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Gynecomastia

By Daniel Champigny - Jan 20, 2020

Gynecomastia

 

Today, we will be reviewing gynecomastia, a somewhat rarely encountered entity in the primary care world, but an important topic nonetheless. Gynecomastia is a major contributor of cosmetic distress for patients. Pathophysiology, etiology, history, exam, and treatment will be covered as a quick review to provide you with the tools for excellent patient care.

 

What is gynecomastia?

By definition, gynecomastia is an increase in the glandular breast tissue in males as a result of an increase in estrogens. The process can be physiologic in nature, a normal part of growth or can be pathologic due to medical conditions or medications (Zacharia and Gopalakrishnan, 2016).

 

Pathophysiology

As estrogen increases, there are multiple physiologic changes in the breast tissue that contribute to the end result of gynecomastia. The ratio of estrogen relative to androgen increases and this contributes to ductal cell hyperplasia, increased vascularity and increase in breast tissue.

 

Physiological vs Pathological

It is important to note that in some cases, gynecomastia is physiological and not a concern. In many newborns, the finding is present given the fact that the placenta converts DHEA to

DHEA-S, which increases estradiol. In adolescent boys, a transient rise in estradiol at puberty can contribute to a temporary gynecomastia. In these cases, it is easy for the new clinician to become overwhelmed and order a significantly expensive work up, but being aware of the condition allows us to provide simple reassurance.

 

History

When taking a history, it is important to continue to use our OPQRST pneumonic. How long has the breast tissue been present? Is it painful? Is it still getting worse? Is there an associated nipple discharge? In some cases, gynecomastia may be also associated with hypogonadism, so asking about sex drive, muscle mass, hair loss is also important.

 

Past Medical History, Family History and Medications

A complete medical and surgical history as well as family history is also very important to help identify possible pathology. A complete review of systems should be performed to assure completeness. The review of medication list is also paramount, as a simple answer may come from asking the patient what medications they are prescribed.

 

System Specific Exam vs Comprehensive Exam

In primary practice, it can be easy to perform an abbreviated exam when a patient comes in for a specific concern and sometimes this is adequate. For example, if a patient comes in for a skin lesion in the leg they are concerned for skin cancer, it is probably reasonable to examine that area only. In cases like this, where the diagnosis is unclear and many other body systems may be the culprit, it is important to perform a comprehensive physical exam.

 

Physical Exam

The clinician again should be cautious not to miss other potential positive physical exam findings. A neck exam to palpate for the thyroid is important to determine if a thyroid disorder could contribute. In addition, an abdominal exam can palpate for possible abdominal masses, hepatomegaly, or evidence of cirrhosis/ascites. A complete genitourinary exam including palpating the testicles for masses, evaluating testicular size, hair loss.

 

The Breast Exam

Next, the clinician should hone in on the area of concern. It is important to identify the breasts and examine for asymmetry. Do they look different? Is the gynecomastia or abnormality unilateral or bilateral? Is the area tender? Is there associated nipple discharge? Is there a hard palpable discrete mass? Is there any associated axillary lymphadenopathy?

 

Work-up & Differential Diagnoses

After our history and physical, we must formulate our differential diagnosis. As a new graduate, there are a million different things we could do, many tests we could order. It is important to be judicious in deciding the patient’s work up, as it may be costly.

The differential diagnosis of gynecomastia includes:

  1. Pseudo-gynecomastia
  2. Medication induced gynecomastia
  3. Breast cancer
  4. Lipoma
  5. Mastitis
  6. Sebaceous cyst
  7. Hematoma
  8. Germ cell tumor
  9. Adrenal tumor
  10. Hypogonadism
  11. Pituitary tumor.

Up to 25% of cases of gynecomastia are idiopathic in nature. (Zacharia and Gopalakrishnan, 2016).

 

Medication-induced Gynecomastia

As discussed above, medication induced gynecomastia is common.

Numerous culprits include:

  • Spironolactone
  • CCBs
  • PPIs
  • Ketoconazole
  • Phenytoin
  • Certain anti-depressants

 

Non-Medication Induced Gynecomastia

Other causes include:

  • Marijuana
  • excessive alcohol intake
  • Heroin
  • Methadone
  • Amphetamines

(Zacharia and Gopalakrishnan, 2016).

 

Laboratory Tests     

Our work up will depend on our concerns and the different disorders which we are concerned about. There are numerous possible lab tests available, but some of which might include:

  • LH, FSH, testosterone, estradiol
  • HCG
  • TSH
  • CBC and CMP
  • Prolactin (if nipple discharge is present)
  • Urine drug screen (for illegal drugs)

 

Imaging 

It is also very important to consider imaging in these cases as well. In many cases, an ultrasound of the breast in general can help provide us with a great deal of information regarding the presence of gynecomastia, lipoma, breast cancer, and identify the size and consistency of any masses that are present.

 

Imaging - Testicular Mass

If there is concern for testicular mass or hypogonadism, a testicular ultrasound is needed.

 

Imaging- Adrenal, endocrine or reproductive tumors

If there is concern for an adrenal, endocrine, or reproductive tumor, then a chest x-ray or CT scan of the chest, abdomen and pelvis may be needed (Zacharia and Gopalakirshnan, 2016).

 

When to Biopsy?

If there is a concerning, fixed or discrete breast mass then a biopsy should be performed to rule out breast cancer.

 

Treatment – medication or drug related

In many cases, gynecomastia can resolve on its own in about 6 months without any specific treatment. The first step in treatment for medication related gynecomastia is to remove the offending agent if possible. Patient should be encouraged to avoid illegal drugs and in some cases, the gynecomastia may be a major motivator. It is important to note that early in disease, medical therapy can reverse the tissue growth, but after about 1 to 2 years, fibrotic tissue forms which requires surgical removal.

 

Treatment – Endocrine Pathology

Patients with concerning endocrine disease should be referred to an endocrinologist for management. If low testosterone is the culprit, this should be replaced. There are not currently any FDA approved medication treatments for gynecomastia, but SERMs such as tamoxifen and raloxifene have shown some promise and may be used to decrease gynecomastia.

 

References

Zacharia, C.C. and Gopalakrishnan, G. (2016). Gynecomastia. The 5 minute Clinical Consult. Wolters Kluwer.

 

This article or blog post should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.