Gynaecomastia

Question 1

What is gynaecomastia

Answer 1

A benign proliferation of the glandular tissue of the male breast

Question 2

How does gynaecomastia develop

Answer 2

Oestrogens stimulate ductal epithelial growth and proliferation of the periductal fibroblasts

Question 3

What are the 4 main things that define the net oestrogen/androgen balance

Answer 3

The production of oestrogen/ androgens or their precursors by the adrenals and testes
Aromatase activity
Sex hormone-binding globulin (SHBG) levels
The responsiveness of the target cells to androgens and oestrogens

Question 4

What is aromatase

Answer 4

The enzyme that converts androgens to oestrogen in peripheral tissues e.g. adipose tissue, liver, skin, muscle , bone and kidney

Question 5

What might account for pubertal gynaecomastia

Answer 5

Serum oestradiol rises to adult levels before serum testosterone and this transient imbalance in oestrogen/ testosterone level may be the cause

Question 6

What should gynaecomastia be differentiated from

Answer 6

pseudogynaecomastia and breast cancer

Question 7

What is pseudogynaecomastia

Answer 7

excessive adipose tissue often seen in obese men

Question 8

On examination, what finding indicates gynaecomastia rather than pseudogynaecomastia

Answer 8

Having the patient on their back and palpating.
There will be a rubbery/ firm disk of glandular tissue extending concentrically from the nipple in gynaecomastia
In pseudogynaecomastia, the fingers will not meet any resistance until they reach the nipple

Question 9

List some causes of gynaecomastia

Answer 9

Puberty
Drugs - oestrogens, anti androgens, spironolactone
Hypogonadism - reduced serum testosterone production
Chronic liver disease - enhanced aromatisation
Chronci renal failure - reduced serum testosterone due to Leydig cell dysfunction
Thyrotoxicosis - enhanced aromatisation
Tumours - testicular germ cells tumours or oestrogen secreting adrenal tumours

Question 10

What should be measured in a patient who does not have one of the possible causative conditions

Answer 10

Serum hCG, LH, testosterone, oestradiol, T4, TSH

Question 11

What should happen if the hCG is elevated

Answer 11

a testicular ultrasound scan should be performed to look for a testicular germ cell tumour

Question 12

What is the diagnosis if testosterone is low and LH levels are increased

Answer 12

Diagnosis is primary hypogonadism

Question 13

What is the diagnosis if testosterone is low and LH levels are low or inappropriately normal

Answer 13

secondary hypogonadism

Question 14

What is the diagnosis if all tests are normal

Answer 14

Idiopathic gynaecomastia

Question 15

What should be done if the estradiol levels are increased and LH levels are low or normal

Answer 15

testicular ultrasound to look for a Leydig or Sertoli cell tumour

Question 16

What is the initial treatment for gynaecomastia in adolescents

Answer 16

Nothing but follow up in 3-6 months

Normally resolves spontaneously within 6 months to 2 years

Question 17

If a boy has severe gynaecomastia causing substantial tenderness / embarrassment, what should be considered

Answer 17

a 3 month trial of tamoxifen (10mg twice daily)

Question 18

What should patients be told about taking tamoxifen

Answer 18

It is not approved gynaecomastia

Question 19

What should men with persistent gynaecomastia (>1-2 years) who find it psychologically troubling be offered

Answer 19

surgery - the breast tissue has probably become fibrotic and medical therapy is unlikely to be effective

Question 20

Who is physiological gynaecomastia common in

Answer 20

infants
adolescents
elderly men

Question 21

If a testicular ultrasound is normal, what further imaging should be performed

Answer 21

Chest radiograph and abdominal CT