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Gynecomastia
 

Gynecomastia

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  • For teenage boys gynaecomastia is not common, but it is okay in teenage. Even tablets are available for teenage boys as a remedy for gynaecomastia. But gynaecomastia surgery is the only option if you corss teenage. woman plastic surgeons in India can be reached through www.thecosmeticsurgery.org
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    Gynecomastia Gynecomastia Presentation Transcript

    • 19-Year-Old With Gynecomastia Anastassia Amaro, MD Fellow, Endocrinology and Metabolism Washington University School of Medicine December 15, 2005
    • Case report Cc: 19 yo WM with bilateral breast enlargement for 3 months. First unilateral, then bilateral within a month Pain and tenderness Usual state of health
    • Gynecomastia is a benign enlargement of the male breast resulting from a proliferation of the glandular component of the breast.
    • Differential Diagnosis of Gynecomastia Pseudogynecomastia Breast carcinoma Neurofibroma Lipoma Dermoid Cyst
    • True Gynecomastia Result of absolute or relative estrogen excess 50% idiopathic Physiologic in: Neonatal Period Resolves within wks (Santen, Endocrinology vol. 3: 2335-2341, 2001) Puberty 60% by age 14 Resolves within 3 yrs (Santen, Endocrinology vol. 3: 2335-2341, 2001) >60 years of age
    • Sex Hormone Production in Males Estradiol Estron Extraglandular 1 Tissues 2 2 1 Testosterone Androstenedione Testosterone Androstenedione Circulation Estradiol Estrone Steroid- Cholesterol Leydig Secreting Cell Pregnenolone Tissues Progesterone Adrenal Testis 17α-Hydroxyprogesterone 1- 17β-hydroxysteroid dehydrogenase Androstenedione 2 – aromatase 1 Testosterone 2 Modified from Braunstein, End-Rel Cancer Estradiol 1999; 6:315-324.
    • Androgen-Estrogen Dynamics in Normal Men 8% Androstenedione Testosterone 5200 mcg/day 5% 3000 mcg/day 0.3% 1.6% Secretion Testes, 6 From Testosterone, 17 From Estradiol, 21 93% Extraglandular From Androstendione, 45 Formation From Estrone, 22 49% Estradiol, Estrone, 45 mcg/day 66 mcg/day From MacDonald et al. J Clin Endocrinol Metab 1979; 49:905-916
    • Plasma Testosterone 2% free 44% bound to SHBG 54% bound to albumin and other proteins (Dunn et al., J Clin Endocrinol Metab 1981; 53(1):58-68) ~50% active fraction (Partridge, Clin Endocrinol Metab 1986; 15(2):259-78)
    • Androgen Action From Griffin, N Engl J Med 1992; 326:611-618
    • Structure of Estrogen Receptor
    • Distribution of Estrogen Receptors and Aromatase in the Male Reproductive System From Rochira et al, Asia J Androl 2005; 7:3-20
    • Role of Estrogen and Aromatase in Male Physiology Grumbach. Ann N Y Acad Sci 2004;1038:7-13
    • Aromatase Aromatase P450 enzyme: Cyp19 gene, located on chromosome 15. (Means et al, J Biol Chem 1989; 264:19385-19391) Activity demonstrated in testes, brain, skin fibroblasts, adipocytes, breast stromal cells. (Simpson et al. 1994, Sasano et al. 1996)
    • Androgen-Estrogen Dynamics in Normal Men 8% Androstenedione Testosterone 5200 mcg/day 5% 3000 mcg/day 0.3% 1.6% Secretion Testes, 6 From Testosterone, 17 From Estradiol, 21 93% Extraglandular From Androstendione, 45 Formation From Estrone, 22 49% Estradiol, Estrone, 45 mcg/day 66 mcg/day From MacDonald et al. J Clin Endocrinol Metab 1979; 49:905-916
