Gynecomastia resident survival guide: Difference between revisions

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{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0";
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! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align=center| {{fontcolor|#2B3B44|Gynecomastia <BR>Resident Survival Guide}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Diagnosis|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Do's|Do's]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
|}
__NOTOC__
__NOTOC__


{{WikiDoc CMG}}; {{AE}} {{IF}}
{{WikiDoc CMG}}; {{AE}} {{IF}}
{{SK}} [[Gynecomastia management]], [[Gynecomastia work-up]], [[Approach to gynecomastia]]
==Overview==
==Overview==
This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.
Gynecomastia is a benign male breast enlargement. It can be [[physiological]], occuring with [[infancy]], [[puberty]] and old age. Gynecomastia can also be [[Pathological|pathologica]]<nowiki/>l, arising with [[obesity]], [[steroid]] use, [[pharmacologic]] agents, medical conditions including chronic liver and [[renal]] failure or [[Hypogonadism|hypogonadism.]] The diagnosis is primarily clinical. Laboratory investigations typically performed are blood [[hormone]] levels, [[renal function tests]] and [[liver function tests]]. [[Ultrasound]] or [[mammography]] imaging modalities are also common in diagnosis. Treatment is aimed at resolution of the underlying condition. [[Pharmacologic]] options include [[Selective estrogen receptor modulator|SERMs]], [[androgens]] and [[aromatase inhibitors]]. Surgery is usually reserved for patients with either [[psychological]] stresses, extensive [[gynecomastia]] or failure of medical treatment.


==Causes==
==Causes==
Line 11: Line 33:


