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  Gynecomastia
 
Authors: Shehzad Basaria, MD, Adrian Dobs Last modified: January 2, 2002
DIAGNOSTIC CRITERIA

  EPIDEMIOLOGY

  • There is a tri-modal presentation of gynecomastia.
  • Gynecomastia is common in infancy with 60-90% of infants having transient gynecomastia as a result of estrogenic environment during pregnancy.
  • The second peak occurs during puberty affecting 10-70% of boys. The peak incidence is at 13-14 yrs and it regresses after 18-24 months.
  • The third peak is between age 50-80 yrs affecting 20-60% of men.

  RISK FACTORS

  • Hypogonadism, androgen insensivity syndrome.
  • Old age, chronic disease, malnutrition.
  • Medications - anti-ulcer, anti-depressants, anti-psychotics
  • Liver disease, alchoholism, renal failure, hyperthyroidism.
  • Feminizing adrenal tumors.
  • Testicular tumors (choriocarcinoma).
  • Idiopathic--25% men have no detectable cause.

  SIGNS AND SYMPTOMS

  • Galacatorrhea
  • Breast tenderness
  • Symptoms of hypogonadism - sexual dysfunction, osteoporosis
  • Breast size measured by Tanner classification: I-none,II-bud, III- around 3 cm, IV-sepration of areaola from breast, V-full female breast

  DIFFERENTIAL DIAGNOSIS

  • Prolactin-secreating pituitary tumor
  • Medications - anti-psychotics, H2 blockers, estrogens, antidepressants
  • Male hypogonadism
  • Andropause - age-dependent decline in serum testosterone
  • Breast cancer

  LABORATORY FINDINGS

  • Low serum total and free testosterone levels in patients with hypogonadism.
  • Prolactin levels may be elevated. Levels are between 20-100 ng/dl in drug-induced hyperprolactinemia, 100-200 in pituitary microadenomas, >200 in macroadenomas.
  • FSH (follicle-stimulating hormone) and LH (luteinizing hormone) are low in prolactin secreting tumors and elevated in primary hypogonadism.
  • Estradiol levels between 25-75 pg/ml may be seen in liver disease. >75 pg/ml suggests estrogen or HCG-secreating tumor
 
TREATMENT
SURGICAL RESECTION
  • For those men who have failed medical therapy.
  • Liposuction is sometimes adequate.
  • For large sagging breasts, plastic surgery is needed. Excessive fat and glandular tissue is excised.
MEDICAL THERAPY
  • Testosterone replacement with Testoderm 5-10 mg/day or Androgel 5-10 gm/day in hypogonadal patients.
  • Anti-estrogens like Tamoxifen (response rate 50-80%) and Clomiphene (RR 36-95%).
  • Aromatase inhibitor (Testolactone).
  • Danazol and percutaneous DHT (dihydrotestosterone) gel.
 
IMPORTANT POINTS/RECOMMENDATIONS
  • Often difficult to distinguish between breast and adipose tissue ultrasound may be useful
  • Mammogram should be done if a family history of breast cancer, palpable firm mass
 
REFERENCES
  1. Braunstein GD. ;  Gynecomastia. ;  New Engl J Med 1993;328:490

  2. Wilson JD, Aiman J, MacDonald PC. ;  The pathogenesis of gynecomastia. ;  Adv Intern Med 1980;25:1.

  3. Thompson DF, Carter JR. ;  Drug-induced gynecomastia. ;  Pharmacotherapy 1993;13:37.

  4. McDermott MT, Hofeldt FD, Kidds GS. ;  Tamoxifen therapy for painful idiopathic gynecomastia. ;  South Med J 1990;83:1283

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