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Diseases » Gynecomastia » Causes
 

Causes of Gynecomastia

Contents
  1. Gynecomastia: Introduction
  2. List of Causes
  3. Drugs/substances (36 causes)
  4. Hidden causes
  5. Excerpts from book chapters
  6. Complication causes
  7. Causes of symptoms
  8. Related cause information

List of causes of Gynecomastia

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Gynecomastia) that could possibly cause Gynecomastia includes:

More causes: see full list of causes for Gynecomastia

Causes of Gynecomastia (Diseases Database):

The follow list shows some of the possible medical causes of Gynecomastia that are listed by the Diseases Database:

Source: Diseases Database

Gynecomastia Causes: Book Excerpts

Gynecomastia as a complication of other conditions:

Other conditions that might have Gynecomastia as a complication may, potentially, be an underlying cause of Gynecomastia. Our database lists the following as having Gynecomastia as a complication of that condition:

Gynecomastia as a symptom:

Conditions listing Gynecomastia as a symptom may also be potential underlying causes of Gynecomastia. Our database lists the following as having Gynecomastia as a symptom of that condition:

Medications or substances causing Gynecomastia:

The following drugs, medications, substances or toxins are some of the possible causes of Gynecomastia as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

See full list of 36 medications causing Gynecomastia


Related information on causes of Gynecomastia:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Gynecomastia may be found in:

Causes of Gynecomastia: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Gynecomastia.

Breast Pain & Discharge: Differential Diagnosis
(In a Page: Signs and Symptoms)

Breast pain

  • Fibrocystic change
    –Most common benign breast condition
    –Clinically present in 50% and histologically in 90% of women
  • Mastitis
    –Associated with lactation
  • Extramammary causes of pain (e.g., cervical radiculitis, costochondritis, herpes zoster, angina)
  • Breast cancer
    –Occurs in 1/9 women (lifetime risk)
  • Cyst
  • Breast abscess
  • Unilateral or bilateral gynecomastia
  • Phylloides tumor
  • Intraductal papilloma
  • Fat necrosis
  • Trauma
  • Fibroadenoma
  • Lipoma
  • Pregnancy
    Breast discharge
  • Duct ectasia
  • Galactorrhea
  • Mondor's disease
  • Chronic nipple stimulation
  • Pregnancy
  • Hypothyroidism
  • Sarcoidosis
  • Systemic lupus erythematosus
  • Cirrhosis or other hepatic disease
  • Breast cancer
    –Occurs in 1/9 women (lifetime risk)
  • Intraductal papilloma
  • Fibrocystic change
  • Medications (e.g., phenothiazines, metoclopramide, tricyclic antidepressants, reserpine, opiates, cimetidine, androgens)
  • Hypothalamic and pituitary abnormalities (e.g., prolactinoma, acromegaly, empty sella syndrome)
  • Pseudocyesis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Gynecomastia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • 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

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Enlarged Anterior Fontanelle: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Hypothyroidism
    –Primary congenital hypothyroidism occurs in 1/4,000 live births, more in females (2:1)
    –Ectopic thyroid gland is the most common etiology; may also be caused by thyroid dysgenesis, thyroid dyshormonogenesis, hypothalamic-pituitary hypothyroidism
    –Physical findings include prolonged jaundice, macroglossia, doughy skin, umbilical hernia, weak hoarse cry, hypotonia, poor feeding, sparse hair, dry skin, constipation, abdominal distension, poor growth, developmental delay, slow deep-tendon reflexes, broad flat nose
    –Acquired hypothyroidism is most commonly due to iodine deficiency or chronic autoimmune thyroiditis
  • Increased intracranial pressure
    –Usually accompanied by increased head circumference
    –Hydrocephalus
    –Trauma
    –Acute CNS infections (meningitis or encephalitis)
  • Skeletal dysplasias
    –Rickets
    –Achondroplasia
    –Osteogenesis imperfecta
  • Genetic/chromosomal disorders
    –Down syndrome (trisomy 21): Associated with mental retardation, hypotonia, epicanthal folds, slanted palpebral fissures, small ears, Brushfield spots of iris, clinodactyly, single palmar crease, cardiac defects, brachycephaly, protruding tongue, short neck, large space between first and second toes
    –Apert syndrome
    –Trisomy 13
    –Trisomy 18
    –Silver-Russell syndrome
    –Cleidocranial dysostosis
    –Kenny syndrome
  • Fetal hydantoin syndrome
  • Intrauterine growth retardation
  • Zellweger (cerebrohepatorenal) syndrome
  • Hurler syndrome (type I mucopolysaccharidosis)