===Common Causes===
===Common Causes===
*Drugs:<ref name="pmid22862307">{{cite journal |vauthors=Deepinder F, Braunstein GD |title=Drug-induced gynecomastia: an evidence-based review |journal=Expert Opin Drug Saf |volume=11 |issue=5 |pages=779–95 |year=2012 |pmid=22862307 |doi=10.1517/14740338.2012.712109 |url=}}</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="pmid26404748">{{cite journal| author=Lainscak M, Pelliccia F, Rosano G, Vitale C, Schiariti M, Greco C et al.| title=Safety profile of mineralocorticoid receptor antagonists: Spironolactone and eplerenone. | journal=Int J Cardiol | year= 2015 | volume= 200 | issue= | pages= 25-9 | pmid=26404748 | doi=10.1016/j.ijcard.2015.05.127 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26404748  }} </ref><ref name="pmid17267908">{{cite journal| author=Henley DV, Lipson N, Korach KS, Bloch CA| title=Prepubertal gynecomastia linked to lavender and tea tree oils. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 5 | pages= 479-85 | pmid=17267908 | doi=10.1056/NEJMoa064725 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17267908  }}</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="pmid17881754">{{cite journal |vauthors=Braunstein GD |title=Clinical practice. Gynecomastia |journal=N. Engl. J. Med. |volume=357 |issue=12 |pages=1229–37 |year=2007 |pmid=17881754 |doi=10.1056/NEJMcp070677 |url=}}</ref> <ref name="pmid25905330">{{cite journal |vauthors=De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng JCM |title= |journal= |volume= |issue= |pages= |year= |pmid=25905330 |doi= |url=}}</ref> <ref name="pmid12736278">{{cite journal |vauthors=Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K, Bryant M, Bulun SE |title=Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene |journal=N. Engl. J. Med. |volume=348 |issue=19 |pages=1855–65 |year=2003 |pmid=12736278 |doi=10.1056/NEJMoa021559 |url=}}</ref><ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref><ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
** Block synthesis of testosterone- Ketoconazole, Spironolactone, Metronidazole, Etomidate, Finasteride
*Drugs:
** [[Antiandrogens]]- Bicalutamide, flutamide, Nilutamide
** Block synthesis of [[testosterone]]- [[Ketoconazole]], [[Spironolactone]], [[Metronidazole]], [[Etomidate]], [[Finasteride]]
**[[Antiandrogens]]- [[Bicalutamide]], [[flutamide]], [[Nilutamide]]
**[[5-alpha-reductase inhibitor|5-Alpha reductase inhibtors]]- Finasteride
**[[5-alpha-reductase inhibitor|5-Alpha reductase inhibtors]]- Finasteride
**[[Cimetidine|Cimetidine]]
**[[Cimetidine]]
** Hormones
** Hormones
***[[Estrogen]]
***[[Estrogen]]
Line 21: Line 44:
***[[Human chorionic gonadotropin|Human chorionic gonadotropin (hCG)]]
***[[Human chorionic gonadotropin|Human chorionic gonadotropin (hCG)]]
***[[human growth hormone|Recombinant human growth hormone]]
***[[human growth hormone|Recombinant human growth hormone]]
** Testicular damage- Busulfan, Nitrosurea, Vincristine, Ethanol
** Testicular damage- [[Busulfan]], [[Nitrosourea]], [[Vincristine]], [[Ethanol]]
**[[Gynecomastia causes#Causes in Alphabetical Order|Other drugs]]
**[[Gynecomastia causes#Causes in Alphabetical Order|Other drugs]]
*[[Idiopathic]]<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="pmid28613563">{{cite journal |vauthors=Vandeven H, Pensler J |title= |journal= |volume= |issue= |pages= |year= |pmid=28613563 |doi= |url=}}</ref>
*[[Idiopathic]]
*[[Physiologic]]:<ref name="pmid17881754">{{cite journal |vauthors=Braunstein GD |title=Clinical practice. Gynecomastia |journal=N. Engl. J. Med. |volume=357 |issue=12 |pages=1229–37 |year=2007 |pmid=17881754 |doi=10.1056/NEJMcp070677 |url=}}</ref><ref name="pmid25905330">{{cite journal |vauthors=De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng JCM |title= |journal= |volume= |issue= |pages= |year= |pmid=25905330 |doi= |url=}}</ref>
*[[Physiologic]]:
**[[Adolescence]]
**[[Adolescence]]
**[[Aging]]
**[[Aging]]
**I[[Infancy|nfancy]]
**I[[Infancy|nfancy]]
*[[Pathological|Pathologic:]]<ref name="pmid24389786">{{cite journal| author=Ladizinski B, Lee KC, Nutan FN, Higgins HW, Federman DG| title=Gynecomastia: etiologies, clinical presentations, diagnosis, and management. | journal=South Med J | year= 2014 | volume= 107 | issue= 1 | pages= 44-9 | pmid=24389786 | doi=10.1097/SMJ.0000000000000033 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24389786  }} </ref><ref name="pmid25905330">{{cite journal |vauthors=De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng JCM |title= |journal= |volume= |issue= |pages= |year= |pmid=25905330 |doi= |url=}}</ref><ref name="pmid18728126">{{cite journal| author=Wagner MS, Wajner SM, Maia AL| title=The role of thyroid hormone in testicular development and function. | journal=J Endocrinol | year= 2008 | volume= 199 | issue= 3 | pages= 351-65 | pmid=18728126 | doi=10.1677/JOE-08-0218 | pmc=2799043 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18728126  }} </ref><ref name="pmid2310274">{{cite journal |vauthors=Cavanaugh J, Niewoehner CB, Nuttall FQ |title=Gynecomastia and cirrhosis of the liver |journal=Arch. Intern. Med. |volume=150 |issue=3 |pages=563–5 |year=1990 |pmid=2310274 |doi= |url=}}</ref>
*[[Pathological|Pathologic:]]
**[[Cirrhosis of liver]]
**[[Cirrhosis of liver]]
**[[Chronic kidney disease|Chronic kidney disease]]
**[[Chronic kidney disease|Chronic kidney disease]]
Line 37: Line 60:
**[[Testicular tumor|Testicular tumors]]
**[[Testicular tumor|Testicular tumors]]


===Less Common Causes<ref name="pmid12736278">{{cite journal| author=Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K et al.| title=Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 19 | pages= 1855-65 | pmid=12736278 | doi=10.1056/NEJMoa021559 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12736278  }} </ref>===
===Less Common Causes===
*[[Aromatase|Aromatase overexpression]]
*[[Aromatase|Aromatase overexpression]]
*[[Androgen insensitivity syndrome|Androgen insensitivity syndrome]]
*[[Androgen insensitivity syndrome|Androgen insensitivity syndrome]]
Line 52: Line 75:


===Genetic Causes===
===Genetic Causes===
*[[Familial|Familial prepubertal gynecomastia]]<ref name="pmid12736278">{{cite journal |vauthors=Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K, Bryant M, Bulun SE |title=Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene |journal=N. Engl. J. Med. |volume=348 |issue=19 |pages=1855–65 |year=2003 |pmid=12736278 |doi=10.1056/NEJMoa021559 |url=}}</ref>
*[[Familial|Familial prepubertal gynecomastia]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[gynecomastia]] according to American Family Physicians. ({{cite web |url=https://www.aafp.org/afp/2012/0401/p716.html |title=Gynecomastia - American Family Physician |format= |work= |accessdate=}})
Shown below is an algorithm summarizing the diagnosis of [[gynecomastia]] according to the Endocrine Society and European Association of Andrology.<ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <ref name="pmiddoi.org/10.1210/jc.2010-1720">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi.org/10.1210/jc.2010-1720 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref><br>
 
'''Abbreviations:'''
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Gynecomastia (Breast tissue enlargement)}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Gynecomastia (Breast tissue enlargement)}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01=Newborn |A02= Physiological; resolves within 4 weeks}}
{{familytree | | | | | | | | | |)|-| A01 |-| A02 | | | |A01=Newborn |A02= Physiological; resolves within 4 weeks}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01= Drugs (see list here) |B02= Discontinue implicated drug }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01= [[Drugs]] (see list above) |B02= Discontinue implicated drug }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01= Pseudogynecomastia|A02= Weight loss}}
{{familytree | | | | | | | | | |)|-| A01 |-| A02 | | | |A01= Pseudogynecomastia|A02= Weight loss}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01= Features of malignancy|A02=Mammography; Breast USG; Biopsy }}
{{familytree | | | | | | | | | |)|-| A01 |-| A02 | | | |A01= Features of [[malignancy]]|A02=Mammography; Breast [[USG]]; [[Biopsy]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01= Testicular mass|A02= Testicular USG}}
{{familytree | | | | | | | | | |)|-| A01 |-| A02 | | | |A01= Testicular mass|A02= Testicular USG}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=True Gynecomastia}}
{{familytree | | | | | | | | | B01 | | | | | |B01=True Gynecomastia}}
{{familytree | | | | | | | | | |,|-|-|-|-|-|-|-|.| }}
{{familytree | | | | | | | | | |,|-|-|-|-|-|-|-|.| }}
{{familytree | | | | | | | | | C02 | | | | | C03 |-| A01 | |C02=• Testosterone<br>• Estradiol(E2)<br>• Luteinizing hormone (LH) <br>• Prolactin • Follicle Stimulating Hormone (FSH)<br>• Beta- hCG <br> |C03=• Thyroid function tests<br>• Liver function tests<br>• Renal function tests<br>| A01= If deranged,correct underlying disease}}
{{familytree | | | | | | | | | C02 | | | | | C03 |-| A01 | |C02=• [[Testosterone]]<br>• [[Estradiol]](E2)<br>• [[Luteinizing hormone]] (LH) <br>• [[Prolactin]] • [[Follicle Stimulating Hormone]] (FSH)<br>• [[Beta- hCG]] <br> |C03=• [[Thyroid]] function tests<br>• [[Liver]] function tests<br>• [[Renal]] function tests<br>| A01= If deranged,correct underlying disease}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | }}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | }}
{{familytree | D01 | | D02 | | D03 | | D04 | | D05 |D01=• Low testosterone<br>• High LH<br>|D02=• Low testosterone<br>• Low LH<br>|D03=• High Estradiol<br>• Low LH<br>|D04=• High Prolactin<br>|D05=• High beta-hCG<br>}}
{{familytree | D01 | | D02 | | D03 | | D04 | | D05 |D01=• Low [[testosterone]]<br>• High [[LH]]<br>|D02=• Low [[testosterone]]<br>• Low [[LH]]<br>|D03=• High [[Estradiol]]<br>• Low [[LH]]<br>|D04=• High [[Prolactin]]<br>|D05=• High beta-hCG<br>}}
{{familytree | |!| | | |!| | | |!| | | |!| | | | |!| }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | |!| }}
{{familytree | E01 | | E02 | | E03 | | E04 | | | E05 |E01=Primary hypogonadism|E02=Secondary hypogonadism|E03=Testicular USG|E04=MRI head for <br>• Pituitary adenoma<br>• Empty sella<br>• Panhypopituitarism <br> |E05=Testicular USG }}
{{familytree | E01 | | E02 | | E03 | | E04 | | | E05 |E01=[[Primary hypogonadism]]|E02=[[Secondary hypogonadism]]|E03=Testicular [[USG]]|E04=[[MRI]] head for <br>• [[Pituitary adenoma]]<br>• [[Empty sella]]<br>• [[Panhypopituitarism]] <br> |E05=Testicular [[USG]] }}
{{familytree | | | | | | | |,|-|^|-|.| | | | |,|-|^|-|.| }}
{{familytree | | | | | | | |,|-|^|-|.| | | | |,|-|^|-|.| }}
{{familytree | | | | | | | J01 | | J02 | | | J03 | | J04 |J01=Sertoli or Leydig cell tumor|J02=Evaluate for<br> •Adrenal neoplasm<br>• Exogenous estrogen use<br>• Obesity (excess aromatase)<br>|J03=Germ cell tumor|J04=If normal; evaluate for<br> • Extragonadal germ cell tumor<br>• Non-trophoblastic beta hCG secreting tumors<br> }}
{{familytree | | | | | | | J01 | | J02 | | | J03 | | J04 |J01=[[Sertoli]] or [[Leydig cell tumor]]|J02=Evaluate for<br> •[[Adrenal]] neoplasm<br>• Exogenous [[estrogen]] use<br>• [[Obesity]] (excess [[aromatase]])<br>|J03=[[Germ cell tumor]]|J04=If normal; evaluate for<br> • Extragonadal [[germ cell tumor]]<br>• Non-trophoblastic [[beta hCG]] secreting tumors<br> }}
{{familytree/end}}
{{familytree/end}}


