Editing Gynaecomastia


Benign proliferation of the glandular tissue of the male breast.

== '''Aetiology''' ==

* '''Most commonly:'''
** Physiological high serum oestradiol to testosterone (25%)
*** Neonates
*** Puberty
*** Elderly
** Drugs (20%)
*** Spironolactone
*** Recreational including THC
*** Oestrogens 
*** Etc. 
** No detectable abnormality (25%)
** Increased oestrogens: (10%)
*** Cirrhosis/malnutrition
*** Testicular tumours
*** Hyperthyroidism
** Decreased androgens: (10%)
*** Hypogonadism
*** CKD
* '''Drugs''' (most commonly things that affect androgen/oestrogen synthesis)
** Antiandrogens/inhibitors of androgen synthesis
** Antibiotics
** Antiulcer drugs
** Cancer chemotherapeutic drugs
** Cardiovascular drugs
*** ACE inhibitors
*** Amiodarone
*** CCBs
*** Digoxin
*** Methyldopa
*** Reserpine
*** Statins
*** '''Spironolactone'''
** Drugs of abuse
*** '''Alcohol'''
*** Amphetamines
*** Heroin
*** '''THC'''
*** Methadone
** Hormones
*** Androgens
*** '''Anabolic steroids'''
*** Chorionic gonadotropin
*** '''Oestrogens'''
*** Growth hormone
** Psychoactive drugs
*** Diazepam
*** Haloperidol
*** Phenothiazines
*** Tricyclic antidepressants
*** Atypical antipsychotics
** Other
*** Domperidone

== '''Pathophysiology''' ==

* Pubertal hypertrophy
** Unilateral or bilateral
** Can be painful and tender
** Tends to regress with adulthood
* Senescent hypertrophy 
** Men >50yo
** Usually asymptomatic
** Frequently unilateral

== '''Clinical''' ==

* Definition: palpable breast tissue extending outside the area under the nipple, or recent growth and heaviness.
* Smooth, firm, saucer-shaped
* Four typical features:
** Glandular tissue centrally located
** Symmetrical in shape
** Usually bilateral
** Tender to palpation during early or growth phase

== '''Workup''' ==

* Imaging not usually recommended
** Consider mammography if unilateral and some doubt 
** Mammogram - 'fan-shaped density emanating from the nipple, gradually blending into surrounding fat'
** USS if discrete lump identified
* Investigate for common causes
** FBE, UEC, TSH as standard
** If no obvious cause: hCG, LH, FSH, testosterone, oestradiol, AFP, prolactin
*** If elevated hCG plus suppressed LH - likely testicular or extragonadal germ cell tumour
*** High oestradiol + low LH suggests testicular tumour (Leydig or Sertoli)
** Reasonable to do morning serum total testosterone concentration in older men
* Histology
** Glandular changes are the same regardless of aetiology
** Extent of glandular proliferation depends on intensity and duration of the growth stimulation
** Early - extensive ductal epithelial hyperplasia, increase in stromal and periductal connective tissue, and proliferation of the periductal inflammatory cells
** Late, after 12 or more months: more fibrosis

== '''Diagnosis''' ==

* Made on physical examination - concentric, rubbery-to-firm disk of tissue, often mobile, located directly beneath the areolar area
* Differential:
** Pseudogynaecomastia - which is due to an increase in breast fat, not glandular tissue - diffuse breast enlargement without any subareolar glandular tissue. Fingers won't meet any resistance until they reach the nipple.
** Breast cancer - usually can be distinguished on examination. Typically unilateral, non-tender, often fixed masses found eccentric to the nipple-areolar complex.

== '''Treatment''' ==

* Fix cause
* In adolescents - almost always pubertal gynaecomastia, which resolves spontaneously in most cases. Observation without surgery. Consider surgery if there is unilateral enlargement, it fails to regress, or is cosmetically unacceptable.
* Medical treatment
** Companion recommends tamoxifen 10mg daily for up to 6 months
* Surgery
** High risk of poor cosmesis, seroma, numb nipple, nipple necrosis
** Liposuction has been done in this setting

[[Category:Breast]]