GYNECOMASTIA

Question 1

Presentation of a patient with Gynecomastia.

Answer 1

(1) Sub-areolar glandular hyperdensity which is may be unilateral or bilateral,
and may be painful or non-painful
(2) Common transient finding in pubertal males which generally self-resolves

Question 2

Pathophysiology of a patient with Gynecomastia.

Answer 2

(1) Estrogen is a tropic hormone. Under the influence of estrogen (or other
biochemicals capable of stimulating estrogen receptors) breast tissue may
grow.

Question 3

Etiologies of a patient with Gynecomastia.

Answer 3

(1) Any condition resulting in excess estrogen, or testosterone which is
metabolically linked to the estrogen via aromatase (excess testosterone may
be peripherally converted to estrogen)

Question 4

Excess estrogen may be from:

Answer 4

(a) Normal physiology
1) Aging
2) Obesity (truncal and visceral adipose tissue is especially hormonally
active)
3) Puberty
(b) Endocrine disease
1) Androgen insensitivity syndrome
2) Diabetic lymphocytic mastitis
3) Prolactinoma
4) Hyper/Hypothyroidism
5) Hypogonadism (primary or secondary)
6) Klinefelter Syndrome (XXY chromosome)
(c) Systemic disease
1) Chronic liver disease
2) Chronic kidney disease
3) Spinal cord injury
(d) Neoplasms
1) Adrenal tumors
2) Bronchogenic lung cancer
3) Breast cancer
4) Testicular cancer (hCG secreting tumors)
5) Pituitary prolactinoma
(e) Drugs
1) Alcohol
2) Anabolic steroids
3) OTC supplements with androgenic precursors
4) Antipsychotics
5) Opioids
6) Marijuana
7) Isoniazid
8) Spironolactone

Question 5

Evaluation of a patient with Gynecomastia.

Answer 5

1) Physical exam (both upright and supine): Use thumb and index finger as
pincers to examine subareolar tissue as compared to nearby adipose tissue.
a) Adipose tissue should be diffuse and non-tender
b) Breast tissue will be dense and may be tender or nontender
c) True gynecomastia will be localized to subareolar region only
d) RED FLAGS:
(1 Asymmetry
(2 Density located away from subareolar region
(3 Nipple retraction
(4 Nipple bleeding or discharge
(5 Unusual firmness
e) Examine testicles for size and masses
2) Radiographic:
a) All masses or presence of beta hCG warrant testicular ultrasound
b) Further imaging or biopsy may be indicated if malignancy is suspected
3) Initial labs:
a) Free testosterone with SHBG to calculate bioavailable testosterone
b) LH and FSH
c) Liver function panel
d) Renal panel to evaluate BUN and Creatinine
e) Beta hCG (NOT the pregnancy test, there is a specific tumor marker lab
that must be specially ordered)
f) Estradiol
g) Thyroid function panel
h) Prolactin
4) Treatment for true gynecomastia
a) Pubertal gynecomastia is generally self-resolving
b) Adult: Behavioral / iatrogenic
(1 Evaluate for supplement use which VERY common in active duty
population. Reliability of self-reported use is poor so counsel patient
regarding risks even if use is denied.
(2 Evaluate for anabolic steroid use.
(3 Evaluate for excess alcohol intake.
(4 Evaluate for potentially offending medications and adjust when
possible (e.g. spironolactone may be switched to eplerenone).
c) Adult: Pharmacologic (estrogen inhibition)
(1 Selective estrogen receptor modulator (SERM)
(a Raloxifine
(b Tamoxifine
(2 Aromatase inhibitor (prevents peripheral conversion of testosterone to
estrogen)
(a Anastrozole
(3 Testosterone therapy for males with hypogonadism
d) Adult: Refractory cases
(1 Radiation therapy
(2 Surgery
5) Referral
a) Recommend referral to family practice or internal medicine for initial
evaluation.