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]

Synonyms and Keywords: Gynecomastia management, Gynecomastia work-up, Approach to gynecomastia

Overview

Gynecomastia is a benign male breast enlargement. It can be physiological, occuring with infancy, puberty and old age. Gynecomastia can also be pathological, arising with obesity, steroid use, pharmacologic agents, medical conditions including chronic liver and renal failure or hypogonadism. The diagnosis is primarily clinical. Laboratory investigations typically performed are blood hormone levels, renal function tests and liver function tests. Ultrasound or mammography imaging modalities are also common in diagnosis. Treatment is aimed at resolution of 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

[1] [1] [2] [3][4][5]

Less Common Causes

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.[6] [7]
Abbreviations:

 
 
 
 
 
 
 
 
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. [6] [7] [8]

 
 
 
 
 
 
 
 
• Discontinue the causative drug
• Treat the underlying cause[6]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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)[9]
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

References

  1. 1.0 1.1 Braunstein GD (2007). "Clinical practice. Gynecomastia". N Engl J Med. 357 (12): 1229–37. doi:10.1056/NEJMcp070677. PMID 17881754.
  2. 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)
  3. Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K, Bryant M, Bulun SE (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.
  4. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  5. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  6. 6.0 6.1 6.2 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.
  7. 7.0 7.1 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).
  8. 8.0 8.1 Gruntmanis U, Braunstein GD (2001). "Treatment of gynecomastia". Curr Opin Investig Drugs. 2 (5): 643–9. PMID 11569940.
  9. Khan HN, Blamey RW (2003). "Endocrine treatment of physiological gynaecomastia". BMJ. 327 (7410): 301–2. doi:10.1136/bmj.327.7410.301. PMC 1126712. PMID 12907471.
  10. 10.0 10.1 Johnson RE, Murad MH (2009). "Gynecomastia: pathophysiology, evaluation, and management". Mayo Clin Proc. 84 (11): 1010–5. doi:10.1016/S0025-6196(11)60671-X. PMC 2770912. PMID 19880691.