Epub Feb Breast J. Epub Apr 8. Ther Clin Risk Manag. Epub Mar Mayo Clin Proc. Indian J Endocrinol Metab. Shozu M, Fukami M, Ogata T ; Understanding the pathological manifestations of aromatase excess syndrome: lessons for clinical diagnosis.
Expert Rev Endocrinol Metab. Breast cancer incidence invasive statistics ; Cancer Research UK. Swerdloff RS et al. Gynecomastia: Etiology, Diagnosis, and Treatment. J Urol. Prostate Cancer Prostatic Dis. Epub Jan Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions.
Egton Medical Information Systems Limited has used all reasonable care in compiling the information but make no warranty as to its accuracy.
The injection of exogenous testosterone inhibits natural production of testosterone, which cannot recover rapidly enough between steroid-injecting cycles to prevent estrogen predominance. Attempts to prevent gynecomastia with the use of concomitant tamoxifen or other aromatase inhibitors may result in irreversible adverse effects.
Liver injury may impair hepatic degradation of estrogens and increase levels of sex hormone—binding globulin that contribute to increased peripheral estrogens. Patients with alcohol-related liver disease are at particular risk of gynecomastia because phytoestrogens in alcohol and the direct inhibition of testosterone production by ethanol further disrupt the estrogen-to-testosterone ratio.
Gynecomastia may be the only presenting symptom in men with primary hypogonadism. For example, one-half of men with Klinefelter syndrome have gynecomastia. Although testicular tumors are rare, approximately 10 percent of persons with testicular tumors present with gynecomastia alone.
Adrenal tumors may secrete estrogen and estrogen precursors, causing a similar disruption in the estrogen-to-testosterone ratio. These tumors can be detected by elevated serum dehydroepiandrosterone sulfate levels or increased urinary ketosteroid levels. Similarly, the presence of human chorionic gonadotropin hCG in serum can be used to detect hCG-secreting tumors that may include testicular germ cell, liver, gastric, or bronchogenic carcinomas. All of these tumors require surgical excision.
Gynecomastia occurs in 10 to 40 percent of men with hyperthyroidism, although it is rarely the only symptom at presentation. Hormonal dysfunction is common in men with renal failure because of overall suppression of testosterone production and direct testicular damage secondary to uremia. Conditions that impair absorption, such as ulcerative colitis and cystic fibrosis, may result in gynecomastia.
Refeeding after prolonged malnutrition can also trigger breast tissue proliferation. Although malnutrition suppresses hormone production, refeeding helps resume production. However, the liver lags in recovery and cannot fully degrade estrogens. Although obesity causes pseudogynecomastia a proliferation of adipose rather than glandular tissue , elevated weight is also associated with true gynecomastia.
New research suggests that leptin and aromatase activity associated with obesity contribute to increased circulating estrogens, causing gynecomastia. Other rare causes of gynecomastia include exposure to phthalates and lead, emotional stress, and repetitive mechanical stress causing unilateral symptoms.
Additionally, patients with human immunodeficiency virus infection may develop gynecomastia from the disease process or use of antiretroviral medications.
No cause is found in 25 percent of patients who develop gynecomastia. Some patients with gynecomastia may present with breast pain, embarrassment, or fear of breast cancer. In other patients, gynecomastia is discovered on routine physical examination and causes no emotional or physical distress. Understanding the patient's concerns can help direct treatment. The history should rule out other causes of breast enlargement, such as those listed in Table 3.
Symptoms that last longer than one to two years suggest nonphysiologic causes that require intervention for resolution. Nipple discharge; skin changes; rapidly enlarging, firm breast masses; coincident testicular masses; or systemic symptoms such as weight loss should raise concern.
Information from references 31 through The physical examination should include evaluation of height and weight, and examination of the breasts, genitals, liver, lymph nodes, and thyroid. Assessment of symmetry and consistency of breast tissue is critical on breast examination.
Most commonly, gynecomastia is bilateral, although unilateral symptoms can occur and are usually left-sided. Palpable, firm glandular tissue in a concentric mass around the nipple areolar complex is most consistent with gynecomastia. Increases in subareolar fat are more likely pseudogynecomastia, whereas hard, immobile masses should be considered breast carcinoma until proven otherwise.
Similarly, masses associated with skin changes, nipple retraction, nipple discharge, or enlarged lymph nodes should raise concern for malignancy. The history and physical examination should direct the laboratory and imaging workup Figure 1. Laboratory studies to investigate the underlying cause of gynecomastia should include measurement of hepatic transaminase, serum creatinine, and thyroid-stimulating hormone levels for all patients.
