3. Gynaecomastia is an enlargement
of the male breast, secondary to
proliferation of both epithelial and
stromal components .
Gynaecomastia term is derived
from Greek words gynae (female)
and mastos(breast). Enlargement
of the male breast looking like
women breast
4. Prevalence
• Gynaecomestia is a common
condition . In various studies its
prevalence is found to be about
36% in healthy young adult males ,
57% in healthy old males.
• The neonatal period - In neonates it is
estimated that 60 to 90% of infants have
transient gynaecomastia due to
transplacental transfer of maternal
estrogens……...
5. ........This stimulus for breast
growth ceases as the estrogens
are cleared from the neonatal
circulation and the breast tissue
gradually regresses over a 2 to 3
week period . It usually
regresses completely by the end
of first year.
6. Puberty
• Transient gynaecomastia may occur
in up to 60% boys. It may first appear
at as early as 10 years of age, with a
peak onset between 13 to 14 years,
followed by an involution that is
generally complete by 16 to 17 years
7. In old age
• The incidence of gynaecomastia
increase in advancing age , with the
highest prevalence found at the age of
50 to 80 years range. Ageing is
associated with progressive testicular
dysfunction with reduction in serum
testosterone level and, in some cases,
elevated Luteinising hormone (LH).
8.
9.
10. Pathophysiology
• Gynaecomastia results from an
altered estrogen – androgen balance ,
in favor of estrogen, or increase
breast sensitivity to a normal
circulating estrogen level. The
imbalance is between the stimulatory
effect of estrogen and the inhibitory
effect of androgen.
11. Estrogens induced ductal
epithelial hyperplasia , ductal
elongation and branching,
proliferation of the periductal
fibroblasts, and an increase in
vascularity . The histologic
picture is similar in male and
female breast tissue after
exposure to estrogen.
12. • Estrogen production in males is
mainly from the peripheral conversion
of androgens ( testosterone and
androstenedione ) through the action
of the enzyme aromatase, mainly in
muscles, skin and adipose tissue in
the form of estrone and estradiol.
• The normal production ratio of
testosterone to estrogen in males is
approximately 100:1. But in ciculation
it is 300:1.
13. Histopathology
• Characteristic findings include
proliferation of ductules and stroma
(consisting of connective tissue
elements such as fibroblasts, collagen
and myofibroblasts) and occasional
acini. Gynaecomastia of short duration
consists of a prominent ductular
component with loose stroma. Long
standing gynaecomastia consists of
dense stroma with few ductules.
14.
15.
16. Causes
Physiological Gynaecomastia
• New born
• Adolescence
• Aging
Pathological Gynaecomastia
Deficient production or action of
testosterone
• Congenital anorchia
• Androgen resistance (testicular
feminization and reifenstein syndrome
18. ….
Increase estrogen production
Increased estrogen secretion
• Testicular tumor
• True hermaphroditism
• Carcinoma of the lungs and other tumor
producing HCG
……….
19. …....
Increase substrate for extra glandular
aromatase
• Adrenal disease
• Liver disease (cirrhosis of the liver)
• Malnutrition
• Hyperthyroidism
Increase in extra glandular aromatase
………
20. Drugs
• Estrogens
• Drugs that enhances estrogen secretions
( gonadotropins , clomiphen )
• Inhibitors of testosterone synthesis or
action
I. Ketoconazole
II. Metronidazole
III. Alkylating agent
IV. Cisplatin
V. Spironolactone
VI. Cimetidine
VII. Flutamide
24. • Most patients of gynaecomastia are
asymptomatic
• It may be an incidental finding during routine
physical examination
• The main presenting symptom in patient with
recent onset of gynaecomastia is usually
breast or nipple pain and tenderness and
those who present late usually complain of
breast enlargement
Clinical features and
diagnostic evaluation
25. Physical examination
• Perform a thorough examination of breast ,
noting their size and consistency. Also
determine the presence of any nipple
discharge or axillary lymphadinopathy.
• Differentiate between the true
gynaecomastia and pseudo gynaecomastia
/ lipomastia.
• Gynaecomastia can be detected when the
size of glandular tissue exceeds 0.5 cm in
diameter. ………..
26. ……
• Examination of the testicles , noting there
size and consistency. Carefully look for
any nodules or asymmetry
• Note signs of feminization, including
typical body hair distribution and
eunuchoid habitus
• Check for any stigmata of chronic liver
diseases , thyroid disease or renal
disease
27. Simon’s classification of
gynaecomastia
Group 1
• Minor but visible breast enlargement without
skin redundancy
Group 2A
• Moderate breast enlargement without skin
redundancy
Group 2B
• Moderate breast enlargement with minor skin
redundancy
Group 3
• Gross breast enlargement with skin redundancy
that looks like a pendulous female breast
28.
29.
30.
