Work up of gynecomastia

Nilanjan Sengupta,MD,DMAssistant Professor

Department of EndocrinologyNRS Medical College

Kolkata

Hormonal control of breast development

• estradiol stimulates glandular cells

• testosterone inhibits growth & differentiation

• GH,cortisol,IGF1,insulin act permissively

• thyroid hormones increase SHBG level

• cortisol & prolactin lower T levels (hypothalamic & testicular effects)

Gynecomastia : the problem

• common condition : not always pathological• pubertal gynecomastia : 65% by age 15• 30% of normal military recruits have palpable

breast tissue• 40% men (40-44y)have palpable breast tissue• upto 70% hospitalized patients (50-69y) have

palpable breast tissue• upto 83% of hospitalized men with gynecomastia

– breast tissue diameter <5cm

Physiological vs pathological gynecomastia

• challenging• common• association with obesity• psedogynecomastia• pathological arbitrarily defined : palpable tissue > 4cm >2cm & tender >2cm & increasing

Causes

• estradiol excess

• testosterone deficiency

• estrogen – testosterone imbalance

• regulatory hormone excess

• drugs

• others

Aromatase associated causes of gynecomastia

• obesity• ageing• aromatase excess syndrome (familial, sporadic)• neoplasms (eutopic & ectopic productions)• idiopathic• thyrotoxicosis

unifying feature of several causes- known & unknown of gynecomastia

Evaluation

• whom to evaluate

• how to evaluate

Candidates needing evaluation

• breast tenderness

• rapid enlargement

• eccentric, hard or irregular mass

• lesion >4cm in diameter

Candidates not requiring evaluation

• asymptomatic

• stable

• obese

• <5cm

History

• family history : familial aromatase excess, Peutz Zeghers syndrome, Carney complex

• personal history : marijuana• time of onset • duration (beyond 12mo breast becomes

irreversibly fibrotic)• rate of progression• pain• symptoms of androgen deficiency

History

• drugs : finasteride, biculatamide, spironolactone, domperidone,βblockers, calcium channel blockers, amiodarone, diazepam, enalapril, metronidazole……..

• inadvertent estrogen exposure : industrial, coital exposure involving women using vaginal estrogen cream, from women using estrogen containing cosmetics

History

• systemic diseases : CLD, CKD, diabetes

• endocrinopathies : thyrotoxicosis, hypothyroidism, acromegaly, Cushing’s syndrome

• psychological assessment : depression, social withdrawal, scholastic deterioration

Examination : local

• presence or absence of breast disc• diameter of breast disc• to pinch the tissue between thumb &

forefinger lateral to nipple; ability to flip an edge of tissue at the interface of normal & glandular tissue signifies gynecomastia

• comparison of consistency with abdominal fat or fat in the axillary line

• tenderness

Simon classification of gynecomastia

Grade Enlargement Skin excess

I small absent

IIA moderate absent

IIB moderate present

III large present

Simon classification of gynecomastia

• fatty, low grade breast without glandular tissue : suction assisted lipectomy (SAL), ultrasound assisted liposuction (UAL)

• I : simple excision; SAL,UAL (adjunctive)

• II : simple excision, + SAL

• III : total mastectomy with free nipple grafting, modified radical mammoplasty

Examination : systemic

• features of hypogonadism

• asymmetrical testes (testicular tumor)*

• probable systemic illnesses : may be too obvious

*50% palpable; rest require ultrasound for detection

Investigations

• to distinguish glandular tissue from fat

mammography

ultrasonography (less sensitive)

• to exclude neoplasm : excision biopsy

Biochemical investigations

• testosterone

• 17β estradiol

• DHEAS

• LH

• β hCG

• thyroid function test

• liver function test

proceed further according to lead

Conclusion

• to differentiate gynecomastia from lipomastia

• to differentiate physiological from pathological gynecomastia

• to separate gynecomastia that is relatively innocuous from those that connote serious underlying endocrinopathy or medical disorder

Conclusion

• to assess patient’s attitude towards gynecomastia & psychological stress ,if any

• work up should be judicious & purposeful : detailed work up may not be necessary or rewarding in many instances

• if no apparent abnormality is detected, wait & watch policy may be adopted along with reassurance