    • Gynecomastia: Deficient Testosterone Formation Testosterone Androstenedione Secretion Extraglandular Estradiol Estrone Formation Examples: Primary Gonadal Failure, congenital Kleinfelter’s, Hermaphroditism Primary Gonadal Failure, acquired Viral Orchitis, Granulomatosis Hypothalamic or Pituitary Disease From Griffin and Wilson, Williams Textbook of Endocrinology, Tenth Edition,18:709-769, 2003
    • Gynecomastia: Increased Estrogen Secretion Testosterone Androstenedione Secretion Estradiol Estrone Extraglandular Formation Examples: Leydig Cell and Sertoli Cell Tumors True Hermaphroditism HCG-Secreting Tumors From Griffin and Wilson, Williams Textbook of Endocrinology, Tenth Edition,18:709-769, 2003
    • Gynecomastia: Increased Extraglandular Estrogen Formation - Increased Substrate Testosterone Androstenedione Secretion Extraglandular Estradiol Estrone Formation Examples: Adrenal Tumors Congenital Adrenal Hyperplasia 17ß-HSD 3 Deficiency Hyperthyroidism, Liver Disease From Griffin and Wilson, Williams Textbook of Endocrinology, Tenth Edition,18:709-769, 2003
    • Increased Extraglandular Estrogen Formation – Increased Aromatase Enzyme Testosterone Androstenedione Secretion Extraglandular Estradiol Estrone Formation Examples: Hereditary Increase Liver Carcinoma Obesity, Hyperthyroidism From Griffin and Wilson, Williams Textbook of Endocrinology, Tenth Edition,18:709-769, 2003
    • Prolactin and Gynecomastia Prolactin is normal in gynecomastia. No gynecomastia in males with hyperprolactinemia unless testicular failure due to pituitary mass effect or LH suppression. Prolactin has no role in Gynecomastia. From Griffin and Wilson, Williams Textbook of Endocrinology, Tenth Edition,18:709-769, 2003
    • Drugs and Gynecomastia Estrogens and Estrogen Mimetics Drugs That Inhibit Testosterone Estrogen (incl. topical, phyto-, and Action environmental) Spironolactone Digitalis Cimetidine, Ranitidine Drugs That Enhance Endogenous Antiandrogens (cyproterone, Estrogen Formation flutamide, zanoterone) HCG Unknown Mechanism Clomiphene citrate Protease Inhibitors, Isoniazid Drugs That Inhibit Testosterone CaCB, ACE-I, Methyldopa, Amio Synthesis Omeprazole Ketoconazole Diazepam, Tricyclic Antidepresants Alkylating Agents Theophylline Spironolactone From Griffin and Wilson, Williams Textbook of Endocrinology, Tenth Edition,18:709-769, 2003
    • Diagnostic Evaluation of Gynecomastia History Duration of breast enlargement Presence of breast pain or tenderness Drug history (prescription, over-the-counter, occupational, or recreational) Sexual functioning Changes in virilization Changes in weight Symptoms of hyperthyroidism
    • Case Report - History Puberty completed by age 15 Duration of breast enlargement 3 months Presence of breast pain or tenderness yes Drug history (prescription, OTC, or recreational) none Sexual functioning normal Changes in virilization none Changes in weight none Symptoms of hyperthyroidism tremor, ↑ perspiration NO palpitations, anxiety, changes in hair, appetite, or bowel habits
    • Case Report – History PMH: elevated BP in PCP office, MVP SHx: student, no tobacco, social ETOH, marijuana x 5 total, no soy products FH: Graves disease in mother, HTN in father Allergies: none Medications: none
