Gynaecomastia

Question 1

What is gynaecomastia?

Answer 1

When males develop breast tissue due to an imbalanced ratio of oestrogen and androgen activity.

Usually benign.

Question 2

Epidemiology

Answer 2

At least a third of men experience gynaecomastia in their lifetime

Usually entirely reversible

Question 3

Pathophysiology of physiological gynaecomastia

Answer 3

Most commonly occurs in adolescence from delayed testosterone surge relative to oestrogen at puberty.

It can also happen in older population due to decreasing testosterone levels.

Question 4

Causes of pathological gynaecomastia

Answer 4

Lack of testosterone
Klinefelter’s, Androgen insensitivity, Testicular atrophy, renal disease

Increased oestrogen levels
Liver disease, hyperthyroidism, obesity, adrenal tumours, Leydig’s cell tumours

Medication
Digoxin, metronidazole, spironolactone, chemo, goserelin, antipsychotics, anabolic steroids

Idiopathic

Question 5

Clinical features

Answer 5

Insidious onset

Ask about associated symptoms and comorbidities

Rubbery or firm mass that stat from underneath the nipple and spreads outwards

Testicular examination should be done as well

Question 6

Dx

Answer 6

Pseudogynaecomastia

Question 7

Investigations

Answer 7

Triple assessment if suspecting malignancy

LFTs, U&Es

Hormone profile with LH and testosterone

Question 8

What does high LH and low test suggest?

Answer 8

Testicular failure

Question 9

What does low LH and low testo suggest?

Answer 9

Increased oestrogen

Question 10

What does high LH and high testo suggest?

Answer 10

Androgen resistance

Gonadotrophin-secreting malignancy

Question 11

Management

Answer 11

Depends on cause

Reassurance should be enouhg

Tamoxifen can be used, especially if tender

Surgery is only done if medical treatment have failed