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gynecomastia

Benign proliferaton of glandular tissue in the male breast. Etiology: 1) persistent pubertal gynecomastia (25%) 2) idiopathic 25% 3) chronic illness - cirrhosis 4) malnutrition 5) hypogonadism 6) hyperthyroidism 7) testicular tumors (germ cell tumors) 8) pharmaceutical agents - spironlactone, cimetidine, androgen antagonists, HIV1 protease inhibitors, 5-alpha reductase inhibitors (finasteride, dutasteride), opioids 9) chronic renal failure Epidemiology: - common in infants, adolescents, older adults Pathology: 1) decrease in androgens, increase in estrogens 2) androgen receptor antagonism 3) increased sex-hormone binding globulin 4) histology changes in breasts over time a) initial phase: generally present for 6 months - epithelial hyperplasia, proliferation & lengthening of ducts, increase in stromal & periductal connective tissue, proliferation of periductal inflammatory cells, periductal edema, stromal fibroblast proliferation b) late phase: after 12 months - increased number of ducts, marked dilation of ducts, little or no epithelial cell proliferation, increased stroma, stromal fibrosis, no inflammation Clinical manifestations: - rubbery of firm mass extending concentrically from the nipple Diagnostic criteria: - subareolar glandular tissue >= 0.5 cm in diameter, usually bilateral Laboratory: - serum testosterone 8AM - serum estradiol - serum beta-chorionic gonadotropin - serum LH - serum TSH [3] Radiology: - mammogram - unilateral gynecomastia in a male is a concern for breast cancer [3] Differential diagnosis: - breast cancer - fat deposits in men with obesity [3] Management: 1) prevention: - avoid pharmaceutical agents associated with gynecomastia 2) chronic, mild, asymptomatic gynecomastia in males does not warrant evaluation [3] 3) treatment during active proliferative phase may be beneficial [3] 4) long-standing gynecomastia is resistant to treatment due to fibrosis [3] 5) pharmaceutic agents - androgens - testosterone, may exacerbate gynecomastia, but useful for hypogonadism - danazol 6) estrogen antagonists (investigational -> treatment of choice) [3] a) clomiphene b) tamoxifen 7) aromatase inhibitors (investigational -> treatment of choice) [3] 8) surgery a) subcutaneous mastectomy b) liposuction

Related

pharmaceutical agents associated with gynecomastia

General

chronic breast disease; chronic mammary gland disease

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 830
  2. UpToDate 14.1 http://www.utdol.com
  3. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med. 2007 Sep 20;357(12):1229-37. PMID: 17881754
  5. Dickson G. Gynecomastia. Am Fam Physician. 2012 Apr 1;85(7):716-22. Review. PMID: 22534349 Free Article
  6. Sansone A, Romanelli F, Sansone M, et al. Gynecomastia and hormones. Endocrine. 2017;55:37-44. PMID: 27145756