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Gynecomastia: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

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.

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, a genetic disorder. Before puberty, symptoms also include abnormally small testicles and a slight mental deficiency; after puberty, sparse facial hair, a small penis, decreased libido, and impotence.

Liver cancer

Liver 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.

Pituitary tumor

A pituitary tumor is a hormone-secreting tumor that 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, a headache, or partial bitemporal hemianopia that may progress to blindness.

Reifenstein’s syndrome

Reifenstein’s syndrome is a genetic disorder that produces painless bilateral gynecomastia at puberty. Associated signs may include hypospadias, testicular atrophy, and an underdeveloped penis.

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.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Breast nodule [Breast lump]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Adenofibroma. The extremely mobile or “slippery” feel of this benign neoplasm helps distinguish it from other breast nodules. The nodule usually occurs singly and characteristically feels firm, elastic, and round or lobular, with well-defined margins. It doesn't cause pain or tenderness, can vary from pinhead size to very large, commonly grows rapidly, and usually lies around the nipple or on the lateral side of the upper outer quadrant.

❑ Areolar gland abscess. Areolar gland abscess is a tender, palpable mass on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever may also be pres-ent.

❑ Breast abscess. A localized, hot, tender, fluctuant mass with erythema and peau d'orange typifies an acute abscess. Associated signs and symptoms include fever, chills, malaise, and generalized discomfort. With a chronic abscess, the nodule is nontender, irregular, and firm and may feel like a thick wall of fibrous tissue. It's commonly accompanied by skin dimpling, peau d'orange, nipple retraction and, sometimes, axillary lymphadenopathy.

❑ Breast cancer. A hard, poorly delineated nodule that's fixed to the skin or underlying tissue suggests breast cancer. Malignant nodules typically cause breast dimpling, nipple deviation or retraction, or flattening of the nipple or breast contour. Between 40% and 50% of malignant nodules occur in the upper outer quadrant.

Nodules usually occur singly, although satellite nodules may surround the main one. They're usually nontender. Nipple discharge may be serous or bloody. (A bloody nipple discharge in the presence of a nodule is a classic sign of breast cancer.) Additional findings include edema (peau d'orange) of the skin overlying the mass, erythema, tenderness, and axillary lymphadenopathy. A breast ulcer may occur as a late sign. Breast pain, an unreliable symptom, may be present.

❑ Fibrocystic breast disease. The most common cause of breast nodules, this fibrocystic condition produces smooth, round, slightly elastic nodules, which increase in size and tenderness just before menstruation. The nodules may occur in fine, granular clusters in both breasts or as widespread, well-defined lumps of varying sizes. A thickening of adjacent tissue may be palpable. Cystic nodules are mobile, which helps differentiate them from malignant ones. Because cystic nodules aren't fixed to underlying breast tissue, they don't pro- duce retraction signs, such as nipple deviation or dimpling. Signs and symptoms of premenstrual syndrome — including headache, irritability, bloating, nausea, vomiting, and abdominal cramping — may also be present.

❑ Mammary duct ectasia. The rubbery breast nodule in mammary duct ectasia, a menopausal or postmenopausal disorder, usually lies under the areola. It's commonly accompanied by transient pain, itching, tenderness, and erythema of the areola; thick, sticky, multicolored nipple discharge from multiple ducts; and nipple retraction. The skin overlying the mass may be bluish green or exhibit peau d'orange. Axillary lymphadenopathy is possible.

