Gynecomastia
Julie Adkins, Jill C. Cash, Mellisa A. Hall, Cheryl A. Glass, Angelito Tacderas, and Jenny Nelson Mullen
Definition
A.Gynecomastia is an enlargement of the breast tissue in males.
Incidence
A.Common in newborns, approximately 40% to 69% of adolescent boys will experience breast enlargement. It is also seen in men (between the ages of 50 and 80) with excessive weight gain.
Pathogenesis
A.Male breast duct proliferation occurs due to a hormonal imbalance of estrogen. Pathologic conditions such as pituitary tumors, systemic disorders, kidney disease, thyroid disorders, and liver disease can cause symptoms to occur. Medications can also induce symptoms. These medications include antiandrogens, antidepressants, cimetidine, ranitidine, omeprazole, aldactone, chemotherapeutic agents, amiodarone, diltiazem, nifedipine, digoxin, methyldopa, reserpine, hormones, and sedatives.
Predisposing Factors
A.Age (men older than 65 years) with excessive weight gain
B.Family history.
C.Malnutrition with severe weight loss.
D.Obesity.
E.Peutz–Jeghers syndrome.
F.Hypogonadism (primary—testicular or secondary—central).
G.Thyroid disease, primarily thyrotoxicosis.
H.Estrogen or human chorionic gonadotropin (HCG) secreting tumors.
I.Medications associated with gynecomastia: Antiandrogens, ketoconazole, metronidazole, calcium channel blockers, spironolactone, omeprazole, cimetidine, ranitidine, steroids, marijuana, methadone, antivirals, anti-pyschotics, statins/fibrates, and digitalis.
Common Complaints
A.Enlargement of breast tissue with or without discomfort.
Other Signs and Symptoms
A.Asymptomatic.
B.Type I: Nodule present under areola tissue area.
C.Type II: Nodule palpable under and beyond areola area.
D.Type III: Breast enlargement without contour separation of tissue.
Subjective Data
A.Identify when breast development first appeared.
B.Determine whether enlargement is unilateral or bilateral.
C.Review the progression of enlargement.
D.Note any pain, discharge, or masses that are palpable.
E.List current medications, drugs, and alcohol and substance abuse.
F.Review the patient’s medical history.
G.Note the patient’s family history of gynecomastia.
H.Explore nutritional intake.
I.Discuss the patient’s level of physical activity (sports, hobbies, etc.).
J.Note use of herbal products.
Objective Data
A.Inspect breasts bilaterally and surrounding nodes for enlargement or skin changes.
B.Palpate breast tissue systematically and surrounding nodes. Gynecomastia can usually be appreciated once the glandular tissue reaches 0.5 cm or larger.
C.Palpate testes for masses or atrophic changes.
D.Body mass index (BMI).
Differential Diagnoses
A.Gynecomastia.
B.Obesity: Fatty breast enlargement without glandular involvement.
C.Breast cancer: Fixed, firm nodule in tissue with dimpling and/or breast discharge.
D.Neurofibroma.
E.Lipoma.
Diagnostic Tests
A.Prolactin level.
B.Thyroid-stimulating hormone (TSH).
C.HCG.
D.Serum luteinizing hormone (LH).
E.Testosterone level.
F.Estradiol level.
G.Mammography for suspicious breast masses in adult males.
Plan
A.General interventions:
1.Identify any pathologic condition. If none is identified, reassure the patient that normal resolution will occur over time.
B.Patient teaching:
1.Reinforce weight reduction if weight gain is a factor in the condition.
C.Pharmaceutical therapy:
1.Antiestrogens (tamoxifen).
2.Androgens (testosterone replacement).
3.Aromatase inhibitors (anastrozole).
4.Discontinue medications that may induce symptoms if possible.
Follow-Up
A.Follow-up is dependent on etiology and/or patient needs.
Consultation/Referral
A.Consult a physician or refer to an endocrinologist if the male patient is noted to have breast enlargement for longer than 2 years.
Individual Considerations
A.Adult men diagnosed with prostate cancer who are treated with an antiandrogen monotherapy are at higher risk for the development of gynecomastia.
B.Geriatric men: Gynecomastia is a common finding secondary to a decrease in testosterone production and an increase in sex hormone binding globulin that lowers free testosterone levels. Testosterone treatment for geriatrics increases the risk of prostate cancer and cardiac events.