Levels of serum beta hCG, serum dehydroepiandrosterone sulfate, or urinary ketosteroid should be obtained to rule out testicular, adrenal, or other tumors when clinically suspected.
Likewise, total and free testosterone, estradiol, luteinizing hormone, and follicle-stimulating hormone levels define hormonal imbalances resulting from primary or secondary hypogonadism.
Hyperprolactinemia is not common in patients with gynecomastia. Laboratory studies may be ordered using a stepwise approach guided by history and physical examination, but a diagnosis of physiologic gynecomastia should not be made until underlying etiologies have been excluded. Recommendations for imaging studies are based mainly on case reports and expert opinion. Some studies have suggested routine testicular ultrasonography in men with gynecomastia to detect nonpalpable testicular tumors that were missed on clinical examination.
Breast imaging should be guided by examination. Just as in women, mammography and breast ultrasonography may be useful in men if the physical examination raises suspicion for breast malignancy. Fine-needle aspiration of masses for cytology should be pursued only if malignancy is suspected.
Men with Klinefelter syndrome have a risk of breast cancer 16 to 30 times higher than other men. Even with a reassuring examination, men with gynecomastia and Klinefelter syndrome may require imaging. Few patients with gynecomastia need treatment for cosmesis or analgesia. For patients with nonphysiologic gynecomastia, treatment is directed toward improving the underlying illness or discontinuing use of the contributing.
Watchful waiting with biannual follow-up is appropriate for those with physiologic gynecomastia who are untroubled by symptoms and who have no features that suggest underlying disease or malignancy. Early treatment will maximize benefit in men with significant physical symptoms or emotional distress.
Medications are more effective if used as early as possible after symptoms are first noted, whereas surgery can be performed at any time with similar results. A number of medications have been used to treat gynecomastia. A retrospective chart review of men presenting to a breast clinic for gynecomastia found that only 13 of patients required medication for treatment.
Patients were treated with 10 mg of tamoxifen per day for three months, and 10 of the 13 had resolution of pain and breast enlargement. Gynecomastia is a common adverse effect of bicalutamide Casodex therapy that may prompt some men to discontinue prostate cancer treatment. Tamoxifen has been recommended as a preventive agent for gynecomastia in these patients.
A double-blind study of men randomized to receive 20 mg of tamoxifen once per day with bicalutamide or bicalutamide alone found that after six months, gynecomastia and breast pain were significantly reduced in men who received tamoxifen 8.
In a retrospective chart review of 38 patients in a pediatric endocrinology clinic, raloxifene Evista; 60 mg once per day for three to nine months reduced pubertal gynecomastia in 91 percent of patients, whereas tamoxifen 10 to 20 mg twice per day for three to nine months was effective in 86 percent of patients.
Dihydrotestosterone, danazol, and clomiphene Clomid have also been used to treat gynecomastia with varying success. More studies are needed to assess the effectiveness of aromatase inhibitors, such as anastrozole Arimidex; 1 mg per day. One trial of 42 pubertal boys demonstrated a 57 percent reduction in breast volume with anastrozole treatment.
Surgery can be performed at any time to reduce breast tissue, and a number of techniques have been used. However, unilateral symptoms, high-grade disease, and long duration of symptoms are also associated with more surgical complications. If pseudogynecomastia is suspected, no workup is needed, and the patient can be reassured that weight loss will lead to resolution of pseudogynecomastia and also be most beneficial for overall health. Data Sources: Essential Evidence Plus and PubMed were searched for relevant articles using the following search terms: gynecomastia, physiologic gynecomastia, and breast enlargement.
Each term was searched individually and in conjunction with the following terms: males, men, diagnosis, treatment, and management. Search dates: December 10 to 25, Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Kansas, Wichita, KS e-mail: gdickson kumc.
Reprints are not available from the author. Braunstein GD. Clinical practice. N Engl J Med. Breast development in the newborn. Arch Dis Child. Incidence of gynaecomastia in young males and its relationship to somatometric parameters. Ann Hum Biol. Beneficial effects of raloxifene and tamoxifen in the treatment of pubertal gynecomastia.
J Pediatr. Hormonal studies and physical maturation in adolescent gynecomastia. Pubertal gynecomastia and transient elevation of serum estradiol level. Am J Dis Child. Gynecomastia in a hospitalized male population. Am J Med. Drug-induced gynecomastia. Eckman A, Dobs A. Expert Opin Drug Saf. Antipsychotic medication in children and adolescents: a descriptive review of the effects on prolactin level and associated side effects.
J Child Adolesc Psychopharmacol. Nuttall FQ. Gynecomastia as a physical finding in normal men. J Clin Endocrinol Metab. Gynecomastia in adolescent boys.