Line 88: Line 111:
----
----
❑ Obtain a detailed history<br>
❑ Obtain a detailed history<br>
❑ Examine the breasts to rule out malignancy<br>
❑ Examine the [[breast]]s to rule out [[malignancy]]<br>
❑ Stop drugs that may cause gynecomastia <br>
❑ Stop drugs that may cause [[gynecomastia]] <br>
----
----
'''Obtain laboratory tests'''
'''Obtain laboratory tests'''
----
----
❑ Testosterone <br>
❑ [[Testosterone]] <br>
❑ Estradiol <br>
❑ [[Estradiol]] <br>
❑ Beta hCG <br>
❑ Beta [[hCG]] <br>
❑ Luteinizing hormone (LH) <br>
❑ [[Luteinizing hormone]] (LH) <br>
❑ Follicle Stimulating Hormone (FSH) <br>
❑ [[Follicle Stimulating Hormone]] (FSH) <br>
❑ Prolactin <br>
❑ [[Prolactin]] <br>
----
----
'''Treat underlying disorders'''
'''Treat underlying disorders'''
----
----
❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor
❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor
----
</div>}}
</div>}}
{{familytree/end}}
{{familytree/end}}




Shown below is an algorithm summarizing the treatment of [[gynecomastia]] according to the American Family Physicians. ({{cite web |url=https://www.aafp.org/afp/2012/0401/p716.html |title=Gynecomastia - American Family Physician |format= |work= |accessdate=}})
Shown below is an algorithm summarizing the treatment of [[gynecomastia]] according to the Endocrine Society and European Association of Andrology. <ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <ref name="pmiddoi.org/10.1210/jc.2010-1720">{{cite journal| author=Schmoldt A, Benthe HF, Haberland G| title=Digitoxin metabolism by rat liver microsomes. | journal=Biochem Pharmacol | year= 1975 | volume= 24 | issue= 17 | pages= 1639-41 | pmid=doi.org/10.1210/jc.2010-1720 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10  }} </ref>  <ref name="pmid11569940">{{cite journal| author=Gruntmanis U, Braunstein GD| title=Treatment of gynecomastia. | journal=Curr Opin Investig Drugs | year= 2001 | volume= 2 | issue= 5 | pages= 643-9 | pmid=11569940 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11569940  }} </ref>
guidelines.


