Gynecomastia

Gynecomastia: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Adolescence

❑ Drugs

❑ Obesity

❑ Cirrhosis

❑ Chronic renal failure

❑ Hyperthyroidism

❑ Bilateral orchiectomy

❑ Ectopic hCG

❑ Primary hypogonadism

Diagnostic Approach

In true gynecomastia, a ridge of glandular tissue is palpable symmetrically beneath the areola. Gynecomastia must be distinguished from breast cancer, which is an eccentric firm mass with fixation, overlying skin dimpling, or nipple retraction, and regional adenopathy. Gynecomastia may be unilateral in one-third of cases, and it may be tender or painful.

Clinical Findings

Adolescence  Gynecomastia is a normal transient physiologic phenomenon in pubertal boys, and is often unilateral.

Drugs  Exogenous estrogens, such as milk or meat from estrogen-fed cattle, may cause gynecomastia. Spironolactone, H² antagonists, digitoxin, phenothiazines, amphetamines, reserpine, methyldopa, isoniazid, ketoconazole, imipramine, phenytoin, heroin, marijuana, antiandrogens, and anabolic steroids can all induce gynecomastia. A clue is unilateral gynecomastia or asymmetric enlargement.

Obesity  Excess breast tissue appears in proportion to excess in other tissues. Aging also increases body fat versus lean mass, with a fall in testosterone production.

Cirrhosis  Look for concomitant signs such as spider angiomata, palmar erythema, ascites, and testicular atrophy.

Chronic renal failure  Gynecomastia occurs in 50% of men on hemodialysis.

Hyperthyroidism  Weight loss, tachycardia, goiter, tremor, or exophthalmos may suggest this diagnosis.

Bilateral orchiectomy  Whether traumatic or intentional in treatment of prostate cancer, gynecomastia is accompanied by a decrease in beard growth and muscle mass, and smooth skin.

Ectopic hCG  This may be produced by choriocarcinoma of the testis and tumors of the lung, liver, pancreas, colon, or stomach. Examine for a testicular mass or a change in size or consistency of the testis. An abdominal mass suggests adrenocortical carcinoma.

Primary hypogonadism  In Klinefelter syndrome gynecomastia develops during puberty in a patient with long limbs, small firm testes, and underdeveloped secondary sexual characteristics.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

More About Gynecomastia

• Back to disease: Gynecomastia: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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