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Gynaecomastia

Definition:
Gynaecomastia is - presence of female-type mammary gland (s) in a male.

Etiology: (based on Pathophysiologic Mechanisms)

1. Physiological
   1. Neonatal (due to action of placental oestrogens on neonatal breast parenchyma)
   2. Adolescence (due to excess estradiol relative to testosterone)
   3. Senescence (due to fall in plasma testosterone levels with aging, resulting in a relative hyperestrinism)
2. Iatrogenic (Drugs)
   1. Drugs with Estrogen excess state -
      1. Enhanced estrogen synthesis (HCG)
      2. Drugs with Oestrogenic / Oestrogen related activity (mnemonic MADE - Marijuana, Anabolic Steroids, Digitalis, Estrogens)
   2. Drugs that Inhibit the action or synthesis of testosterone (mnemonic PACKS - Phenytoin, Antineoplastic agents, Cimetidine, Ketoconazole, Spironolactone, Diazepam)
   3. Drugs with Idiopathic mechanisms (mnemonic FTV - Furosemide, Tricyclic antidepressants, Verapamil, Reserpine)
3. Pathological
   1. Estrogen excess state
      1. Gonadal origin
         1. True hermaphroditism
         2. Nongerminal neoplasms tumors of testis (Leydig cell tumor, Sertoli cell tumor, Granulosa-theca cell tumor)
         3. Germ cell tumors (Choriocarcinoma, Seminoma & Teratoma, Embryonal Carcinoma)
      2. Nontesticular tumors (Naevus, Adrenocortical neoplasms, Lung carcinoma, Hepatocellular carcinoma)
      3. Others (Endocrine disorders, Alcoholic & Nonalcoholic cirrhosis, Nutritonal alteration states)
   2. Androgen deficiency state
      1. Primary testicular failure (mnemonic KARE)
         1. Klinefelter's syndrome (XXY)
         2. Kallmann syndrome
         3. Kennedy disease with associated gynaecomastia
         4. ACTH Deficiency
         5. Androgen biosynthesis defects (hereditary)
         6. Reifenstein syndrome (XY)
         7. Rosewater, Gwinup, Hamwi familial gynecomastia (XY)
         8. Eunuchoidal males (congenital anorchia)
      2. Secondary testicular failure (Remember Congenital , Traumatic, Infective/Inflammatory, Neoplastic,etc)
         1. Cryptorchidism, Hydrocele, Varicocele, Spermatocele
         2. Trauma
         3. Orchitis
         4. Irradiation
      3. Renal failure
   3. Systemic diseases with Idiopathic mechanisms (you CANT remember this, ok, mnemonic is - CANT)
      1. CNS - related causes from anxiety and stress
      2. AIDS (acquired immune deficiency syndrome)
      3. Nonneoplastic diseases of lung
      4. Trauma to chest wall

Clinical Diagnosis:

• Features of  Physiological Gynaecomastia of Adolescence -
  1. Age - Typically between 12  - 15 years
  2. Often Unilateral
• Features of Physiological Gynaecomastia of Senescence -
  1. Age - 50 - 70 years age group is most commonly affected
  2. Usually Bilateral
• Suspicious features - suggestive of Early Male Breast Cancer
  1. Dominant non-tender masses
  2. Local areas of firmness, irregularity or asymmetry

Investigations:

• In a non-obese patient, at least 2 cms of subareolar breast tissue must be present before gynaecomastia can be confirmed
• Mammography & USG - help to differentiate indistinguishable or ill-defined contiguous fatty tissue from male breast lesions and soft tissue structures
• Investigations to rule out the etiological causes

Risks Concerned:

• Gynaecomastia DOES NOT predispose the male breast to development of breast cancer
• Hypoandrogenic state in primary testicular failure Klinefelter's syndrome is - associated with increased risk for breast cancer in men

Management:

• Medical
  • Is of value when a specific diagnosis has been established
     
  • Testosterone - for disorders of androgen deficiency
  • Danazol - side effects are significant
  • Tamoxifen citrate - has had encouraging initial results
     
• Surgical
  • Is reserved for idiopathic causes of gynaecomastia in which all other investigations have failed to reveal the etiology
  • Transareolar Mastectomy - for large, progressive gynaecomastia refractory to drug discontinuance or therapy of an endocrine defect, it is the most effective therapy, especially in the young adult.

[Contributed by Dr. Rohit Tekriwal]