Gynecomastia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Jay Pensler, M.D., Northwestern University Feinberg School of Medicine [2]

Overview

Gynecomastia, or gynaecomastia, pronounced Template:IPA is the development of abnormally large mammary glands in males resulting in breast enlargement, which can sometimes cause secretion of milk.[1] The term comes from the Greek gyne meaning "woman" and mastos meaning "breast". The condition can occur physiologically in neonates, 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 [2]. The common type of gynecomastia in males undergoing pueberty is idiopathic in nature.One should be aware 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 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 a 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 an appropriate medical workup to establish and if necessary treat any concomitant disorder. [3] [4].

Differential Diagnosis of Causes of Gynecomastia

In alphabetical order. [5] [6]

Physiologic gynecomastia occurs in neonates, at or before puberty and with aging. Many cases of gynecomastia are idiopathic, meaning they have no clear cause. 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,[7] and other chronic illness. Gynecomastia as a result of spinal cord injury and refeeding after starvation has been reported.[8] In 25% of cases, the cause of the gynecomastia is not known.

Medications cause 10-20% of cases of gynecomastia in post-adolescent adults. These include cimetidine, omeprazole, spironolactone, imatinib mesylate, finasteride and certain antipsychotics. 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 GnRH analogs can also cause gynecomastia. Marijuana use is also thought by some to be a possible cause; however, published data is contradictory.[9]

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.[10][11]

Decreased testosterone production can occur in congenital or acquired testicular failure, for example in genetic disorders 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.

Although stopping these medications can lead to regression of the gynecomastia, surgery is sometimes necessary to eliminate the condition.

Repeated topical application of products containing lavender and tea tree oils 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.[12]

Pathophysiology and Etiology

There are three broad causes of gnyecomastia:

Decreased Testosterone

Increased Estrogens

Other (physiologic)

  • Benign gynecomastia of adolescence
  • Drugs
  • Familial gynecomastia
  • Gynecomastia in the newborn
  • Gynecomastia of aging

Diagnosis

The condition usually can be diagnosed by examination by a physician. Occasionally, imaging by X-rays or ultrasound is needed to confirm the diagnosis. Blood tests are required to see if there is any underlying disease causing the gynecomastia.

History and Symptoms

  • Complete history exam should include the following:
    • Family history
    • Developmental history
    • Associated symptoms
    • Detailed past medical history
    • Careful drug history

Physical Examination

A thorough exam to exclude other primary causes is in orer.

Laboratory Findings

Electrolyte and Biomarker Studies

Chest X Ray

MRI and CT

Echocardiography or Ultrasound

  • Ultrasound used to differentiate between suspicious lesions and normal glandular tissue

Other Imaging Findings

  • Mammogram may be indicated if cancer is suspected

Other Diagnostic Studies

  • Karyotype analysis is used to diagnose Klinefelter's syndrome

Treatment

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 androgens or aromatase inhibitors 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, 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.

As a summary:

  • Most cases of gynecomastia resolve spontaneously and therefore do not require treatment
  • Always treat underlying disease etiologies
  • If possible, discontinue harmful/offending medications

Pharmacotherapy

  • For elderly patients who have extreme pain, tenderness or embarrassment:

Surgery and Device Based Therapy

Indications for Surgery

  • Surgery is indicated if patients have no response to medical therapies

Prognosis

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.[13] 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, or drooping chest.

References

  1. ↑ The American Heritage Stedman's Medical Dictionary. "KMLE American Heritage Medical Dictionary definition of gynecomastia".
  2. ↑ Adolescent gynecomastia
  3. ↑ Braunstein, GD (1993). "Gynecomastia". N Engl J Med. 328 (7): 490–5. PMID 8421478. Unknown parameter |month= ignored (help)
  4. ↑ Allee, Mark R (2006-11-15). "Gynecomastia". WebMD, Inc. (emedicine.com). Retrieved 2007-05-20.
  5. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  6. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  7. ↑ Peyriere, H (1999). "Report of gynecomastia in five male patients during antiretroviral therapy for HIV infection". AIDS. 13 (15): 2167–9. PMID 10546872. Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help)
  8. ↑ Heruti, RJ (1997). "Gynecomastia following spinal cord disorder". Arch Phys Med Rehabil. 78 (5): 534–7. PMID 9161376. Unknown parameter |month= ignored (help); Unknown parameter |coauthors= ignored (help)
  9. ↑ Thompson D, Carter J. "Drug-induced gynecomastia". Pharmacotherapy. 13 (1): 37–45. PMID 8094898.
  10. ↑ Glass, AR (1994). "Gynecomastia". Endocrinol Metab Clin North Am. 23 (4): 825–37. PMID 7705322. Unknown parameter |month= ignored (help)
  11. ↑ Braunstein, GD (1999). "Aromatase and Gynecomastia". Endocr Relat Cancer. 6 (2): 315–24. PMID 10731125. Unknown parameter |month= ignored (help)
  12. ↑ Henley D, Lipson N, Korach K, Bloch C (2007). "Prepubertal gynecomastia linked to lavender and tea tree oils". N Engl J Med. 356 (5): 479–85. PMID 17267908.
  13. ↑ Wiesman, IM.; et al. "Gynecomastia: An Outcome Analysis".

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