Gynecomastia in a hospitalized male population. Am J Med. Gynecomastia: clinicopathologic study of cases. Am J Clin Pathol. Moore NP. The oestrogenic potential of the phthalate esters. Reprod Toxicol. Endocrine-disrupting chemicals: an Endocrine Society scientific statement.
Endocr Rev. Aromatase and steroid receptors in gynecomastia and male breast carcinoma: an immunohistochemical study. J Clin Endocrinol Metabol. Measurement of androgen and estrogen receptors in breast tissue from subjects with anabolic steroid-dependent gynecomastia. Life Sci. Adolescent gynecomastia: not only an obesity issue. Ann Plast Surg. A physiologic role for testosterone in limiting estrogenic stimulation of the breast. Pearlman G, Carlson HE.
Gynecomastia: an update. The Endocrinologist. Endocrinology of gynaecomastia. Ann Clin Biochem. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc. Plasma phthalate levels in pubertal gynecomastia. Evaluation of anti-androgenic activity of di- 2-ethylhexyl phthalate. Agency for Toxic Substances and Disease Registry. Toxicological profile for di- 2-ethylhexyl -phthalate.
Epidemic of gynecomastia among illegal Haitian entrants. Public Health Rep. Epidemic of gynecomastia among haitian refugees: exposure to an environmental antiandrogen. Endocr Pract. Luteinizing hormone and human chorionic gonadotropin decrease type 25 alpha-reductase and androgen receptor protein levels in women's skin.
Progesterone stimulates mammary gland ductal morphogenesis by synergizing with and enhancing insulin-like growth factor-I action. Progesterone, prolactin, and gynaecomastia in men with liver disease. High serum progesterone in hyperthyroid men with Graves' disease. Expression of prolactin receptors in normal, benign, and malignant breast tissue: an immunohistological study.
J Clin Pathol. Correll CU. Effect of hyperprolactinemia during development in children and adolescents. J Clin Psychiatry. Coexpression and cross-regulation of the prolactin and sex steroid hormone receptors in breast cancer.
Ruan W, Kleinberg DL. Insulin-like growth factor I is essential for terminal end bud formation and ductal morphogenesis during mammary development. Mazur T, Clopper RR. Pubertal disorders. Psychology and clinical management. Endocrinol Metab Clin North Am. Longitudinal effects of aging on serum total and free testosterone levels in healthy men.
Baltimore Longitudinal Study of Aging. Serum levels of free and bound testosterone in hyperthyroidism. Clin Endocrinol Oxf. Klinefelter's syndrome.
Deciduoid-like stromal cells in a diabetic patient with bilateral gynecomastia: a potential diagnostic pitfall. Virchows Arch ; 6 Gynecomastia in HIV-infected patients receiving antiretroviral therapy.
Goldman RD. Drug-induced gynecomastia in children and adolescents. Can Fam Physician. Holzbeierlein JM. Managing complications of androgen deprivation therapy for prostate cancer. Urol Clin North Am. Marijuana: interaction with the estrogen receptor. J Pharmacol Exp Ther. Basaria S.
Androgen abuse in athletes: detection and consequences. The role of mammography in male patients with breast symptoms. Sonographic features of gynecomastia. J Ultrasound Med. Male gynecomastia and risk for malignant tumours--a cohort study. BMC Cancer. Male breast cancer. Multidisciplinary meeting on male breast cancer: summary and research recommendations.
J Clin Oncol. Review article: epidemiology of male breast cancer. A meta-analysis of published case-control studies and discussion of selected aetiologic factors. Int J Cancer.
Prevalence of Klinefelter's syndrome in male breast cancer patients. Anticancer Res. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction.
Plast Reconstr Surg. Ratnam BV. A new classification and treatment protocol for gynecomastia. Aesthet Surg J. Classification and surgical correction of gynecomastia. Cordova A, Moschella F. Algorithm for clinical evaluation and surgical treatment of gynaecomastia. J Plast Reconstr Aesthet Surg. Hammond DC. Surgical correction of gynecomastia. A comparison of danazol and placebo in the treatment of adult idiopathic gynaecomastia: results of a prospective study in 55 patients.
Ann R Coll Surg Engl. Buckle R. Danazol therapy in gynaecomastia; recent experience and indications for therapy. Postgrad Med J. Treatment of persistent pubertal gynecomastia with dihydrotestosterone heptanoate. J Pedriat. Alagaratnam TT. Idiopathic gynecomastia treated with tamoxifen: a preliminary report.
Clin Ther. Tamoxifen therapy for painful idiopathic gynecomastia. South Med J.
0コメント