GYNAECOMASTIABY:

Dr PIRAH KORAIfcps-ii traineecmc larkana

 Gynecomastia is the development of abnormally large mammary glands in males resulting in breast enlargement.

Gynaecomastia can happen in males of any age or weight. 

Gynaecomastia is very common in boys going through puberty, happening in more than half of all normal adolescent males, and usually goes away over time. In older men, enlargement of the breast tissue happens in about one-third of men.

In about half of cases, enlargement is found in both breasts; in the other cases it only affects one breast.

Gynaecomastia can appear as a small lump that becomes tender as the mass becomes larger.

What is gynaecomastia?

Breast prominence due solely to excessive adipose is often termed

pseudogynaecomastia or sometimes lipomastia.

 fat deposition without glandular proliferation, on exam fingers will not meet any resistance until they reach the nipple

What is Pseudogynaecomastia?

Gynecomastia has three peaks.

1. Infancy: 60-90% transient due to high maternal estrogen. Normally regresses over 2-3 week period.

2. Adolescence: 4-69% with wide variation due to examiner observation. Onset 10-12y/o and peaks 13-14y/o. Normally regresses w/in 18mo and persistence uncommon after 17y/o.

3. Older men: 24-65% with highest prevalence in the 50-80y/o.

Prevalence

Drugs: 10-25% (e.g: Digoxin, Furosemide, anabolic steroids, marijuana, opioids and excessive alcohol intake)

Idiopathic : 25% Persistent pubertal gynecomastia: 25% Cirrhosis or malnutrition: 8% Primary hypogonadism: 8% Testicular tumors: 3% Secondary Hypogonadism: 2% Hyperthyroidism: 1.5% Chronic renal insufficiency: 1%

Etiologies in patients seeking help for Gynecomastia

The basic mechanisms of gynecomastia include : 1.decrease in androgen production 2.an increase in estrogen production 3.increased availability of estrogen precursors for peripheral conversion to estrogen.

Androgen receptor blockade and increased binding of androgen to sex-hormone binding globulin (SHBG).

Estrogen-like or antiandrogen effects of Drugs

Pathophysiologic causes for Gynecomastia

Family history

Clinical examination

Laboratory tests

Imaging

Diagnosis

◦Onset◦Bilateral/unilateral◦Pain◦Change in size◦Nipple discharge◦Drugs/medications◦PMH◦Family history

History

◦ Look for signs and sx of liver and kidney disease

◦ Evaluate for hyperthyroidism, eg. Weight loss, tachycardia, goiter, tremor, or exophthalmos.

◦ Seek for signs and sx that may suggest hypogonadism, eg. Impotence, decreased libido, strenght, and change in testicular size.

◦ Check for abdominal mass and testicular mass.

◦ Careful breast exam.

Complete Physical Exam

◦ if gynecomastia of recent onset, persistent, or painful/tender and has no clear physiologic etiology. BMP, LFT’s, TSH, LH, FSH, hCG, Prolactin, Estradiol,

Testosterone, Androstenedione

Imaging

◦ US and mammogram for any eccentric or discrete mass.

 

Laboratory tests

Treat the underlying cause

Watchful waiting

Medical options:

Androgens Anti-estrogens (as tamoxifen  and

clomiphene)and aromatase inhibitors

 Aromatase inhibitors such as Letrozole 

TREATMENT

Liposuction

Gland excision

Skin sculpture

Reduction mammoplasty

Or a combination of these surgical techniques

Surgical options

Permanent numbness, compromise of blood supply, irregular contour, hematoma, seroma, wound

infection

Complications