Gynecomastia
Gynecomastia: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Occurring only in males, gynecomastia refers to increased breast size due to excessive mammary gland development. Usually bilateral, gynecomastia may be associated with breast tenderness and milk secretion.
Normally, several hormones regulate breast development. Estrogens, growth hormone, and corticosteroids stimulate ductal growth, while progesterone and prolactin stimulate growth of the alveolar lobules. Hormonal imbalance — particularly a change in the estrogen-androgen ratio and an increase in prolactin — is a likely contributing factor. Gynecomastia commonly results from the effects of estrogens and other drugs. It may also result from hormone-secreting tumors and from endocrine, genetic, hepatic, or adrenal disorders. Physiologic gynecomastia may occur in neonatal, pubertal, and geriatric males because of normal fluctuations in hormone levels.
History
Begin the history by asking the patient when he first noticed his breast enlargement. How old was he at the time? Since then, have his breasts gotten progressively larger, smaller, or stayed the same? Does he also have breast tenderness or discharge? Have him describe the discharge, if any. Ask him if he’s ever had his nipples pierced and, if so, did he experience any complications as a result of the piercing? Next, take a thorough drug history, including prescription, over-the-counter, herbal, and street drugs. Then explore associated signs and symptoms, such as a testicular mass or pain, loss of libido, decreased potency, and loss of chest, axillary, or facial hair.
Physical assessment
Focus the physical examination on the breasts, testicles, and penis. As you examine the breasts, note any asymmetry, dimpling, abnormal pigmentation, or ulceration. Observe the testicles for size and symmetry. Then palpate them to detect nodules, tenderness, or unusual consistency. Look for normal penile development after puberty, and note hypospadias.
Medical causes
Breast cancer
Painful unilateral gynecomastia develops rapidly in males with breast cancer. Palpation may reveal a hard or stony breast lump suggesting a malignant tumor. Breast examination may also detect changes in breast symmetry; skin changes, such as thickening, dimpling, peau d’orange, or ulceration; a warm, reddened area; and nipple changes, such as itching, burning, erosion, deviation, flattening, retraction, and a watery, bloody, or purulent discharge.
Cirrhosis
A late sign of cirrhosis, bilateral gynecomastia results from failure of the liver to inactivate circulating estrogens. It’s typically accompanied by testicular atrophy, decreased libido, impotence, and loss of facial, chest, and axillary hair. Other late signs and symptoms include mental changes, bleeding tendencies, spider angiomas, palmar erythema, severe pruritus and dry skin, fetor hepaticus, enlarged superficial abdominal veins and, possibly, jaundice and hepatomegaly.
Hypothyroidism
Typically, hypothyroidism produces bilateral gynecomastia along with bradycardia, cold intolerance, weight gain despite anorexia, and mental dullness. The patient may display periorbital edema and puffiness in the face, hands, and feet. His hair appears brittle and sparse and his skin is dry, pale, cool, and doughy.
Klinefelter’s syndrome
Painless bilateral gynecomastia first appears during adolescence in Klinefelter’s syndrome. Before puberty, symptoms also include abnormally small testicles and slight mental deficiency; after puberty, sparse facial hair, a small penis, decreased libido, and impotence.
Malnutrition
Painful unilateral gynecomastia (known as refeeding gynecomastia) may occur when the malnourished patient begins to take nourishment again. Other effects of malnutrition include apathy, muscle wasting, weakness, limb paresthesia, anorexia, nausea, vomiting, and diarrhea. Inspection may reveal dull, sparse, dry hair; brittle nails; dark, swollen cheeks and lips; dry, flaky skin; and, occasionally, edema and hepatomegaly.
Pituitary tumor
A pituitary tumor causes bilateral gynecomastia accompanied by galactorrhea, impotence, and decreased libido. Other hormonal effects may include enlarged hands and feet, coarse facial features with prognathism, voice deepening, weight gain, increased blood pressure, diaphoresis, heat intolerance, hyperpigmentation, and thickened, oily skin. Paresthesia or sensory loss and muscle weakness commonly affect the limbs. If the tumor expands, it may cause blurred vision, diplopia, headache, or partial bitemporal hemianopia that may progress to blindness.
Renal failure (chronic)
Chronic renal failure may produce bilateral gynecomastia accompanied by decreased libido and impotence. Among its more characteristic features, however, are ammonia breath odor, oliguria, fatigue, decreased mental acuity, seizures, muscle cramps, and peripheral neuropathy. Common GI effects include anorexia, nausea, vomiting, and constipation or diarrhea. The patient also typically has bleeding tendencies, pruritus, yellow-brown or bronze skin and, occasionally, uremic frost and increased blood pressure.
Testicular failure (secondary)
Commonly associated with mumps and other infectious disorders, secondary testicular failure produces bilateral gynecomastia that appears after normal puberty. This disorder may also cause sparse facial hair, decreased libido, impotence, and testicular atrophy.
Testicular tumor
Choriocarcinomas, Leydig’s cell tumors, and other testicular tumors typically cause bilateral gynecomastia, nipple tenderness, and decreased libido. Because these tumors are usually painless, testicular swelling may be the patient’s initial complaint. A firm mass and a heavy sensation in the scrotum may occur.
Thyrotoxicosis
With thyrotoxicosis, bilateral gynecomastia may occur with loss of libido and impotence. Cardinal findings include tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos. An atrial or ventricular gallop may also occur.
Other causes
Drugs
When gynecomastia is an effect of drugs, it’s typically painful and unilateral. Estrogens used to treat prostate cancer, including diethylstilbestrol, estramustine, and chlorotrianisene, directly affect the estrogen-androgen ratio. Drugs that have an estrogen-like effect, such as cardiac glycosides and human chorionic gonadotropin, may do the same. Regular use of alcohol, marijuana, or heroin reduces plasma testosterone levels, causing gynecomastia. Other drugs — such as flutamide, cyproterone, spironolactone, cimetidine, and ketoconazole — produce this sign by interfering with androgen production or action. Some common drugs, including phenothiazines, tricyclic antidepressants, and antihypertensives, produce gynecomastia in an unknown way.
Treatments
Gynecomastia may develop within weeks of starting hemodialysis for chronic renal failure. It may also follow major surgery or testicular irradiation.
Specialconsiderations
To make the patient as comfortable as possible, apply cold compresses to his breasts and administer analgesics. Prepare him for diagnostic tests, including chest and skull X-rays and blood hormone levels.
Some patients are helped by tamoxifen, an antiestrogen, or by testolactone, an inhibitor of testosterone-to-estrogen conversion. Surgical removal of breast tissue may be an option if drug treatment fails.
Pediatric pointers
In neonates, gynecomastia may be associated with galactorrhea (“witch’s milk”). This sign usually disappears within a few weeks of birth but may persist until age 2.
Most males have physiologic gynecomastia at some time during adolescence, usually around age 14. This gynecomastia is usually asymmetrical and tender; it commonly resolves within 2 years and rarely persists beyond age 20.
Patient counseling
Because gynecomastia may alter the patient’s body image, provide emotional support. Reassure the patient that treatment can reduce gynecomastia. Be sure to explain all treatments and procedures to the patient.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
More About Gynecomastia
More Medical Textbooks Online about Gynecomastia
Review other book chapters online related to Gynecomastia:
Medical Books Excerpts
- Gynecomastia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Gynecomastia
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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