    • Diagnostic Evaluation of Gynecomastia Physical Examination Thyroid and signs of thyroid hormone excess Breast examination, suspicious findings suggestive of malignancy Abdominal examination for possible adrenal mass or hepatomegaly Examination of genitalia, testicular size, testicular mass Degree of virilization: body hair, voice, muscles
    • Case Report- Physical Examination BP 140/75, HR 82, RR 14, wt 157 lbs Gen: NAD, physically fit HEENT: no exophthalmos, no lid lag Thyroid: palpable, slightly enlarged, soft, no nodules, no LAD Chest: bilateral tender mobile rubbery masses extending concentrically from the nipples, 2 cm in diameter, no LAD Heart: RRR, soft systolic murmur Abdomen: no organomegaly Neuro: DTR brisk Genitalia: Tanner 5, testicular volume 20 ml, no masses Virilization: appropriate for age
    • Diagnostic Evaluation of Gynecomastia Laboratory evaluation Serum creatinine Liver enzymes Serum total and free testosterone (T) LH, FSH Estradiol (E2) TSH, free thyroxine (FT4) Beta-HCG Serum DHEA-S
    • Case Report – Laboratory Evaluation CMP – normal Reference Range Total T 1820 300-950 ng/dl Free T 29.1 9.0-30.0 ng/dl LH 7.0 1.5-9.0 IU/L E2 80 10-50 pg/ml TSH <0.02 0.4-6.2 mcIU/ml FT4 2.8 0.9-1.8 ng/dl Beta-HCG <5.0 0-5 IU/L DHEA-S 2.96 1.25-6.19 mcg/ml
    • Case Report – Diagnosis & Treatment 24-hour thyroid uptake of I-131 52% (normal range 10-30%) Ds: Diffuse Toxic Goiter (Graves’ Disease) Rx: 9.8 mCi of I-131
    • Case Report – Follow-up 8 wks post I-131 Rx Weight gain: 2 lbs Perspiration and tremor have improved. BP 135/80 DTR: normal Gynecomastia has resolved.
    • Case Report – Follow-up Labs At Ds 8 wks FU Reference Range Total T 1820 846 300-950 ng/dl Free T 29.1 21.9 9.0-30.0 ng/dl LH 7.0 4.4 1.5-9.0 IU/L E2 80 49 10-50 pg/ml TSH <0.02 <0.02 0.4-6.2 mcIU/ml FT4 2.8 0.9 0.9-1.8 ng/dl
    • Gynecomastia in Hyperthyroidism Hyperthyroidism accounts for 2% of all adult gynecomastia. Gynecomastia as the presenting manifestation of hyperthyroidism is rare. From Ismail and Barth, Ann Clin Biochem 2001; 38(6):596-607
    • Gynecomastia in Hyperthyroidism – Proposed Mechanisms Direct stimulation of peripheral aromatase (Southern et al. J Clin Endocrinol Metab 1974; 38:207-14) Stimulation of peripheral aromatase by increased LH (Southern et al. J Clin Endocrinol Metab 1974; 38:207-14) Increased Androstenediol and DHEA-S production (Tagawa et al. Endocr J 2001; 48(3):345-54)
    • Gynecomastia in Hyperthyroidism – Proposed Mechanisms Androstenedione Testosterone Secretion Estradiol Estrone Extraglandular Formation
    • Hormone Levels in Hyperthyroid Men N Total T Free T E2 LH DHEAS ADIOLS Kidd et al. 7(2) 1008±104 13 ±2.4 104 ±16 15.5 ±1.5 1979 Chan et al. 1(1) 1339 nl 1999 Abalovich 25(6) 930 ±33 62 ±25 7.8 ±4.7 et al. 1999 Tagawa et 9(?) 7.43 ±3.91 1.49 ±0.69 al. 2001 1820 29.1 80 7.0 2.96 Normal 300-950 9.0-30.0 10-50 1.5-9.0 1.25-6.19 0.01-0.69 Range ng/dl pg/ml pg/ml IU/L mcg/ml micromol/l
    • Hyperthyroidism and Gonadal Dysfunction From Meikle, Thyroid 2004; 14 Suppl1:17-25
    • Hyperthyroidism and Gonadal Dysfunction The correlation of FT4 with free T area under the curve after HCG administration and LH area under the curve after GnRH administration From Meikle, Thyroid 2004; 14 Suppl1:17-25
    • Hyperthyroidism and Gonadal Dysfunction Sperm Counts and Sperm Motility in Hyperthyroidism From Meikle, Thyroid 2004; 14 Suppl1:17-25
    • Thank You