Gynaecomastia

Question 1

What is gynaecomastia

Answer 1

Breast enlargement in males

May be unilateral or bilateral

Question 2

What is the pathology of gynaecomastia

Answer 2

Hyperplasia of the stromal and ductal tissue, usually due to increased circulating oestrogens and/or decreased testosterone

Question 3

What is the relation between gynaecomastia and breast cancer

Answer 3

Gynaecomastia itself doesn’t predispose to breast cancer

However high levels of circulating oestrogens associated with gynaecomastia also predispose to male breast cancer

Question 4

How can the causes of gynaecomastia be classified

Answer 4

Physiological

Pathological:

• Due to decreased androgens
• Due to increased oestrogens

Drugs

Idiopathic

Question 5

What are the physiological causes of gynaecomastia

Answer 5

Neonatal

Pubertal - usually disappears before adulthood

Question 6

What are the pathological causes of gynaecomastia

Answer 6

Decreased androgens:

• Hypogonadism - reduced androgen production
  
  • Testicular atrophy
  • Klinefelter’s syndrome (47, XXY)
  • Hyperprolactinaemia
  • Renal failure
• Androgen resistance
  
  • Androgen insensitivity syndrome

Increased oestrogens:

• Increased secretion
  
  • Testicular tumours
  • Lung carcinoma
• Increased peripheral aromatization
  
  • Liver disease
  • Adrenal disease
  • Thyrotoxicosis

Question 7

What are the drug causes of gynaecomastia

Answer 7

Cardiac - ACEI, calcium channel blockers, spironolactone, digoxin, amiodarone

Gastro - PPIs (eg. cemetidine)

Antibiotics - metronidazole, ketoconazole

Neurological - TCAs, methyldopa, diazepam

Recreational - cannabis, anabolic steroids, alcohol excess (esp. beer)

Question 8

What are some useful tests in a patient with gynaecomastia

Answer 8

Plasma alpha feto-protein and beta-HCG - raised levels may indicate testicular tumour

Testosterone and LH - to look for hypogonadism

Thryoid function tests

Question 9

How would you manage a patient with gynaecomastia

Answer 9

Treat the underlying cause

It is usually reversible

Medications - tamoxifen or danazol

Surgery - subcutaneous mastectomy (for cosmetic reasons)

Question 10

What would make you concerned about breast cancer in a patient with gynaecomastia

Answer 10

Older age

Unilateral gynaecomastia

Firm or hard nodules within the breast tissue

Lymphadenopathy in the axillary or supraclavicular fossa