GYNECOMATIA

male breast enlargement

*Excess estrogen action

* Increased Estrogen / androgen ratio

True gynecomastia :

glandular breast tissue >4 cm often tender

distinguished from excess adipose tissue *firmer *fibrous-like cords.

Pubertal causes

• high estradiol to testosterone ratio and estrone to adrenal androgens(Eearlier rise in estrogen than testostrone)

• Local formation of estrogen ?

Gynecomastia of AgingGynecomastia of Aging

_ Decreases testosterone

_ increase peripheral aromatization

Exclusion: * take medications * concurrent disorders

Physiologic GynecomastiaGynecomastia in newbornAdolescent gynecomastiaGynecomastia of aging

Testostrone deficiency Congenital defects Congenital anorchia Klinefelter's Androgen resistance testosterone synthesis

Secondary testicular failure viral orchitis , trauma , castration, neurologic , granulomatous, renal failure

Increased estrogen production: * Increased testicular estrogen secretion

Testicular tumors Bronchogenic carcinoma & other tumors producing hCG

True hermaphroditism

* Increased extraglandular aromatase liver tumors , adrenal tumors , inherited disorder .

* Increased substrate for aromatase

increased androstenedione for extraglandular estrogen

formation

CAH hyperthyroidism adrenal tumors

Low catabolism of androstenedione liver diseaseliver disease

Obesity increased aromatization of androgen precursors to estrogens.

DrugsDrugsEstrogens , drugs act like estrogen diethylstilbestrol, estrogen-containing cosmetics, birth control pills, digitalis, estrogen-contaminated foods,phytoestrogens)Drugs enhance endogenous estrogen formation gonadotropins, clomipheneDrugs inhibit testosterone synthesis or action (ketoconazole, metronidazole, cimetidine, etomidate, alkylating agents, cisplatin, flutamide,spironolactone)

Drugs that act by unknown mechanisms (busulfan, isoniazid, methyldopa, calcium channelblocking agents, captopril, tricyclic antidepressants, penicillamine,diazepam, marijuana, heroin)

Idiopathic Gynecomastia3/4 of cases

work-up 1. careful drug history

2.physical examination

asymmetrical testes raise the possibility of testicular tumorssmall testes bilaterally suggests testicular

insufficiency

karyotype to exclude Klinefelter syndrom..

3. Evaluation of liver function.

4. endocrine work-up• LH and testosterone.

• DHEAS & urinary 17 ketosteroids (elevated in adrenal states)

• plasma estradiol

• hCG elevated with testicular tumors

more extensive evaluation:

–recent onset–rapid growth–tender tissue

The relative risk of breast cancer is increased in men with gynecomastia

TREATMENT

primary cause can be corrected , breast enlargement usually subsides over several months.

long duration surgery is the most effective therapy.Indications for surgery include severe psychologicpsychologic or cosmetic problemscosmetic problems, continued growth continued growth oror tendernesstenderness, , or suspected malignancysuspected malignancy.

antiestrogens tamoxifen (20 mg/d) reduces pain and breast size ( in two-thirds).

Aromatase inhibitors in early proliferative phase. testolactone, anastrazole, letrozole, or fromestane

Medical management is successful when is gynecomastia recent onset

Testosterone administration inconsistent effects in Klinefelter but cause dramatic improvement in other forms of testicular failure (e.g., anorchia, viral orchitis).

tamoxifen and clomiphene.

Aromatase inhibitor

Danazol weak androgen inhibits gonadotropin secretion.

dihydrotestosterone