❑ Mastitis. With mastitis, breast nodules feel firm and indurated or tender, flocculent, and discrete. Gentle palpation defines the area of maximum purulent accumulation. Skin dimpling and nipple deviation, retraction, or flattening may be present, and the nipple may show a crack or abrasion. Accompanying signs and symptoms include breast warmth, erythema, tenderness, and peau d'orange as well as a high fever, chills, malaise, and fatigue.

❑ Paget's disease. Paget's disease is a slow-growing intraductal carcinoma that begins as a scaling, eczematoid unilateral nipple lesion. The nipple later becomes reddened and excoriated and may eventually be completely destroyed. The process extends along the skin as well as in the ducts, usually progressing to a deep-seated mass.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Mastitis and breast engorgement: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Mastitis develops when a pathogen that typically originates in the nursing infant’s nose or pharynx invades breast tissue through a fissured or cracked nipple and disrupts normal lactation. The most common pathogen of this type is Staphylococcus aureus; less frequently, it’s S. epidermidis or beta-hemolytic streptococci. Rarely, mastitis may result from disseminated tuberculosis or the mumps virus. Predisposing factors include a fissure or abrasion on the nipple; blocked milk ducts; and an incomplete let-down reflex, usually due to emotional trauma. Blocked milk ducts can result from a tight bra or prolonged intervals between breast-feedings. Causes of breast engorgement include venous and lymphatic stasis, and alveolar milk accumulation. (See Physiology of lactation, page 982.)

Mastitis occurs postpartum in about 1% of pregnant women, mainly in primiparas who are breast-feeding. It occurs occasionally in nonlactating females and rarely in males. All breast-feeding mothers develop some degree of engorgement, which isn’t an infectious process.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Gynecomastia: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

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.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Breast nodule [Breast lump]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adenofibroma

The extremely mobile or “slippery” feel of an adenofibroma—a benign neoplasm—helps distinguish it from other breast nodules. The nodule usually occurs singly and characteristically feels firm, elastic, and round or lobular, with well-defined margins. It doesn’t cause pain or tenderness, can vary from pinhead size to very large, often grows rapidly, and usually is located around the nipple or on the lateral side of the upper outer quadrant.

Areolar gland abscess

A tender, palpable abscess on the periphery of the areola caused by an infection and inflammation of Montgomery’s glands. Fever may also be present.

Breast abscess

A localized, hot, tender, fluctuant mass with erythema and peau d’orange typifies an acute abscess. Associated signs and symptoms include fever, chills, malaise, and generalized discomfort. In a chronic abscess, the nodule is nontender, irregular, and firm and may feel like a thick wall of fibrous tissue. It’s commonly accompanied by skin dimpling, peau d’orange, and nipple retraction and sometimes by axillary lymphadenopathy.

Breast cancer

A hard, poorly delineated nodule that’s fixed to the skin or underlying tissue suggests breast cancer. Malignant nodules commonly cause breast dimpling, nipple deviation or retraction, or flattening of the nipple or breast contour. Between 40% and 50% of malignant nodules occur in the upper outer quadrant of the breast.

Malignant nodules are usually nontender and occur singly, although satellite nodules may surround the main one. Nipple discharge may be serous or bloody. (A bloody nipple discharge in the presence of a nodule is a classic sign of breast cancer.) Additional findings may include edema and dimpling (peau d’orange) of the skin overlying the mass, erythema, accentuated veins, and axillary lymphadenopathy. A breast ulcer may occur as a late sign. Breast pain, an unreliable symptom, may be present.

