Gynecomastia

Gynecomastia: Excerpt from In A Page: Pediatric Signs and Symptoms

Gynecomastia is benign breast tissue enlargement in males, affecting up to two-thirds of boys in adolescence. The majority of cases are secondary to normal developmental changes involving a transient imbalance of the estrogen/testosterone ratio. Peak for pubertal cases occurs at Tanner stage II–III, and most spontaneously regress.

Differential Diagnosis

• Pubertal
  –Prevalence 40–69% in adolescent males
  –Onset by 10–12 years old
  –Peaks at 13–14 years, Tanner III staging
  –Resolution in 1–2 years in 75%
  –Obese patients more affected

• Several drugs can cause gynecomastia
  –Antiandrogens: Flutamide, finasteride, ketoconazole, spironolactone
  –GI agents: Cimetidine, ranitidine
  –Calcium channel blockers: Verapamil, nifedipine
  –Illicit drugs: Marijuana, heroin, methadone, amphetamines
  –Hormones: Androgens, anabolic steroids, estrogens
  –Psychiatric: Phenothiazines, diazepam, tricyclic antidepressants

• Androgen insufficiency
  –Klinefelter syndrome (47, XXY)
  –Seminiferous tubule dysgenesis
  –Testicular failure
  –Androgen-insensitivity syndrome, androgen receptor defects
  –Biosynthetic defects in testosterone production
  –Isolated LH deficiency
• Excess estrogen
  –Feminizing adrenocortical tumors (rare)

• Testicular neoplasms
  –Germ cell tumors: Associated with hCG production; hCG leads to Leydig cell dysfunction and increased aromatase
  –Leydig cell tumors secrete estradiol
  –Sertoli cell tumors: Associated with excessive aromatase activity

• Pseudogynecomastia
  –Fat deposition without glandular development
  –Seen in obesity
• Other breast enlargement (not true gynecomastia)
  –Neurofibroma
  –Carcinoma of breast
  –Hemangioma
  –Lipoma
• Reifenstein syndrome
• Kallmann syndrome
• Liver cirrhosis

Workup and Diagnosis

• History
  –Breast characteristics
  –Duration
  –Progressive or regressing
  –Unilateral/bilateral
  –Associated erythema, tenderness, and/or discharge
  –Medication exposure
  –Change in appearance of testicles
  –Pubertal onset
  –Erectile function
  –Liver or kidney problems
• Physical exam
  –Abdominal exam for mass
  –Testicular exam for mass
  –Genital exam for Tanner staging
  –Chest exam for size and texture of tissue

• Labs
  –Investigation indicated for severe, prolonged, or sudden onset for the adolescent, for prepubertal boys, for pubertal boys with minimal viralization and/or small testes, and for child with CNS complaints
  –Karyotype
  –Serum gonadotropin (LH)
  –Serum testosterone
  –Serum estradiol
  –Serum hCG

Treatment

• Pubertal
  –No treatment if pubertal development and physical exam are normal
  –Re-evaluation in 6 months
• Cessation of drugs when implicated
• Testosterone replacement if indicated for hypogonadism
• Weight loss for pseudogynecomastia
• Surgery (reduction mammoplasty) if severe and psychologically distressing
• Persistent pubertal gynecomastia
  –Therapy is investigational; no large trials completed yet
  –Antiestrogens (clomiphene and tamoxifen)
  –Aromastase inhibitors (testolactone)

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Gynecomastia

• Back to disease: Gynecomastia: Introduction
• Next Book Extract About Gynecomastia: Enlarged Anterior Fontanelle (In A Page: Pediatric Signs and Symptoms)
• More Book Extracts: All Online Books for Gynecomastia

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Enlarged Anterior Fontanelle (In A Page: Pediatric Signs and Symptoms)

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