Gynecomastia medical therapy: Difference between revisions

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{{Gynecomastia}}
{{Gynecomastia}}
{{CMG}}
{{CMG}} {{AE}} {{HS}}


==Overview==
==Medical Therapy==
Treating the underlying cause of the gynecomastia may lead to improvement in the condition. Patients should talk with their doctor about revising any medications that are found to be causing gynecomastia; often, an alternative medication can be found that avoids gynecomastia side-effects, while still treating the primary condition for which the original medication was found not to be suitable due to causing gynecomastia side-effects (e.g., in place of taking spironolactone the alternative eplerenone can be used.)  [[Selective estrogen receptor modulator]] medications, such as [[tamoxifen]] and [[clomiphene]], or [[androgen]]s  or [[aromatase inhibitor]]s such as [[Letrozole]] are medical treatment options, although they are not universally approved for the treatment of gynecomastia. Endocrinological attention may help during the first 2-3 years. After that window, however, the breast tissue tends to remain and harden, leaving surgery (either [[liposuction]], gland excision, skin sculpture, [[Breast reduction|reduction mammoplasty]], or a combination of these surgical techniques) the only treatment option. Many American insurance companies deny coverage for surgery for gynecomastia treatment on the grounds that it is a cosmetic procedure. [[Radiation therapy]] is sometimes used to prevent gynecomastia in patients with prostate cancer prior to estrogen therapy.  Compression garments can camouflage chest deformity and stabilize bouncing tissue bringing emotional relief to some. There are also those who choose to live with the condition.
As a summary:
* Most cases of gynecomastia resolve spontaneously and therefore do not require treatment
* Always treat underlying disease etiologies
* If possible, discontinue harmful/offending medications
== Pharmacotherapy ==
* For elderly patients who have extreme pain, tenderness or embarrassment:
*:* [[Androgens]]
*:* Antiestrogens
*:* [[Aromatase]]


==Overview==
==Overview==
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
Gynecomastia is usually a self-limited condition, reassurance and follow-ups are recommended. Causative medications should be withheld and any underlying condition leading to gynecomastia should be thoroughly investigated and treated. [[Pharmacologic|Pharmacologic therapy]] is beneficial for the first several months until [[fibrous tissue]] replaces the [[glandular tissue]]. [[Pharmacologic]] options include [[Selective estrogen receptor modulator|SERMs]], [[androgens]] and [[aromatase inhibitors]].
*Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
*The majority of cases of [disease name] are self-limited and require only supportive care.
 
*[Disease name] is a medical emergency and requires prompt treatment.
 
*The mainstay of treatment for [disease name] is [therapy].
 
*The optimal therapy for [malignancy name] depends on the stage at diagnosis.
* [Therapy] is recommended among all patients who develop [disease name].
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


==Medical Therapy==
==Medical Therapy==
*Asymptomatic gynecomastia usually does not require treatment; reassurance is all that is required.
*[[Asymptomatic]] gynecomastia usually does not require treatment; reassurance is all that is required.
*Treatment of symptomatic gynecomastia (discomfort, tenderness, psychological stresses) is guided by the patient's goal.
*Treatment of [[symptomatic]] gynecomastia (discomfort, [[tenderness]], [[psychological stress]]) is guided by the patient's goal.
*In gynecomastia with the identifiable underlying cause, treatment of that underlying cause can address the symptoms.
*In gynecomastia with the identifiable underlying cause, treatment of that underlying cause can address the symptoms.
*If the gynecomastia is believed to be due to a use of a medication, withdrawal of that medication should lead to improvement over a period of a few months.  
*If the gynecomastia is believed to be a [[medication]] effect, withdrawal of that [[medication]] should lead to improvement over a period of a few months.  
 