Fibrocystic breast disease

The most common cause of breast nodules, this condition produces smooth, round, slightly elastic nodules that increase in size and tenderness just before menstruation. The nodules may occur in fine, granular clusters in both breasts or as widespread, well-defined lumps of varying sizes. A thickening of adjacent tissue may be palpable. Cystic nodules are mobile, which helps differentiate them from malignant ones. Because cystic nodules aren’t fixed to underlying breast tissue, they don’t produce retraction signs, such as nipple deviation or dimpling. A clear, watery (serous), or sticky nipple discharge may appear in one or both breasts. Signs and symptoms of premenstrual syndrome—including headache, irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.

Intraductal papilloma

Intraductal papilloma is a small, benign nodule that grows in the lactiferous ducts. A single larger nodule can sometimes be palpated, but multiple diffuse nodules usually resist palpation. Soft and poorly delineated papillomas usually lie in the subareolar margin. The primary sign of this disorder is a serous or bloody nipple discharge, typically from only one duct. Breast pain and tenderness may also occur.

Mammary duct ectasia

This disorder, which affects menopausal or postmenopausal women, produces a rubbery breast nodule that usually lies under the areola. It’s commonly accompanied by transient pain, itching, tenderness, and erythema of the areola; a thick, sticky, multicolored nipple discharge from multiple ducts; nipple retraction; and a bluish green discoloration or peau d’orange on the skin overlying the mass. Axillary lymphadenopathy may also occur.

Mastitis

In mastitis, breast nodules feel firm and indurated or tender, flocculent, and discrete. Gentle palpation defines the area of maximum purulent accumulation. Skin dimpling and nipple deviation, retraction, or flattening may be present, and the nipple may show a crack or abrasion. Accompanying signs and symptoms include breast warmth, erythema, tenderness, and peau d’orange as well as high fever, chills, malaise, and fatigue.

Nipple adenoma

Although similar in symptoms to Paget’s disease, adenomas rarely produce a deep-seated mass.

Paget’s disease

Paget’s disease is a slow-growing intraductal carcinoma that begins as a scaling, eczematoid nipple lesion on one side. The nipple later becomes reddened and excoriated and may eventually be completely destroyed. The process extends along the skin as well as in the ducts, usually progressing to a deep-seated mass.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Gynecomastia: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Adolescence

❑ Drugs

❑ Obesity

❑ Cirrhosis

❑ Chronic renal failure

❑ Hyperthyroidism

❑ Bilateral orchiectomy

❑ Ectopic hCG

❑ Primary hypogonadism

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Breast Mass/Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

Breast Mass

❑ Fibrocystic disease

❑ Fibroadenoma

❑ Breast cancer

❑ Intraductal papilloma

❑ Mastitis

❑ Hematoma

❑ Thrombophlebitis

❑ Galactocele

Breast Discharge

❑ Drugs

❑ Postpartum lactation

❑ Prolactin-secreting pituitary adenoma

❑ Intraductal papilloma

❑ Fibrocystic disease

❑ Breast cancer

❑ Mammary duct ectasia

❑ Repeated nipple stimulation

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Gynecomastia: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

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.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Breast nodule: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Adenofibroma

The extremely mobile or “slippery” feel of an adenofibroma (a benign neoplasm) helps distinguish it from other breast nodules. The nodule usually occurs singly and characteristically feels firm, elastic, and round or lobular, with well-defined margins. It doesn’t cause pain or tenderness, can vary from pinhead size to very large, typically grows rapidly, and usually lies around the nipple or on the lateral side of the upper outer quadrant.

Areolar gland abscess

An areolar gland abscess is characterized by a tender, palpable abscess on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever, local swelling, and drainage may also be present, and the patient may complain of malaise.

Breast abscess

A localized, hot, tender, fluctuant mass with erythema and peau d’orange typifies an acute breast abscess. Associated signs and symptoms include fever, chills, malaise, and generalized discomfort. With a chronic abscess, the nodule is nontender, irregular, and firm and may feel like a thick wall of fibrous tissue. It’s commonly accompanied by skin dimpling, peau d’orange, and nipple retraction and sometimes by axillary lymphadenopathy.

