Gynaecomastia

Question 1

What is gynaecomastia?

Answer 1

• Males develop breast tissue
• Due to imbalanced ratio of oestrogen and androgen actvity
• Usually benign and reversible but breast cancer can develop 1% cases

Question 2

Pathophys gynaecomastia

Answer 2

• Physiological - adolescence due to delayed testosterone surge relative to oestrogen at puberty, less commonly occurs in older secondary to decreasing testosterone levels with increasing age
• Pathological - changes in oestrogen:androgen ratio, variety causes

Question 3

Underlying causes of pathological gynaecomastia

Answer 3

• Lack of testosterone - Klinefelters, androgen insensitivity, testicular atrophy, renal disease
• Increased oestrogen - liver disease, hyperthyroidism, obesity, adrenal tumours, testicular tumours eg Leydig cell tumours
• Medication - digoxin, metronidazole, spironolactone, chemo, goserelin, antipsychotics, anabolic steroids
• Idiopathic

Question 4

Presentation of gynaecomastia

Answer 4

• Gradual onset
• Ask about associated symptoms and co-morbids
• Screen for underlying causes ge malignancy

Question 5

Examination findings for gynaecomastia

Answer 5

• Rubbery or firm mass (usually >2cm diameter)
• Starts from underneath nipple and spreads outwards over breast region
• Examine testicular region too in young patients esp

Question 6

Differentials for gynaecomastia

Answer 6

• Pseudogynaecomastia
• = adipose tissue in breast region associated with being overweight
• Test by pinching to see if disc of breast tissue present or not

Question 7

Investigations for gynaecomastia

Answer 7

• Only needed if cause is unknown ef LFTs, U&Es, hormone profile eg LH and testosterone
• If malignancy suspected –> triple assessment

Question 8

LH and testosterone patterns and cause

Answer 8

• High LH and low testosterone - testicular failure
• Low LH and low testosterone - increased oestrogen
• High LH and high testosterone - androgen resistance or gonadotrophin secreting malignancy

Question 9

Management of gynaecomastia

Answer 9

• Depends on cause - reversal of cause if possible
• Reassurance
• Tamoxifen to alleviate symptoms esp tenderness
• Later stage fibrosis –> surgery if medical treatments failed