=== Pharmacologic therapy ===
=== Pharmacologic therapy ===
*Pharmacologic medical therapies for gynecomastia include:
[[Pharmacologic]] medical therapies for gynecomastia include:<ref name="pmid17543732">{{cite journal| author=Narula HS, Carlson HE| title=Gynecomastia. | journal=Endocrinol Metab Clin North Am | year= 2007 | volume= 36 | issue= 2 | pages= 497-519 | pmid=17543732 | doi=10.1016/j.ecl.2007.03.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17543732 }} </ref><ref name="pmid17881754">{{cite journal| author=Braunstein GD| title=Clinical practice. Gynecomastia. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 12 | pages= 1229-37 | pmid=17881754 | doi=10.1056/NEJMcp070677 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17881754  }} </ref><ref name="pmid2137877">{{cite journal |vauthors=Biro FM, Lucky AW, Huster GA, Morrison JA |title=Hormonal studies and physical maturation in adolescent gynecomastia |journal=J. Pediatr. |volume=116 |issue=3 |pages=450–5 |year=1990 |pmid=2137877 |doi= |url=}}</ref><ref name="pmid6772358">{{cite journal |vauthors=Friedman NM, Plymate SR |title=Leydig cell dysfunction and gynaecomastia in adult males treated with alkylating agents |journal=Clin. Endocrinol. (Oxf) |volume=12 |issue=6 |pages=553–6 |year=1980 |pmid=6772358 |doi= |url=}}</ref><ref name="pmid21209041">{{cite journal| author=Carlson HE| title=Approach to the patient with gynecomastia. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 1 | pages= 15-21 | pmid=21209041 | doi=10.1210/jc.2010-1720 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21209041  }} </ref><ref name="pmid21479145">{{cite journal| author=Johnson RE, Kermott CA, Murad MH| title=Gynecomastia - evaluation and current treatment options. | journal=Ther Clin Risk Manag | year= 2011 | volume= 7 | issue= | pages= 145-8 | pmid=21479145 | doi=10.2147/TCRM.S10181 | pmc=3071351 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21479145 }} </ref>
**Androgens
==== [[Androgens]] ====
**Aromatase inhibitors
*[[Testosterone]] replacement can improve gynecomastia in [[hypogonadism]] of short duration, but it can worsen gynecomastia in eugonadal men due to [[aromatization]] to [[estradiol]].
**selective estrogen receptor modulators (SERMs)
==== [[Aromatase inhibitors]] ====
 
*[[Aromatase inhibitor]] ([[anastrozole]]) is useful in [[aromatase]] excess syndrome cause of gynecomastia.
===Disease Name===
==== [[SERM|Selective estrogen receptor modulators (SERMs)]] ====
 
*[[Selective estrogen receptor modulator|Selective estrogen receptor modulators]] ([[tamoxifen]], [[raloxifene]]) have been used with varying degree of success with [[tamoxifen]] better than [[raloxifene]].
* '''1 Stage 1 - Name of stage'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose)  
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 2.1 '''Specific Organ system involved 2'''
*** 2.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 2.1.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
 
* 2 '''Stage 2 - Name of stage'''
** 2.1 '''Specific Organ system involved 1 '''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2 '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Latest revision as of 16:52, 28 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]


Overview

Gynecomastia is usually a self-limited condition, reassurance and follow-ups are recommended. Causative medications should be withheld and any underlying condition leading to gynecomastia should be thoroughly investigated and treated. Pharmacologic therapy is beneficial for the first several months until fibrous tissue replaces the glandular tissue. Pharmacologic options include SERMs, androgens and aromatase inhibitors.

Medical Therapy

  • Asymptomatic gynecomastia usually does not require treatment; reassurance is all that is required.
  • Treatment of symptomatic gynecomastia (discomfort, tenderness, psychological stress) is guided by the patient's goal.
  • In gynecomastia with the identifiable underlying cause, treatment of that underlying cause can address the symptoms.
  • If the gynecomastia is believed to be a medication effect, withdrawal of that medication should lead to improvement over a period of a few months.

Pharmacologic therapy

Pharmacologic medical therapies for gynecomastia include:[1][2][3][4][5][6]

Androgens

Aromatase inhibitors

Selective estrogen receptor modulators (SERMs)

References

  1. ↑ Narula HS, Carlson HE (2007). "Gynecomastia". Endocrinol Metab Clin North Am. 36 (2): 497–519. doi:10.1016/j.ecl.2007.03.013. PMID 17543732.
  2. ↑ Braunstein GD (2007). "Clinical practice. Gynecomastia". N Engl J Med. 357 (12): 1229–37. doi:10.1056/NEJMcp070677. PMID 17881754.
  3. ↑ Biro FM, Lucky AW, Huster GA, Morrison JA (1990). "Hormonal studies and physical maturation in adolescent gynecomastia". J. Pediatr. 116 (3): 450–5. PMID 2137877.
  4. ↑ Friedman NM, Plymate SR (1980). "Leydig cell dysfunction and gynaecomastia in adult males treated with alkylating agents". Clin. Endocrinol. (Oxf). 12 (6): 553–6. PMID 6772358.
  5. ↑ Carlson HE (2011). "Approach to the patient with gynecomastia". J Clin Endocrinol Metab. 96 (1): 15–21. doi:10.1210/jc.2010-1720. PMID 21209041.
  6. ↑ Johnson RE, Kermott CA, Murad MH (2011). "Gynecomastia - evaluation and current treatment options". Ther Clin Risk Manag. 7: 145–8. doi:10.2147/TCRM.S10181. PMC 3071351. PMID 21479145.

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