Gynecomastia resident survival guide

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

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

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

• Drugs:
  • Block synthesis of testosterone- Ketoconazole, Spironolactone, Metronidazole, Etomidate, Finasteride
  • Antiandrogens- Bicalutamide, flutamide, Nilutamide
  • 5-Alpha reductase inhibtors- Finasteride
  • Cimetidine
  • Hormones
    • Estrogen
    • Gonadotrophin releasing hormone (GnRH) agonist
    • Human chorionic gonadotropin (hCG)
    • Recombinant human growth hormone
  • Testicular damage- Busulfan, Nitrosurea, Vincristine, Ethanol
  • Other drugs
• Idiopathic
• Physiologic:
  • Adolescence
  • Aging
  • Infancy
• Pathologic:
  • Cirrhosis of liver
  • Chronic kidney disease
  • Hyperthyroidism
  • Primary hypogonadism
  • Persistent pubertal gynecomastia
  • Secondary hypogonadism- primary or secondary
  • Testicular tumors

Less Common Causes

• Aromatase overexpression
• Androgen insensitivity syndrome
• Drugs
• Kallmann syndrome
• Testosterone pathway defects
• Tumors
  • Gastric carcinoma
  • Hepatic Tumor
  • Large cell carcinoma of lung
  • Pituitary Tumor
  • Renal cell carcinoma

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

Genetic Causes

• Familial prepubertal gynecomastia

Diagnosis

Shown below is an algorithm summarizing the diagnosis of gynecomastia according to American Family Physicians. ("Gynecomastia - American Family Physician".)

Gynecomastia (Breast tissue enlargement)

Newborn

Physiological; resolves within 4 weeks

Drugs (see list here)

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 American Family Physicians. ("Gynecomastia - American Family Physician".) guidelines.

Box 1 in Row 1

Box 2 in Row 2

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Do's

• Always evaluate for physiological causes.
• Evaluate for drugs causing gynecomastia.
• Correct underlying causes first.

Don'ts

• The content in this section is in bullet points.

References

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