Breast cancer

A hard, poorly delineated nodule that’s fixed to the skin or underlying tissue suggests breast cancer. Malignant nodules commonly cause breast dimpling, nipple deviation or retraction, or flattening of the nipple or breast contour. Between 40% and 50% of malignant nodules occur in the upper outer quadrant.

Nodules usually occur singly, although satellite nodules may surround the main one. They’re usually nontender. Nipple discharge may be serous or bloody. (A bloody nipple discharge in the presence of a nodule is a classic sign of breast cancer.) Additional findings include edema (peau d’orange) of the skin overlying the mass, erythema, tenderness, and axillary lymphadenopathy. A breast ulcer may occur as a late sign. Breast pain, an unreliable symptom, may be present.

Fibrocystic breast disease

The most common cause of breast nodules, fibrocystic breast disease produces smooth, round, slightly elastic nodules, which increase in size and tenderness just before menstruation. The nodules may occur in fine, granular clusters in both breasts or as widespread, well-defined lumps of varying sizes. A thickening of adjacent tissue may be palpable. Cystic nodules are mobile, which helps differentiate them from malignant ones. Because cystic nodules aren’t fixed to underlying breast tissue, they don’t produce retraction signs, such as nipple deviation or dimpling. A clear, watery (serous), or sticky nipple discharge may appear in one or both breasts. Signs and symptoms of premenstrual syndrome — including headache, irritability, bloating, nausea, vomiting, and abdominal cramping — may also be present.

Intraductal papilloma

The tiny nodules of intraductal papilloma (a benign lesion) usually resist palpation. Nodules large enough to be palpated usually occur singly, but they may be multiple and diffuse. Soft and poorly delineated, the nodules usually lie in the subareolar margin. The primary sign of this disorder is serous or bloody nipple discharge, typically from only one duct. Breast pain and tenderness may occur.

Mammary duct ectasia

The rubbery breast nodule in mammary duct ectasia — a menopausal or postmenopausal disorder — usually lies under the areola. It’s commonly accompanied by transient pain, itching, tenderness, and erythema of the areola; thick, sticky, multicolored nipple discharge from multiple ducts; and nipple retraction. The skin overlying the mass may be bluish green or exhibit peau d’orange. Axillary lymphadenopathy is possible.

Mastitis

With mastitis, breast nodules feel firm and indurated or tender, flocculent, and discrete. Gentle palpation defines the area of maximum purulent accumulation. Skin dimpling and nipple deviation, retraction, or flattening may be present, and the nipple may show a crack or abrasion. Accompanying signs and symptoms include breast warmth, erythema, tenderness, and peau d’orange, plus high fever, chills, malaise, and fatigue.

Paget’s disease

In Paget’s disease, the slow-growing intraductal carcinoma begins as a scaling, eczematoid unilateral nipple lesion. The nipple later becomes reddened and excoriated and may eventually be completely destroyed. The process extends along the skin as well as in the ducts, usually progressing to a deep-seated mass.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Breast Enlargement: Principal Causes of Breast Enlargement
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Infectious
    1. Cellulitis/abscess
  2. Noninfectious
    1. Infancy
      1. Physiologic hypertrophy
    2. Childhood
      1. Premature thelarche
      2. Precocious puberty
      3. Gynecomastia (male)
      4. Neoplasm (rare)
    3. Adolescence
      1. Girls
        1. Cysts
        2. Trauma
        3. Macromastia
        4. Juvenile hypertrophy
        5. Fibrocystic disease
        6. Neoplasm
      2. Boys
        1. Physiologic gynecomastia
        2. Drugs
        3. Klinefelter syndrome
        4. Neoplasm
        5. Other