31. Investigations
• Patients with physiological
gynaecomastia do not require further
evaluation
• Further evaluation is necessary in
patients with the following
I. Breast size greater then 5 cm
(macromastia)
II. A lump that is tender , of recent onset ,
progressive or of unknown duration
III. Sign of malignancy
32. Serum chemistry
LFT
Thyroid function test
Renal function test
Total or free testosterone level ,
serum prolactine , LH , oestradiol ,
dehydroepiandrostenone sulphate
levels to evaluate a patient with
possible feminization syndrome
Urinary 17 ketosteroid
Beta HCG
33. Imaging Studies
USG breast
Mammography
Testicular ultra sonography and
thermography
CT Scan for adrenal gland
MRI for pituitary gland
34. Differential Diagnosis
• Pseudo gynaecomastia
• Breast cancer
• Dermoid cyst
• Haematoma
• Lipoma
• Lymphangioma
• Neurofibroma
35. Treatment
• Generally no treatment is required for
physiological gynaecomastia
• A major factor that should influence the
initial choice of therapy is the duration of
gynaecomastia
• If the patient is at the pubertal age, and
has an otherwise normal general physical
and testicular examination , he probably
has transient or persistent gynaecomastia
….….…
36. Reexamination at six month intervals
should determine whether the
condition is transient or persistent .
At this time , medical or surgical
therapy should be considered. If the
patient is on a drug causing
gynaecomastia , this should be
stopped or changed to another
medication if possible , and
reexamine the patient after one
month .
37. If the drug was the cause ,
then reduction in breast pain
and tenderness should occur
during that time . Similarly ,
breast enlargement following
cytotoxic chemotherapy may
also resolve spontaneously.
38. Treatment of hyperthyroidism and
surgical removal of testicular ,
adrenal , or other causative
tumor may lead to regression in
patients with hypogonadism ,
treatment with testosterone may
produce regression by providing
androgen and suppressing LH
stimulated oestradiol secretion.
39. Medical treatment
• As gynaecomastia has high frequency
of spontaneous regression , the
decision of when to treat is often
difficult. Trials of medical therapy should
be limited to only six months , due to
limited experience and unknown long
term side effects of the drugs . When
gynaecomastia has been present for
more then 2 years , medical therapy is
unlikely to be effective , and surgery
may be the only useful treatment
40. • Options include androgens
(testosterone , danazole) , anti
estrogen( clomiphene , tamoxifen) and
aromatase inhibitors
• Androgen
Testosterone – it is a male sex
hormone given in dose of 200 to 300
mg IM
41. Danazole – it is synthetic steroid analog
with strong antigonadotropic activity
(inhibits LH and FSH) and weak
androgenic action doses are 200 mg bd
for 3 months. It is the only drug liscenced
for the treatment of gynaecomastia in UK.
• Antiestrogen
Clomiphene citrate – it stimulates
release of pitutory gonadotropin 50 to 100
mg QID for 6 months.
42. Tamoxifen – compititive binds to estrogen
receptor , producing a nuclear complex
that inhibits estrogen effects. Dose 10 to
20 mg BD
• Aromatase inhibitors
Testolactone – it is synthetic peripheral
aromatase inhibitors . It blocks production
of estradiol and estrone from testosterone.
Dose 150 mg TDS for 6 months
43. Surgery
Surgical treatment is indicated in patients
in whom the gynaecomastia causes
distress and psychological trauma , when
there is no underlying treatable condition
and when hormonal treatment is failed,
then operative treatment is indicated
Surgical treatment includes
• Open subcutaneous mastectomy
• Endoscopic assisted subcutaneous
mastectomy
• Liposuction assisted mastectomy
• Ultra sound assisted liposuction
44. • Open subcutaneous mastectomy –
this is most commonly performed
procedure in gynaecomastia. This is
carried out through circumareolarincision
between 3 and 9 o clock position. The
length of incision varies
• Endoscopic assisted subcutaneous
mastectomy – with this technique it is
possible to excise the glandular breast
tissue through very small distant incision.
Thus avoiding breast and areolar scar
45.
46.
47.
48.
49.
50.
51.
52.
53.
54. • Liposuction assisted mastectomy
– this is most popular method used to
correct pseudo gynaecomastia.
Advantage compared to the open
subcutaneous mastectomy includes
reduced risk of nipple / aerioral
ischemia , reduced chance of nipple
distortion , lower risk of saucer
deformity and reduced risk of
hemorrhage and hematoma.
55. • This technique is not
recommended for glandular
gynaecomastia. The Incesion is 3
to 4 mm in length, it can be made
in axillary folds or inframammary
fold or periareolar . Post operative
compression garments are
applied for at least two weeks .
56. • Ultrasound assisted
liposuction – this permits
emulsification and cavitations of
glandular tissue which can then be
followed by standard liposuction to
remove excess fat in liquefied tissue
57. Complication of
surgery
• Bleeding and hematoma
• Seroma
• Nipple , areola related complications –
inversions, distortion and alteration of
symmetry and necrosis
• Scar related complications includes
painful hypertrophid or keloid scar
• Breast asymmetry
• Contour irregularity
• Infection
58. Prevention
Two situations exist in which
gynaecomastia can be
prevented. The first is by avoiding
drugs that can cause
gynaecomastia.
The second
area of prevention applies to
patients with prostate cancer who
are about to receive estrogen or
anti androgen therapy.
59. Studies have shown that
prophylactic breast irradiation
(with low dose of 900 red) is
effective in preventing
gynaecomastia in patients with
prostate cancer.
60. Prognosis
Regardless of he etiology of
gynaecomastia the pronosis is
excellent. Studies have shown that
90% of physiological
gynaecomastia involutes
spontaneously within 2 years.
In drug induced gynaecomastia,
withdrawal of the medication leads
to regression in 60% of the patient
61. • If the gynaecomastia is of long
duration it is unlikely to regress
spontaneously.
