Work up of gynecomastia Nilanjan Sengupta,MD,DM Assistant Professor Department of Endocrinology NRS Medical College Kolkata
Work up of gynecomastia
Nilanjan Sengupta,MD,DMAssistant Professor
Department of EndocrinologyNRS Medical College
Kolkata
Hormonal control of breast development
• estradiol stimulates glandular cells
• testosterone inhibits growth & differentiation
• GH,cortisol,IGF1,insulin act permissively
• thyroid hormones increase SHBG level
• cortisol & prolactin lower T levels (hypothalamic & testicular effects)
Gynecomastia : the problem
• common condition : not always pathological• pubertal gynecomastia : 65% by age 15• 30% of normal military recruits have palpable
breast tissue• 40% men (40-44y)have palpable breast tissue• upto 70% hospitalized patients (50-69y) have
palpable breast tissue• upto 83% of hospitalized men with gynecomastia
– breast tissue diameter <5cm
Physiological vs pathological gynecomastia
• challenging• common• association with obesity• psedogynecomastia• pathological arbitrarily defined : palpable tissue > 4cm >2cm & tender >2cm & increasing
Causes
• estradiol excess
• testosterone deficiency
• estrogen – testosterone imbalance
• regulatory hormone excess
• drugs
• others
Aromatase associated causes of gynecomastia
• obesity• ageing• aromatase excess syndrome (familial, sporadic)• neoplasms (eutopic & ectopic productions)• idiopathic• thyrotoxicosis
unifying feature of several causes- known & unknown of gynecomastia
Evaluation
• whom to evaluate
• how to evaluate
Candidates needing evaluation
• breast tenderness
• rapid enlargement
• eccentric, hard or irregular mass
• lesion >4cm in diameter
Candidates not requiring evaluation
• asymptomatic
• stable
• obese
• <5cm
History
• family history : familial aromatase excess, Peutz Zeghers syndrome, Carney complex
• personal history : marijuana• time of onset • duration (beyond 12mo breast becomes
irreversibly fibrotic)• rate of progression• pain• symptoms of androgen deficiency
History
• drugs : finasteride, biculatamide, spironolactone, domperidone,βblockers, calcium channel blockers, amiodarone, diazepam, enalapril, metronidazole……..
• inadvertent estrogen exposure : industrial, coital exposure involving women using vaginal estrogen cream, from women using estrogen containing cosmetics
History
• systemic diseases : CLD, CKD, diabetes
• endocrinopathies : thyrotoxicosis, hypothyroidism, acromegaly, Cushing’s syndrome
• psychological assessment : depression, social withdrawal, scholastic deterioration
Examination : local
• presence or absence of breast disc• diameter of breast disc• to pinch the tissue between thumb &
forefinger lateral to nipple; ability to flip an edge of tissue at the interface of normal & glandular tissue signifies gynecomastia
• comparison of consistency with abdominal fat or fat in the axillary line
• tenderness
Simon classification of gynecomastia
Grade Enlargement Skin excess
I small absent
IIA moderate absent
IIB moderate present
III large present
Simon classification of gynecomastia
• fatty, low grade breast without glandular tissue : suction assisted lipectomy (SAL), ultrasound assisted liposuction (UAL)
• I : simple excision; SAL,UAL (adjunctive)
• II : simple excision, + SAL
• III : total mastectomy with free nipple grafting, modified radical mammoplasty
Examination : systemic
• features of hypogonadism
• asymmetrical testes (testicular tumor)*
• probable systemic illnesses : may be too obvious
*50% palpable; rest require ultrasound for detection
Investigations
• to distinguish glandular tissue from fat
mammography
ultrasonography (less sensitive)
• to exclude neoplasm : excision biopsy
Biochemical investigations
• testosterone
• 17β estradiol
• DHEAS
• LH
• β hCG
• thyroid function test
• liver function test
proceed further according to lead
Conclusion
• to differentiate gynecomastia from lipomastia
• to differentiate physiological from pathological gynecomastia
• to separate gynecomastia that is relatively innocuous from those that connote serious underlying endocrinopathy or medical disorder
Conclusion
• to assess patient’s attitude towards gynecomastia & psychological stress ,if any
• work up should be judicious & purposeful : detailed work up may not be necessary or rewarding in many instances
• if no apparent abnormality is detected, wait & watch policy may be adopted along with reassurance