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INTRODUCTION

Gynecomastia is the increased presence of benign glandular tissue, in the form of a firm mass, around the nipple in males (Fig. 57.1). It is accompanied by increased fat deposition. In contrast, increased fat deposition alone, in the absence of glandular proliferation, is known as pseudogynecomastia. It can be bilateral or unilateral. It is common at birth, puberty, middle age, and in elderly adults. Many cases are idiopathic. Multiple precipitating factors exist including hormonal abnormalities, medication, cirrhosis, hypogonadism, testicular tumors, hyperthyroidism, and chronic renal insufficiency. For this reason, in the appropriate clinical setting, the appearance of gynecomastia demands a medical workup.

Figure 57.1

Characteristic appearance of gynecomastia in a middle-aged male

EPIDEMIOLOGY

Incidence: most common in newborns but also common in puberty and older males

Age: birth (0–3 weeks), puberty (10–17 years), middle-aged and elderly age groups (50–80 years)

Race: none

Sex: males

Precipitating factors: hormonal imbalances, hormonal therapy for prostate cancer, drugs such as, finasteride, cirrhosis, hypogonadism, testicular tumors, hyperthyroidism, chronic renal insufficiency. About one-quarter of cases are idiopathic

PATHOGENESIS

In cases of hormonal imbalances, the fundamental defect is a decrease in androgen levels with a concomitant increase in estrogen levels.

PHYSICAL LESIONS

A firm subcutaneous nodule extends concentrically from the nipple. It may be unilateral or bilateral. In pseudogynecomastia, the examined area is less firm as there is no excess glandular tissue.

DIFFERENTIAL DIAGNOSIS

Breast cancer, pseudogynecomastia, breast hypertrophy.

LABORATORY EXAMINATION

Serum hCG, LH, testosterone, estradiol levels should be investigated in the setting of pain, tenderness, or recent onset or clinical suspicion of endocrine abnormalities. Further workup is indicated in the event of unilateral breast enlargement.

COURSE

This depends on the etiology. Newborn gynecomastia persists for a few weeks. In teenagers, it may last a few years. Discontinuance of medication will ameliorate symptoms in drug-induced cases. In cases of hormonal imbalance, kidney disease, and hyperthyroidism, correction of the underlying illness will produce improvement.

KEY CONSULTATIVE QUESTIONS

  • Medication history

  • Hormonal changes

  • Renal or thyroid disease

  • Hormonal therapy for prostate cancer

  • Associated symptoms

  • Unilateral or bilateral

MANAGEMENT

Most gynecomastia is temporary and will resolve without therapy. If it is related to puberty, clinical observation and follow-up will likely be all that is needed. Discontinuation of an offending medication is typically all that is required to treat drug-induced gynecomastia. Unilateral gynecomastia requires a mammogram with appropriate follow-up as needed. Medical and surgical options are available for patients who have persistent gynecomastia into late puberty producing emotional distress, pain, ...

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