3. Gynecomastia
Gynecomastia is the growth of glandular
tissue in male breasts.
The name comes from the Greek term
(gyne + mastos) meaning "female-like
breasts." It is a benign condition that
accounts for more than 65% of male breast
abnormalities.
Gynecomastia is clearly differentiated from
pseudogynecomastia, which is an
accumulation of excess fat in a male breast.
4. Pseudogynaecomastia
Breast prominence due solely to excessive
adipose is often termed
pseudogynaecomastia or sometimes
lipomastia. fat deposition without glandular
proliferation, on exam fingers will not meet
any resistance until they reach the nipple
5. Prevalence
Gynecomastia has three peaks.
1. Infancy: 60-90% transient due to high maternal
estrogen. Normally regresses over 2-3 week period.
2. Adolescence: 4-69% with wide variation due to
examiner observation. Onset 10-12y/o and peaks
13-14y/o. Normally regresses w/in 18mo and
persistence uncommon after 17y/o.
3. Older men: 24-65% with highest prevalence in
the 50-80y/o.
6. Gynecomastia
Grades
Grade I
Grade IIa
Grade IIb
Grade III
Clinical classification
Mild breast enlargement without skin
redundancy
Moderate breast enlargement without
skin redundancy
Moderate breast enlargement with skin
redundancy
Marked breast enlargement with skin
redundancy and ptosis, which simulates
a female breast
7. Gynecomastia
it is usually unilateral & occur in young man.
there is no hormonal dysfunction in
unilateral Gynecomastia.
Bilateral Gynecomastia may be due to
systemic causes.
Causes of Gynecomastia may be regarded
as:
8. Primary Gynecomastia
physiological causes
Neonatal gynaecomastia
– is due to the trans-placental passage of
maternal oestrogen and may be associated
with a nipple discharge known as 'witch's milk'.
It usually resolves during the first few weeks of
life.
9. Primary Gynecomastia
physiological causes
Pubertal gynaecomastia
– is the commonest male breast lesion. It can be
either unilateral or bilateral. Reassurance is
often the only treatment that is required. The
lesion will generally settle spontaneously but
may persist for months or years.
Senile gynaecomastia
– can be difficult to differentiate from the pseudo-
gynaecomastia due to general adiposity
increasingly seen in old age.
11. Pathophysiology
The basic mechanisms of gynecomastia include :
1.decrease in androgen production
2.an increase in estrogen production
3.increased availability of estrogen precursors for
peripheral conversion to estrogen.
Androgen receptor blockade and increased binding of
androgen to sex-hormone binding globulin (SHBG).
Estrogen-like or antiandrogen effects of Drugs
15. Complete physical
examination
◦ Look for signs and sx of liver and kidney disease
◦ Evaluate for hyperthyroidism, eg. Weight loss,
tachycardia, goiter, tremor, or exophthalmos.
◦ Seek for signs and sx that may suggest hypogonadism,
eg. Impotence, decreased libido, strenght, and change in
testicular size.
◦ Check for abdominal mass and testicular mass.
◦ Careful breast exam. The breasts should be carefully
examined to differentiate true gynecomastia with palpable
glandular tissue from pseudogynecomastia, in which only
adipose tissue can be felt
16. Examination Findings:
The examination is performed by
having the patient lie on his back with
his hands behind his head. The
examiner then places his or her
thumb and forefinger on each side of
the breast and slowly brings them
together
Gynecomastia is appreciated as a
concentric, rubbery-to-firm disk of
tissue, often mobile, located directly
beneath the areolar area.
Pseudogynecomastia presents no
discrete mass,
Other masses due to disorders
such as cancer tend to be
eccentrically positioned (insert)
17. Definition
Gynecomastia is benign
enlargement of the male
breast caused by
proliferation of glandular
breast tissue.
Pseudogynecomastia:
Enlargement of the male
breast, as a result of
increased fat deposition
18. Laboratory tests & Imaging
if gynecomastia of recent onset,
persistent, or painful/tender and has no
clear physiologic etiology.
CBC, LFT’s, TSH, LH, FSH, hCG, Prolactin,
Estradiol, Testosterone, Androstenedione
Imaging
◦ US and mammogram for any eccentric or discrete mass.
27. Gynecomastia – clinical features
The cause is often self evident from a full history
and examination.
The testes should always be examined.
Useful investigations may include
– a chest x-ray,
– full blood count
– and liver function test.
– If there is suspicion of a testicular tumour
then ultrasound should be requested.
– Hormonal assays may confirm
endocrinopathies
28. (a) Axial CT image of the chest with contrast shows bilateral,
triangular areas of soft tissue in the subcutaneous fat in the
expected location of the nipples (arrowheads). (b) CT image
obtained at a lower level than a shows a large mass in the liver
that enhances less than the normal parenchyma ( fibrolamellar
carcinoma ).
29. Treatment
Treat the underlying cause
Watchful waiting
Medical options:
- Androgens
- Anti-estrogens (as tamoxifen and
clomiphene)and aromatase inhibitors
- Aromatase inhibitors such as Letrozole
30. Medical Treatment:
The underlying disease should be corrected if possible,
and offending drugs should be discontinued.
ER antagonists (tamoxifen, 10 to 20 mg daily, or
raloxifene, 60 mg daily) are effective in treating pubertal
and adult gynecomastia and preventing gynecomastia
induced by androgen deprivation therapy.
Other drugs can be used, such as Clomifene (50–
100mg/day), Danazol (300–600mg/day), Testolactone
(450mg/day), Anastrozole (1mg/day).
Medical therapy is ineffective for chronic, fibrous
gynecomastia.
31. Gynecomastia
Treatment of gynecomastia
• for physiological causes reassurance is
all what is needed
• stop drugs causing gynecomastia
• subcutaneous mastectomy in
troublesome cases
• Liposuction - assisted mastectomy
32. Surgery:
With long standing gynecomastia (more
than 1 year): surgical reduction
mammoplasty (i.e. removal of breast
tissue with or without periareolar adipose
tissue) is necessary if breast enlargement
is severe, painful, socially embarrassing or
disfiguring.
33. Surgery
Should be considered in patients who do not
respond to medical therapy or who have long
standing gynecomastia.
Options Include
– Liposuction
– Direct surgical excision, or both
Complications
– Permanent numbness, compromise of blood supply,
irregular contour, hematoma, seroma, wound
infection.
34. Radiation therapy
Low-dosage external beam radiation
therapy (900 cGy or less) is effective, but
less effective than tamoxifen, for
prevention of gynecomastia due to anti-
androgen monotherapy for prostate
cancer.
35. Course and Prognosis
Pubertal gynecomastia usually regresses
spontaneously within 1 or 2 years.
Patients who develop drug-induced
gynecomastia generally have complete or near-
complete regression of the breast changes if the
offending drug is discontinued during the early,
florid stage.
Once gynecomastia from any cause has
reached the fibrotic stage, little or no
spontaneous regression occurs, and medical
therapy is ineffective.