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Scrotal Enlargement: Principal Causes of Scrotal Enlargement
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Painfulscrotal enlargement
    1. Testicular
      1. Torsion of the testis
      2. Orchitis
      3. Trauma
    2. Nontesticular
      1. Torsion of appendages of the testisand epididymis
      2. Epididymitis
      3. Incarcerated inguinal hernia
  2. Nonpainful scrotal enlargement
    1. Testicular
      1. In uterotorsion
      2. Tumor
    2. Nontesticular
      1. Inguinal hernia
      2. Hydrocele
      3. Spermatocele
      4. Varicocele
      5. Henoch-Schönlein purpura
      6. Kawasaki disease
      7. Meconium peritonitis
      8. Tumors of the epididymis, spermaticcord, or scrotal wall
      9. Generalized edema

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Gynecomastia: Medical causes
(Nursing: Interpreting Signs and Symptoms)

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.

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, a genetic disorder. Before puberty, symptoms also include abnormally small testicles and a slight mental deficiency; after puberty, sparse facial hair, a small penis, decreased libido, and impotence.

Liver cancer.Liver 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.

Pituitary tumor.A pituitary tumor is a hormone-secreting tumor that 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, a headache, or partial bitemporal hemianopia that may progress to blindness.

Reifenstein's syndrome.Reifenstein's syndrome is a genetic disorder that produces painless bilateral gynecomastia at puberty. Associated signs may include hypospadias, testicular atrophy, and an underdeveloped penis.

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.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Breast nodule [Breast lump]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Adenofibroma.The extremely mobile or “slippery” feel of this benign neoplasm helps distinguish it from other breast nodules. The nodule usually occurs singly and characteristically feels firm, elastic, and round or lobular, with well-defined margins. It doesn't cause pain or tenderness, can vary from pinhead size to very large, commonly grows rapidly, and usually lies around the nipple or on the lateral side of the upper outer quadrant.

Areolar gland abscess.Areolar gland abscess is a tender, palpable mass on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever may also be present.

Breast abscess.A localized, hot, tender, fluctuant mass with erythema and peau d'orange typifies an acute abscess. Associated signs and symptoms include fever, chills, malaise, and generalized discomfort. With a chronic abscess, the nodule is nontender, irregular, and firm and may feel like a thick wall of fibrous tissue. It's commonly accompanied by skin dimpling, peau d'orange, nipple retraction and, sometimes, axillary lymphadenopathy.

Breast cancer.A hard, poorly delineated nodule that's fixed to the skin orunderlying tissue suggests breast cancer. Malignant nodules typically cause breast dimpling, nipple deviation or retraction, or flattening of the nipple or breast contour. Between 40% and 50% of malignant nodules occur in the upper outer quadrant.

Nodules usually occur singly, although satellite nodules may surround the main one. They're usually nontender. Nipple discharge may be serous or bloody. (A bloody nipple discharge in the presence of a nodule is a classic sign of breast cancer.) Additional findings include edema (peau d'orange) of the skin overlying the mass, erythema, tenderness, and axillary lymphadenopathy. A breast ulcer may occur as a late sign. Breast pain, an unreliable symptom, may be present.

Fibrocystic breast disease.The most common cause of breast nodules, this fibrocystic condition produces smooth, round, slightly elastic nodules, which increase in size and tenderness just before menstruation. The nodules may occur in fine, granular clusters in both breasts or as widespread, well-defined lumps of varying sizes. A thickening of adjacent tissue may be palpable. Cystic nodules are mobile, which helps differentiate them from malignant ones. Because cystic nodules aren't fixed to underlying breast tissue, they don't produce retraction signs, such as nipple deviation or dimpling. Signs and symptoms of premenstrual syndrome—including headache, irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.

Mammary duct ectasia.The rubbery breast nodule in mammary duct ectasia, a menopausal or postmenopausal disorder, usually lies under the areola. It's commonly accompanied by transient pain, itching, tenderness, and erythema of the areola; thick, sticky, multicolored nipple discharge from multiple ducts; and nipple retraction. The skin overlying the mass may be bluish green or exhibit peau d'orange. Axillary lymphadenopathy is possible.

