LM 19.1: Gynecomastia Flashcards
what is gynecomastia?
an increased production of glandular an dstormal male breast tissue
it does not just mean increased adipose tissue
benign condition
when could gynecomastia occur?
if the balance between androgens and estrogens is disrupted
both males and females have androgens and estrogens but normally in males the concentration of androgens is greater than estrogen
an abnormal alteration or disruption of the androgen/estrogen abalone can lead to gynecomastia
phsyiologic vs pathologic gynecomastia?
physiologic: the process occurs in absence of disease
pathologic: disease state
when can physiologic gynecomastia occur during life?
when there are naturally occurring hormonal changes
- early life
- puberty
- later adulthood after 50
how does physiologic gynecomastia in neonates occur?
the placenta provides the fetus with everything it needs
estrogens can cross the placenta and trigger gynecomastia in neonateas
after birth residual estrogen from the placenta can lead to breast development but usually by 1 year old the estrogen levels decrease and the gynecomastia resolves
how does gynecomastia during puberty present?
60-70% of males
can be unilateral or bilateral
lump or mass behind the nipple that can be painful or tender
why does gynecomastia occur physiologically?
the exact cause is unknown but it may be due to:
- high estrogen sensitivity
- increased androgen production
- peripheral conversion of androgens to estrogens in adipose tissue
how do you manage gynecomastia during puberty?
it is NOT associated with lactation or erythema
treatment involves reassurance
lab testing isn’t necessary during puberty if they are healthy and growing
imagining is not required for diagnosis
usually it resolves within 12-15 months and if it doesn’t pathologic causes should be considered
what causes gynecomastia in later adulthood?
50+ year olds
as part of the aging process, men have less testosterone, more fatty tissue and more androgen to estrogen conversion in the fatty tissue
which syndrome can cause pathologic gynecomastia?
Klinefelter Syndrome: 47,XXY
extra X chromosome leads to hypogonadism, underdeveloped secondary sex characteristics and female hair distribution
decreased testosterone, increased LH/ estrogen lead to gynecomastia
thin limbs, tall height, increased learning disabilities and behavioral problems
how can tumors cause gynecomastia?
testicular tumors can cause gynecomastia; 3%
the cause is most likely a disruption of the androgen/estrogen balance
how can cirrhosis cause gynecomastia?
hepatic fibrosis which lads to abnormal hepatic function
this results in lower levels of detoxification and clearance and in this way estrogen can accumulate and cause gynecomastia
what are the pathologic causes of gynecomastia?
- Klinefelter Syndrome
- cirrhosis
- testicular tumors
- thyroid disease
what are the signs of hyperthyroidism?
- weight loss
- sweating
- heat intolerance
- tachycardia/ palpitations
- increased GI motility
- restlessness
- low TSH, high T3/T4
can cause gynecomastia
which substances can trigger gynecomastia?
- alcohol (higher metabolism of androgens)
- anabolic steroids
- marajuana
this is because elevated testosterone can lead to elevated estrogen, triggering gynecomastia
which drugs induce gynecomastia?
- spironolactone
- ketoconazole
- finasteride
- flutamide
- cimetidine
- risperidone
they effect the androgen/estrogen balance
how does spironolactone cause gynemastia?
anti-androgen effect by inhibiting steroid binding
how does ketoconazole cause gynemastia?
inhibits steroid synthesis and has an anti-androgen effect and decreases androgen production
how does finasteride cause gynecomastia?
5-alpha-reductase inhibitor
stops the conversion of testosterone to DHT
used to treat benign prostate hyperplasia
how does flutamide cause gynecomastia?
non-steroidal competitive androgen inhibitor at the androgen receptor
how does cimetidine cause gynecomastia?
H2 blocker and direct testosterone antagonist
prevents DHT from binding at the cytoplasmic receptor
how does risperidone cause gynecomastia?
dopamine D2 receptor antagonist that can also trigger gynecomastia
how could a patient with gynecomastia present clinically?
bilateral or unilateral but bilateral is more common
distinguishable mass of breast tissue that’s symmetrical and in the central breast region
may present with hard, ulcerated mass that is painful
what is in the differential of gynecomastia?
- mastitis
- galactocele
- breast cancer
what is mastitis?
infants less than 2 months
unilateral or bilateral
warm, erythematous swollen or tender breasts with or without nipple discharge
could have breast enlargement from abscess
gynecomastia doesn’t have discharge and isn’t warm or have discharge
what is galactocele?
cystic lesion filled with milk
can be unilateral or bilateral
how does male breast cancer present?
painless, firm mass in the *peripheral breast
may have nipple discharge or bleeding
lymphadenopathy may be present
rare in male children and adolescence but if it’s present there’s a newly developing quickly growing mass
which males are at a higher risk for breast cancer?
- (+) BRCA2 mutation in the family
- Kleinfelter
- radiation exposure
- obesity
- gonadal failure
what imaging modality is the most sensitive and specific for breast cancer?
mamography most sensitiive
US most specific
what is pseudogynecomastia?
increased fatty or adipose tissue in the breast
gynecomastia has increased glandular or stroma tissue that feels like mobile mass behind the areola while pseudogynecomastia doesn’t have a mobile, rubbery mass
how do you diagnose gynecomastia?
history usually
mobile, rubbery mass in the sub-areolar area
in adolescence you dont need to test if they’re healthy and growing
prolactin isn’t necessary unless there’s nipple discharge
imaging isn’t necessary either
