Gynecomastia resident survival guide

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Gynecomastia
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]

Overview

Gynecomastia is a benign male breast enlargement. It can be physiological, such as in infancy, puberty and old age or pathological, which is due to obesity, steroid use, pharmacologic agents, medical conditions including chronic liver and renal failure or hypogonadism. The diagnosis is primarily clinical.Laboratory investigations done are blood hormone levels, renal function tests and liver function tests and imaging such as ultrasound or mammography. Treatment is aimed at treating the underlying condition.Pharmacologic options include SERMs, androgens and aromatase inhibitors. Surgery is usually reserved for patients with either psychological stresses, extensive gynecomastia or failure of medical treatment.

Causes

Life-threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of gynecomastia.

Common Causes

Less Common Causes[10]

To review a complete list of gynecomastia causes, click here.

Genetic Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of gynecomastia according to the Endocrine Society and European Association of Andrology. [11] [12] ("Gynecomastia - American Family Physician".)

 
 
 
 
 
 
 
 
Gynecomastia (Breast tissue enlargement)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Newborn
 
Physiological; resolves within 4 weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drugs (see list above)
 
Discontinue implicated drug
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pseudogynecomastia
 
Weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Features of malignancy
 
Mammography; Breast USG; Biopsy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Testicular mass
 
Testicular USG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
True Gynecomastia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Testosterone
Estradiol(E2)
Luteinizing hormone (LH)
ProlactinFollicle Stimulating Hormone (FSH)
Beta- hCG
 
 
 
 
Thyroid function tests
Liver function tests
Renal function tests
 
If deranged,correct underlying disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Low testosterone
• High LH
 
• Low testosterone
• Low LH
 
• High Estradiol
• Low LH
 
• High Prolactin
 
• High beta-hCG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary hypogonadism
 
Secondary hypogonadism
 
Testicular USG
 
MRI head for
Pituitary adenoma
Empty sella
Panhypopituitarism
 
 
Testicular USG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sertoli or Leydig cell tumor
 
Evaluate for
Adrenal neoplasm
• Exogenous estrogen use
Obesity (excess aromatase)
 
 
Germ cell tumor
 
If normal; evaluate for
• Extragonadal germ cell tumor
• Non-trophoblastic beta hCG secreting tumors

Treatment

Evaluation of Gynecomastia

❑ Obtain a detailed history
❑ Examine the breasts to rule out malignancy
❑ Stop drugs that may cause gynecomastia


Obtain laboratory tests


Testosterone
Estradiol
❑ Beta hCG
Luteinizing hormone (LH)
Follicle Stimulating Hormone (FSH)
Prolactin


Treat underlying disorders


❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor



Shown below is an algorithm summarizing the treatment of gynecomastia according to the Endocrine Society and European Association of Andrology. [11] [12] ("Gynecomastia - American Family Physician".)

 
 
 
 
 
 
 
 
• Discontinue the causative drug
• Treat the underlying cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observe for 3 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If pain/tenderness; proceed with medical therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Androgens and testosterone
Hypogonadism
 
Aromatase inhibitors in prostate cancer
Anastrazole
 
Selective estrogen receptor modulators (SERMs)
Tamoxifen (10-20 mg once daily for 3-9 months)
Raloxifene (60 mg once daily for 3-9 months)
 
Surgery if:
• Persistent for > 12 months
Fibrotic gynecomastia
• Failure of medical therapy
 

Do's

Don'ts

  • Do not treat the gynecomastia without evaluating for an underlying cause.

References

  1. Deepinder F, Braunstein GD (2012). "Drug-induced gynecomastia: an evidence-based review". Expert Opin Drug Saf. 11 (5): 779–95. doi:10.1517/14740338.2012.712109. PMID 22862307.
  2. 2.0 2.1 2.2 Braunstein GD (2007). "Clinical practice. Gynecomastia". N Engl J Med. 357 (12): 1229–37. doi:10.1056/NEJMcp070677. PMID 17881754.
  3. Lainscak M, Pelliccia F, Rosano G, Vitale C, Schiariti M, Greco C; et al. (2015). "Safety profile of mineralocorticoid receptor antagonists: Spironolactone and eplerenone". Int J Cardiol. 200: 25–9. doi:10.1016/j.ijcard.2015.05.127. PMID 26404748.
  4. Henley DV, Lipson N, Korach KS, Bloch CA (2007). "Prepubertal gynecomastia linked to lavender and tea tree oils". N Engl J Med. 356 (5): 479–85. doi:10.1056/NEJMoa064725. PMID 17267908.
  5. Vandeven H, Pensler J. PMID 28613563. Missing or empty |title= (help)
  6. 6.0 6.1 De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng J. PMID 25905330. Vancouver style error: initials (help); Missing or empty |title= (help)
  7. Ladizinski B, Lee KC, Nutan FN, Higgins HW, Federman DG (2014). "Gynecomastia: etiologies, clinical presentations, diagnosis, and management". South Med J. 107 (1): 44–9. doi:10.1097/SMJ.0000000000000033. PMID 24389786.
  8. Wagner MS, Wajner SM, Maia AL (2008). "The role of thyroid hormone in testicular development and function". J Endocrinol. 199 (3): 351–65. doi:10.1677/JOE-08-0218. PMC 2799043. PMID 18728126.
  9. Cavanaugh J, Niewoehner CB, Nuttall FQ (1990). "Gynecomastia and cirrhosis of the liver". Arch. Intern. Med. 150 (3): 563–5. PMID 2310274.
  10. 10.0 10.1 Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K; et al. (2003). "Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene". N Engl J Med. 348 (19): 1855–65. doi:10.1056/NEJMoa021559. PMID 12736278.
  11. 11.0 11.1 Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G; et al. (2019). "EAA clinical practice guidelines-gynecomastia evaluation and management". Andrology. 7 (6): 778–793. doi:10.1111/andr.12636. PMID 31099174.
  12. 12.0 12.1 Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID doi.org/10.1210/jc.2010-1720 Check |pmid= value (help).