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Junior - endo II > 9 - Gynecomastia > Flashcards

9 - Gynecomastia Flashcards

1
Q

What is gynecomastia?

A

The presence of palpable breast tissue in the male

Caused by imbalance of estrogen-androgen ratio

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2
Q

Gynecomastia and cancer?

A

Usually it is benign but you must r/o carcinoma or mastitis

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3
Q

Though the causes of gyneomastia are multiple and diverse there are 6 main etiologies what are they?

A
  1. Idiopathic
  2. Physiologic
  3. Endocrine disease
  4. Systemic diseases
  5. Neoplasms
  6. Medications (59 of them)
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4
Q

What are 2 causes of idiopathic or familial?

A
  1. The Breast tissue is extremely sensitive to estrogens

2. Excessive conversion of estrogen precursors to etrogen

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5
Q

Aromatization?

A

Excessive conversion of estrogen precursors to estrogen

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6
Q

What about physiologic gynecomastia?

A

This is a normal occurrence in:

  • Neonates
  • Puberty
  • Aging
  • Obesity
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7
Q

What causes neonatal gynecomastia?

A

It is a common but transient state caused by the high enstrogenic state of pregnancy .

Seen in 60-90% of infants

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8
Q

Who gets pubertal gynecomastia?

A

Tall and overweight boys ages 10-12

Usually subsides in 1 yr

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9
Q

Describe the tissue of pubertal gynecomastia

A

It is tender discoid enlargement of breast tissue 2-3 cm in diameter beneath the areola

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10
Q

Why do we see a jump of estrogen in puberty?

A

Increased testosterone converts to aromatase which becomes estradiol (estrogen) leading to breast tissue

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11
Q

What causes the shift with aging?

A

1/3 of males age 50-80 see a drop in testosterone

Seen particularly with weight gain

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12
Q

What happens with men when the testosterone levels drop?

A

Sex hormone binding globulin SHBG increases which further reduces free testosterone adding to the imbalance

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13
Q

What role does obesity play in gynecomastia?

A

Increased fat -> increased aromatase

Causes more testosterone to be converted to estradiol

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14
Q

Types of gynecomastia?

A

Pseudogynecomastia - non tender (obesity associated)

Gynecomastia - usually tender

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15
Q

What are some endocrine abnormalaties that can lead to gynecomastia?

A 
Androgen resistance syndrome
Aromatase excess syndrome
Hyperprolactinemia
Klinefelter syndrome 
Hypogonadism
Hyperthyroidism
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16
Q

What are some systemic diseases associated with gynecomastia?

A

Chronic liver disease
Chronic renal disease
Spinal cord injury

Also some meds for these

  • Spirinolactone for liver disease
  • Chemo
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17
Q

Do neoplasms cause gynecomastia?

A

They sure do

Steroid producing neoplasmis (estrogen from adrenals or testes)

HCG-producing neoplasms (testes, lung, hepatocellular, gastric carcinoma)

Breast cancer

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18
Q

What type of mass is associated with male breast cancer?

A

Unilateral, irregular, painless, firm/hard mass that is fixed to underlying tissues

19
Q

What syndrome is associated with breast cancer?

A

Klinefelters syndrome 1:500 men

20
Q

What are some common medications that can lead to the boobage? Think Bob from fight club

A
  1. Marijuana
  2. Amphetamines
  3. Type I and II 5-a-reductase inhibitors (BPH)
  4. Exogenous steroids (50% of athletes who use get this)
  5. HIV HAART therapy
21
Q

What is included in the PE for gynecomastia?

A
  • Inspect nipple, aerola (same as women)
  • Examine symmetry, tenderness, masses, dimpling, nodules (same as women)
  • testicular exam
  • thyroid exam
22
Q

What must be distinguished with breast tissue on males?

A

Distinguish between soft fatty enlargement of obesity vs firm disc of glandular enlargement

23
Q

What is suggestive of cancer?

A

Hard
Irregular
Eccentric
Ulcerating nodule

24
Q

What grading system is used for gynecomastia?

A

Rohrich grading system

Grade I - IV

25
Q

Rohrich grading system?

A

Grade I: minimal hypertrophy w/out ptosis
Grade II: moderate hypertrophy w/out ptosis
Grade III: severe hypertrophy w grade I ptosis
Grade IV: severe hypertrophy with grade II/III ptosis

26
Q

What is IF when grading male breasts?

A

Inframammory fold

27
Q

DDX for gynecomastia?

A

Lipoma
Neurofibroma
Carcinoma
Obesity

All unilateral painless eccentric

28
Q

What labs do i need to order?

A
  • Prolactin and hCH
  • LH and test
  • estradiol (usually normal)
  • TSH/FT4
29
Q

What does prolactin and B-hCH tell us?

A

H hCG: testicular tumor or other cancer

L hCG: primary hypogonadism

30
Q

What do LH and testosterone levels indicate?

A

Low T + high LH: primary hypogonadism

Low T + Low LH: secondary hypogonadism

High T + high LH: androgen resistance

31
Q

What increases estradiol levels?

A

Testicular tumors
Liver disease
Obesity
Increased B-hCG

32
Q

What effect does hyperthyroidism have?

A

Increases SHBG leading to decrease in free T

33
Q

Warning signs that necessitate a full work up?

A 
Recent onset
Rapid growth
Tender tissue
Lean patient
Severe gynecomastia
34
Q

What imaging is warranted?

A

Bilateral mammography and CXR

US if suspicious mammogram findings

35
Q

What is a key test is used to r/o cancer ?

A

Needle biopsy with cytology

Will distinguish tumor from mastitis

36
Q

Tx for pubertal gynecomastia?

A

Observe and reassure, usually spontaneously resolves in 1-2 yrs

37
Q

Tx for medication induced gynecomastia?

A

Stop the med (if possible)

- spironolactone replaced w selective aldosterone antagonist etc

38
Q

Tx for painful or persistent gynecomastia (>12 mo)

A

SERMs: tamoxifen/
- raloxifen (antiestrogens) for 3-9 mo
Aromatase inhibitor (AI)
- Anastrozole or letrozole

39
Q

Which med is most effective for painful/persistent?

A

Raloxifen 60mg daily is most effective

40
Q

Tx for hypogonadism related gynecomastia?

A

Dihydrotestosterone (not converted to estradiol)

May improve or worsen sxs (great…)

41
Q

Do we use radiation?

A

If you have prostate cancer + gynecomastia

Reduces incidence from 85% - 52%

42
Q

Is surgery an option?

A

Surgery is always on the table… get it?

Yes for persistent or severe cases

43
Q

What has 3 horns and gives milk?

A

A cow driving a car

Junior - endo II (7 decks)

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