Mastitis.With mastitis, breast nodules feel firm and indurated or tender, flocculent, and discrete. Gentle palpation defines the area of maximum purulent accumulation. Skin dimpling and nipple deviation, retraction, or flattening may be present, and the nipple may show a crack or abrasion. Accompanying signs and symptoms include breast warmth, erythema, tenderness, and peau d'orange as well as a high fever, chills, malaise, and fatigue.

Paget's disease.Paget's disease is a slow-growing intraductal carcinoma that begins as a scaling, eczematoid unilateral nipple lesion. The nipple later becomes reddened and excoriated and may eventually be completely destroyed. The process extends along the skin as well as in the ducts, usually progressing to a deep-seated mass.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Gynecomastia: Gynecomastia - risk factors
(The 5-Minute Pediatric Consult)

Any situation that leads to an increase in the net effect of estrogen action relative to androgen action at the level of the breast may lead to gynecomastia. These situations could include:

  • Increased estrogen concentration (endogenous or exogenous)
  • Normal estrogen levels with decreased androgen concentrations
  • Congenital reduction in estrogen receptors
  • Pharmacologic blockade of androgen receptors
  • Increased breast or peripheral tissue aromatase, which converts androgens to estrogens
  • Elevated leptin levels may increase aromatase enzyme acticity, stimulate growth of mammary cells or increase breast receptor sensitivity to estrogen
  • Testicular dysfunction
  • High levels of serum gonadotropins or increased sex hormone–binding globulin
  • Elevated estrogen levels lead to proliferation of the ducts and surrounding mesenchymal tissue, resulting in breast enlargement.

Gynecomastia - etiology

  • Physiologic:
    • Neonatal: Transient palpable breast tissue developing in newborns owing to elevated estrogen levels in the fetoplacental unit. This condition resolves as estrogen levels decline.
    • Pubertal: Benign transient gynecomastia occurring in otherwise healthy adolescent males. Breast tissue in pubertal gynecomastia measuring <4 cm in diameter has a high likelihood of spontaneous regression.
    • Involutional: Breast enlargement occurs in old men.
  • Pathologic:
    • Drug-induced:
      • Hormones: Estrogen, androgens, gonadotropins, anabolic steroids, growth hormone, antiandrogens, and cosmetics, foods, hair products, and herbal remedies that contain estrogen
      • Anti-infective agents: Ethionamide, isoniazid, ketoconazole, metronidazole
      • Antiulcer drugs: Cimetidine, ranitidine, omeprazole
      • Chemotherapeutic agents: Alkylating agents, methotrexate, vinca alkaloids
      • Cardiovascular agents: Amiodarone, captopril, digitoxin, diltiazem, enalapril, methyl-dopa, nifedipine, reserpine, spironolactone, verapamil
      • Psychotropic agents: Diazepam, haloperidol, phenothiazines, tricyclic antidepressants
      • Drugs of abuse: Alcohol, amphetamines, heroin, marijuana, methadone
      • Miscellaneous: Metoclopramide, phenytoin, penicillamine, theophylline, gabapentin, clonidine and pregabalin
    • Hypogonadism: Primary or secondary
    • Tumors: Testicular, adrenal, ectopic tumors that produce human chorionic gonadotropin
    • Chronic disease: Hyperthyroidism, renal failure, liver disease, malnutrition with refeeding, HIV infection
    • Congenital disorders: Klinefelter syndrome, vanishing testes syndrome (also known as anorchism, gonadal agenesis, or testicular regression), androgen resistance syndromes, true hermaphroditism, excessive peripheral tissue aromatase
    • Acquired testicular failure: Viral orchitis, trauma, granulomatous disease, or castration
    • Chest wall trauma or intercostal nerve damage following surgery or herpes zoster
    • Psychologic stress
    • Spinal cord injury
>

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008


 » Next page: Symptoms of Gynecomastia

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