Gynecomastia
Gynecomastia: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Occurring only in males, gynecomastia refers to increased breast size due to excessive mammary gland development. This change in breast size may be barely palpable or immediately obvious. 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. Although the pathophysiology of gynecomastia isn’t fully understood, a hormonal imbalance—particularly a change in the estrogen-androgen ratio and an increase in prolactin—is a likely contributing factor. This explains why 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 and physical examination
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 ever had his nipples pierced and, if so, if he developed any complications. Next, take a thorough drug history, including prescription, over-the-counter, herbal, and street drugs. Then explore associated signs and symptoms, such as testicular mass or pain, loss of libido, decreased potency, and loss of chest, axillary, or facial hair.
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
Adrenal carcinoma
Estrogen production by an adrenal tumor may produce a feminizing syndrome in males characterized by bilateral gynecomastia, loss of libido, impotence, testicular atrophy, and reduced facial hair growth. Cushingoid signs, such as moon face and purple striae, may also occur.
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 often 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.
Hermaphroditism
In true hermaphroditism, ovarian and testicular tissues coexist, resulting in external genitalia with both feminine and masculine characteristics. At puberty, the patient typically develops marked bilateral gynecomastia. About 50% of hermaphrodites also experience male menstruation in the form of cyclic hematuria.
Hypothyroidism
Typically, this disorder 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 this genetic disorder. Before puberty, symptoms also include abnormally small testicles and slight mental deficiency; after puberty, sparse facial hair, a small penis, decreased libido, and impotence.
Liver cancer
This type of cancer may produce bilateral gynecomastia and other characteristics of feminization, such as testicular atrophy, impotence, and reduced facial hair growth. The patient may complain of severe epigastric or right-upper-quadrant pain associated with a right-upper-quadrant mass. A large tumor may also produce a bruit on auscultation. Related findings may include anorexia, weight loss, dependent edema, fever, cachexia and, possibly, jaundice or ascites.
Lung cancer
Bronchogenic carcinoma or metastasis to the lung from testicular choriocarcinoma may result in bilateral gynecomastia. Other effects vary according to the tumor’s primary site but usually include anorexia, weight loss, fatigue, chronic cough, hemoptysis, clubbing, dyspnea, and diffuse chest pain. Fever and wheezing may occur.
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
This hormone-secreting 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.
Reifenstein’s syndrome
This genetic disorder produces painless bilateral gynecomastia at puberty. Associated signs may include hypospadias, testicular atrophy, and an underdeveloped penis.
Renal failure (chronic)
This disorder 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
Bilateral gynecomastia may occur with loss of libido and impotence. Cardinal findings include an enlarged thyroid gland, tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, 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 estramustine, 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, 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.
Because gynecomastia may alter the patient’s body image, provide emotional support. Reassure the patient that treatment can reduce gynecomastia. 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 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.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
More About Gynecomastia
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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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