:
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| * Most cases of gynecomastia resolve spontaneously and therefore do not require treatment
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| * Always treat underlying disease etiologies
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| * If possible, discontinue harmful/offending medications
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| == Pharmacotherapy ==
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| * For elderly patients who have extreme pain, tenderness or embarrassment:
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| *:* [[Androgens]]
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| *:* Antiestrogens
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| *:* [[Aromatase]]
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| == Surgery and Device Based Therapy ==
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| * [[Liposuction]]
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| * Surgical excision
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| === Indications for Surgery ===
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| * Surgery is indicated if patients have no response to medical therapies
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| ==Prognosis==
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| Gynecomastia is not physically harmful, but in some cases can be an indicator of other more dangerous underlying conditions. Growing glandular tissue, typically from some form of hormonal stimulation, is often tender or painful. Furthermore, it can frequently present social and psychological difficulties for the sufferer.<ref>{{cite web | url = http://www.annalsplasticsurgery.com/pt/re/annps/abstract.00000637-200408000-00001.htm;jsessionid=F9bRttLWlcgHnBWVVgG3xcHwF1KbpJTPbgyLjKvQJXG977J7s1pP!1570379021!-949856144!8091!-1 | title = ''Gynecomastia: An Outcome Analysis'' | author = Wiesman, IM. et al.}}</ref> Weight loss can alter the condition in cases where it is triggered by obesity, but losing weight will not reduce the glandular component and patients cannot target areas for weight loss. Massive weight loss can result in sagging tissues about the chest, chest [[ptosis (breasts)|ptosis]], or drooping chest. | |
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| ==References==
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| {{Reflist|2}}
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| ==External links to images==
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| *http://medicine.ucsd.edu/Clinicalimg/Thorax-gynecomastia.jpg
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| *http://images.webmd.com/images/hw/media69/medical/hw/n5551142.jpg
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| *http://www.seykota.com/tribe/FAQ/2006_Apr/21/gynecomastia.jpg
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| {{Diseases of the pelvis, genitals and breasts}} | | {{Diseases of the pelvis, genitals and breasts}} |
| {{SIB}}
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| [[de:Gynäkomastie]]
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| [[es:Ginecomastia]]
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| [[fr:Gynécomastie]]
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| [[it:Ginecomastia]]
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| [[ja:女性化乳房]]
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| [[pt:Ginecomastia]]
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| [[nl:Gynecomastie]]
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| [[ru:Гинекомастия]]
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| [[fi:Gynekomastia]]
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| [[sv:Gynekomasti]]
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| [[Category:Signs and symptoms]] | | [[Category:Signs and symptoms]] |
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| [[Category:Breast]] | | [[Category:Breast]] |
| [[Category:Medical conditions related to obesity]] | | [[Category:Medical conditions related to obesity]] |
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| [[pl:Ginekomastia]]
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