Gynecomastia

Key Features

Essentials of Diagnosis

• Palpable enlargement of the male breast, often asymmetric or unilateral

• Fatty gynecomastia is typically nontender

• Glandular gynecomastia is tender

• Gynecomastia must be distinguished from carcinoma or mastitis

General Considerations

Causes

• Endocrine (Table 26–15)

  • Hyperprolactinemia

  • Hyperthyroidism

  • Klinefelter syndrome

  • Hypogonadism

• Systemic disease: chronic liver or kidney disease

• Neoplasm

  • Testicular

  • Adrenal

  • Lung

  • Liver (rare)

• Drugs (selected)

  • Alcohol, marijuana

  • Amiodarone

  • Cimetidine, omeprazole

  • Diazepam

  • Digoxin

  • Estrogens, progestins, testosterone

  • Finasteride

  • Flutamide

  • Isoniazid

  • Ketoconazole

  • Opioids

  • Spironolactone

  • Tricyclic antidepressants

• Pubertal gynecomastia

• HIV infection treated with antiretroviral therapy, especially efavirenz or didanosine; breast enlargement resolves spontaneously in 73% within 9 months

Demographics

• Incidence is increasing in all age groups

• Pubertal gynecomastia develops in 60% of boys, more commonly in teenagers who are overweight

• About 20% of adult gynecomastia is caused by drug therapy

• Fatty pseudogynecomastia is common among elderly men, particularly when there is associated weight gain

Clinical Findings

Symptoms and Signs

• Female-appearing male breast

• Graded according to severity: I (mild), II (moderate), III (severe)

• Breast enlargement may be

  • Fatty

    • Usually diffuse

    • Nontender

  • Glandular

    • Asymmetric or unilateral, "lumpy"

    • Glandular enlargement beneath the areola, may be tender

• Pubertal gynecomastia: tender discoid enlargement of breast tissue beneath the areola, 2–3 cm in diameter

• The following characteristics are worrisome for malignancy

  • Asymmetry

  • Location not immediately below the areola

  • Unusual firmness

  • Nipple retraction, bleeding, or discharge

• Testicular examination must be done, may reveal neoplasm

• Examination must also include

  • An assessment of masculinization

  • Examination of the testes for size and masses

  • Examination of the penis for hypospadias

Differential Diagnosis

• Male breast cancer

• Fatty breast ...