{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | A01 |A01= • Discontinue the causative drug<br>• Treat the underlying cause<br> }}  
{{familytree | | | | | | | | | A01 |A01= • Discontinue the causative drug<br>• Treat the underlying cause<ref name="pmid31099174">{{cite journal| author=Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G | display-authors=etal| title=EAA clinical practice guidelines-gynecomastia evaluation and management. | journal=Andrology | year= 2019 | volume= 7 | issue= 6 | pages= 778-793 | pmid=31099174 | doi=10.1111/andr.12636 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31099174  }} </ref> <br> }}  
{{familytree | | | | | | | | | |!| | | }}  
{{familytree | | | | | | | | | |!| | | | }}  
{{familytree | | | | | | | | | A01 |A01= Observe for 3 months }}
{{familytree | | | | | | | | | A01 |A01= Observe for 3 months }}
{{familytree | | | | | | || | |!| | | }}  
{{familytree | | | | | | | | | |!| | | | }}  
{{familytree | | | | | | | | | A01 |A01= If pain/tenderness; proceed with medical therapy }}
{{familytree | | | | | | | | | A01 |A01= If pain/tenderness; proceed with medical therapy }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | }}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|.| | | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | | | | | }}  
{{familytree | D01 | | D02 | | D03 | | D04 | | D05 |D01=• Low testosterone<br>• High LH<br>|D02=• Low testosterone<br>• Low LH<br>|D03=• High Estradiol<br>• Low LH<br>|D04=• High Prolactin<br>|D05=• High beta-hCG<br>}}
{{familytree | D01 | | D02 | | D03 | | D04 | |D01= [[Androgens]] and [[testosterone]]<br>• [[Hypogonadism]]<br>|D02= [[Aromatase inhibitors]] in [[prostate cancer]]<br>• [[Anastrazole]] <br>|D03=[[Selective estrogen receptor modulators]] (SERMs)<ref name="pmid12907471">{{cite journal| author=Khan HN, Blamey RW| title=Endocrine treatment of physiological gynaecomastia. | journal=BMJ | year= 2003 | volume= 327 | issue= 7410 | pages= 301-2 | pmid=12907471 | doi=10.1136/bmj.327.7410.301 | pmc=1126712 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12907471  }} </ref><br>•[[Tamoxifen]] (10-20 mg once daily for 3-9 months) <br> •[[Raloxifene]] (60 mg once daily for 3-9 months) <br>|D04=Surgery if:<br> • Persistent for > 12 months<br> • [[Fibrotic]] gynecomastia<br> • Failure of medical therapy<br>}}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{familytree | |,|-|^|.| | | | | | | | |!| }}
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
{{familytree | | | | | | | | | | |!| | | | |!| }}
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
{{familytree/end}}
{{familytree/end}}


==Do's==
==Do's==
* Always evaluate for physiological causes.
* Always evaluate for [[physiological]] causes.
* Evaluate for drugs causing gynecomastia.
* Evaluate for drugs causing [[gynecomastia]].
* Correct underlying causes first.
* Correct underlying causes first. <ref name="pmid11569940">{{cite journal| author=Gruntmanis U, Braunstein GD| title=Treatment of gynecomastia. | journal=Curr Opin Investig Drugs | year= 2001 | volume= 2 | issue= 5 | pages= 643-9 | pmid=11569940 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11569940  }} </ref> <ref name="pmid19880691">{{cite journal| author=Johnson RE, Murad MH| title=Gynecomastia: pathophysiology, evaluation, and management. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 11 | pages= 1010-5 | pmid=19880691 | doi=10.1016/S0025-6196(11)60671-X | pmc=2770912 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19880691  }} </ref>


==Don'ts==
==Don'ts==
* The content in this section is in bullet points.
* Do not treat the [[gynecomastia]] without evaluating for an underlying cause. <ref name="pmid19880691">{{cite journal| author=Johnson RE, Murad MH| title=Gynecomastia: pathophysiology, evaluation, and management. | journal=Mayo Clin Proc | year= 2009 | volume= 84 | issue= 11 | pages= 1010-5 | pmid=19880691 | doi=10.1016/S0025-6196(11)60671-X | pmc=2770912 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19880691  }} </ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 20:11, 15 January 2021

Gynecomastia
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]

Synonyms and keywords: Gynecomastia management, Gynecomastia work-up, Approach to gynecomastia

