Gynecomastia
Gynecomastia: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Charles M. Kodner
Gynecomastia is the palpable enlargement of the breast tissue in men. Presentation occurs in three peak age groups, corresponding to the common physiologic causes of breast enlargement. After the neonatal period, the most common causes of gynecomastia are idiopathic (25%), puberty (25%), medications (10% to 20%), cirrhosis or malnutrition (8%), or primary hypogonadism (8%) (1). Klinefelter’s syndrome increases the risk of breast cancer, but other causes do not.
Approach
Most patients with gynecomastia have a transient, physiologic imbalance between circulating estrogens and androgens. Gynecomastia that is persistent or symptomatic, or presents outside the expected age ranges, requires further diagnostic evaluation.
A. Differentiation from pseudogynecomastia. Physical findings are usually adequate to distinguish true breast tissue enlargement from breast enlargement from adipose tissue.
B. Physiologic conditions causing normal, transient gynecomastia.
1. Neonatal period. Transplacental estrogen causes transient breast tissue enlargement in most newborns; this may be associated with nipple discharge; typically, it resolves over 3 to 4 weeks. No additional evaluation is necessary.
2. Puberty. Hormonal changes and breast tissue proliferation during puberty cause transient gynecomastia in adolescent males; this may be asymmetric and it can be tender. The condition usually resolves within 1 year, but can persist for up to 2 years.
3. Older adults. Many men (aged 50–80 years) have palpable breast tissue enlargement that is often physiologic, caused by a relative increase in body fat and increased aromatization of estrogen precursors, but medical disorders or medication effects should be considered (2).
History
Does the history suggest breast cancer or an underlying endocrine disorder? Are there immediately identifiable causes?
A. History. Persistent or rapid breast tissue enlargement may necessitate further evaluation if no diagnosis is apparent. Mild pain or tenderness by itself does not indicate a concerning underlying cause.
B. Medications. Substances that can cause gynecomastia include alcohol, marijuana, androgens, estrogens, digitoxin, cimetidine, spironolactone, ketoconazole, and antiandrogens (1).
C. Medical disorders. Hyperthyroidism, renal failure, liver disease, starvation, or malnutrition can cause gynecomastia. Underlying cancers (lung, liver, kidney) can produce ectopic human chorionic gonadotropin (HCG), which stimulates aromatase activity.
D. Endocrine disorders. Primary testicular failure and Klinefelter’s syndrome can be associated with gynecomastia.
Physical examination (PE)
True gynecomastia is confirmed with the PE. With the patient supine, the breast is grasped between thumb and forefinger and the digits are moved toward the nipple. A firm, rubbery, mobile, disk-shaped mass of tissue beneath the nipple indicates true breast tissue enlargement. A focused PE can help exclude cancer of the breast or testes and some medical or endocrine disorders (Chapter 11.2).
A. Pseudogynecomastia. Adipose tissue deposition produces the soft and poorly defined breast enlargement of pseudogynecomastia.
B. Breast cancer. A unilateral, eccentric mass that is hard or firm, fixed to underlying tissue or associated with overlying skin dimpling, nipple discharge, or retraction, or axillary lymphadenopathy may represent breast cancer.
C. Testicular examination. Congenital anorchia is a rare cause of gynecomastia. Bilateral small testes suggest gonadal failure. Testicular atrophy can result from alcohol abuse, mumps, leprosy, or other granulomatous disorders. Asymmetry or a palpable mass suggests testicular cancer (Chapter 10.7).
Testing
Most patients with physiologic gynecomastia can be readily identified and no further evaluation is required. If pathology is suspected, additional testing may be needed.
A. Clinical laboratory testing. Liver, kidney, and thyroid function should be assessed, if clinically indicated.
B. Diagnostic imaging. Neither mammography nor ultrasound of the breast is usually helpful.
C. Special tests. If an underlying endocrine disorder is suspected, serum HCG, testosterone, estradiol, and luteinizing hormone (LH) levels should be checked. Fine needle aspiration of a mass may be considered to diagnose breast cancer.
Diagnostic assessment
The medical history and PE may be sufficient for diagnostic assessment. The directed PE should focus on detecting breast cancer, testicular tumors, and endocrine disease. Further evaluation is indicated if these conditions are suspected. In cases of gynecomastia that do not resolve, progressive or rapid onset of gynecomastia, or history and PE suggestive of a possible endocrine disorder, measure the levels of serum LH, estradiol, testosterone, and HCG, which constitutes a reasonable screening evaluation for underlying endocrinopathies.
A. Benign gynecomastia. If true gynecomastia appears in one of the expected age ranges and neither the history nor PE suggests an underlying medical or endocrine disorder, then only reassurance and observation are required. Gynecomastia will resolve in 1 to 2 years in most patients; however, those cases that progress or fail to resolve may require further evaluation.
B. Medications. Drugs that cause gynecomastia should be discontinued, if possible, and the patient followed for the resolution of gynecomastia.
C. Testicular insufficiency results in an elevated LH serum level and a normal to low testosterone serum level.
D. Klinefelter’s syndrome. This abnormality is associated with small, firm testes, behavioral abnormalities or mental retardation, an elevated estradiol level, and a diagnostic chromosome analysis.
E. Androgen resistance. Elevated LH and testosterone levels suggest this syndrome.
F. Neoplasia. High HCG levels may indicate a HCG-secreting tumor of the lung, stomach, liver, or kidney, or a testicular or extragonadal germ cell tumor. An elevated HCG should prompt a search for one of these cancers with a detailed PE, a radiograph of the chest, and a computed tomographic scan of the abdomen.
References
1. Braunstein GD. Gynecomastia. N Engl J Med 1993;328:490–495.
2. Frantz AG, Wilson JD. Disorders of breasts in men. In: Wilson JD, Foster DW, eds. Williams textbook of endocrinology, 9th ed. Philadelphia: WB Saunders; 1998:885–900.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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