GYNECOMASTIA

Benign enlargement of the male breast (Palpable, usually bilateral, sometime unilateral) resulting from a proliferation of glandular component of male breast (Gynecomastia).

Physiological gynecomastia- newborn, adolescent, elderly individuals.

Pathological gynecomastia- due to altered estrogen-androgen balance, excess estrogen and/or decreased testosterone or idiopathic.

Softer fatty pseudogynecomastia (lipomastia) in which only adipose tissue is felt.

Glandular gynecomastia- typically tender & fatty gynecomastia typically nontender.

Excess estrogen and androgen deficiency may cause gynecomastia, glandular tissue is firm and rubbery extends concentrically from nipples.

Pubertal gynecomastia (tender discoid enlargement of breast tissue 2–3 cm diameter beneath the areola).

macromastia >5 cm.

Pubertal gynecomastia (tender discoid enlargement of breast tissue 2–3 cm diameter beneath the areola).

Worrisome characteristics of malignancy: location not immediately below the areola, asymmetry, nipple retraction, unusual firmness, bleeding, discharge.

GYNECOMASTIA Causes:

Aging, Obesity, Neonatal period, puberty, Androgen insensitivity syndrome, Hyperprolactinemia, Diabetic lymphocytic mastitis, Hyperprolactinemia, Hyperthyroidism or hypothyroidism, Klinefelter syndrome, Male hypogonadism (primary or secondary), Chronic liver disease, Chronic kidney disease, Breast carcinoma, Alcohol, Spironolactone (common), Anabolic steroids, Androgens (testosterone), GH, growth hormone, GnRH, gonadotropin-releasing hormone.

GYNECOMASTIA Investigation:

Testosterone, 17 Beta Estradiol (E2), Prolactine, LH, FSH, TSH, beta-hCG, AFP, Creatinine, LFT, USG- Testes (scrotum), CBC.

Sex hormone binding globulin (SHBG)- binds androgen more than estrogen, so high estrogen to act on peripheral tissue like breast.

Primary hypogonadism- low testosterone, high LH.

secondary hypogonadism (low testosterone, low or normal LH).

Partial androgen insensitivity syndrome- High testosterone, high LH.

estradiol in testicular tumor

bilateral mammography, CT chest- bronchogenic, metastatic carcinoma

GYNECOMASTIA Treatment:

Pubertal gynecomastia usually resolves spontaneously in 1–2 years.

Drug induced gynecomastia resolves in months (~ 3 months) if offending drug is stopped (eg. spironolactone).

Painful or persistent gynecomastia- may treated with medical treatment, 9–12 months usually (more effective if started early).

Selective estrogen receptor modulator (SERM) treatment useful in true glandular gynecomastia-

Oral Raloxifene, 60 mg OD more effective than Tamoxifen 10mg OD.

{Aromatase inhibitor (AI)} oral Anastrozole, 1mg OD reduces breast volume over 6 months.

Testosterone therapy for men with hypogonadism.

GYNECOMASTIA Surgery:

Surgical correction is reserved for patients with persistent or severe gynecomastia.

Surgery- suction lipectomy and/or removal of glandular breast tissue through nipple sparing periareolar incision. severe cases- removal of nipple-areola complex. pubertal gynecomastia- surgery postponed until completion of puberty

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