Overview

Gynecomastia is a benign male breast enlargement. It can be physiological, occuring with infancy, puberty and old age. Gynecomastia can also be pathological, arising with obesity, steroid use, pharmacologic agents, medical conditions including chronic liver and renal failure or hypogonadism. The diagnosis is primarily clinical. Laboratory investigations typically performed are blood hormone levels, renal function tests and liver function tests. Ultrasound or mammography imaging modalities are also common in diagnosis. Treatment is aimed at resolution of the underlying condition. Pharmacologic options include SERMs, androgens and aromatase inhibitors. Surgery is usually reserved for patients with either psychological stresses, extensive gynecomastia or failure of medical treatment.

Causes

Life-threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of gynecomastia.

Common Causes

[1] [1] [2] [3][4][5]

Less Common Causes

To review a complete list of gynecomastia causes, click here.

Genetic Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of gynecomastia according to the Endocrine Society and European Association of Andrology.[6] [7]
Abbreviations:

 
 
 
 
 
 
 
 
Gynecomastia (Breast tissue enlargement)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Newborn
 
Physiological; resolves within 4 weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drugs (see list above)
 
Discontinue implicated drug
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pseudogynecomastia
 
Weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Features of malignancy
 
Mammography; Breast USG; Biopsy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Testicular mass
 
Testicular USG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
True Gynecomastia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Testosterone
• Estradiol(E2)
• Luteinizing hormone (LH)
• Prolactin • Follicle Stimulating Hormone (FSH)
• Beta- hCG
 
 
 
 
• Thyroid function tests
• Liver function tests
• Renal function tests
 
If deranged,correct underlying disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Low testosterone
• High LH
 
• Low testosterone
• Low LH
 
• High Estradiol
• Low LH
 
• High Prolactin
 
• High beta-hCG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary hypogonadism
 
Secondary hypogonadism
 
Testicular USG
 
MRI head for
• Pituitary adenoma
• Empty sella
• Panhypopituitarism
 
 
Testicular USG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sertoli or Leydig cell tumor
 
Evaluate for
•Adrenal neoplasm
• Exogenous estrogen use
• Obesity (excess aromatase)
 
 
Germ cell tumor
 
If normal; evaluate for
• Extragonadal germ cell tumor
• Non-trophoblastic beta hCG secreting tumors

Treatment

Evaluation of Gynecomastia

❑ Obtain a detailed history
❑ Examine the breasts to rule out malignancy
❑ Stop drugs that may cause gynecomastia

Obtain laboratory tests

❑ Testosterone
❑ Estradiol
❑ Beta hCG
❑ Luteinizing hormone (LH)
❑ Follicle Stimulating Hormone (FSH)
❑ Prolactin

Treat underlying disorders

❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor


Shown below is an algorithm summarizing the treatment of gynecomastia according to the Endocrine Society and European Association of Andrology. [6] [7] [8]

 
 
 
 
 
 
 
 
• Discontinue the causative drug
• Treat the underlying cause[6]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observe for 3 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If pain/tenderness; proceed with medical therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Androgens and testosterone
• Hypogonadism
 
Aromatase inhibitors in prostate cancer
• Anastrazole
 
Selective estrogen receptor modulators (SERMs)[9]
•Tamoxifen (10-20 mg once daily for 3-9 months)
•Raloxifene (60 mg once daily for 3-9 months)
 
Surgery if:
• Persistent for > 12 months
• Fibrotic gynecomastia
• Failure of medical therapy
 

Do's

Don'ts

References

  1. ↑ 1.0 1.1 Braunstein GD (2007). "Clinical practice. Gynecomastia". N Engl J Med. 357 (12): 1229–37. doi:10.1056/NEJMcp070677. PMID 17881754.
  2. ↑ De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng J. PMID 25905330. Vancouver style error: initials (help); Missing or empty |title= (help)
  3. ↑ Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K, Bryant M, Bulun SE (2003). "Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene". N. Engl. J. Med. 348 (19): 1855–65. doi:10.1056/NEJMoa021559. PMID 12736278.
  4. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  5. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  6. ↑ 6.0 6.1 6.2 Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G; et al. (2019). "EAA clinical practice guidelines-gynecomastia evaluation and management". Andrology. 7 (6): 778–793. doi:10.1111/andr.12636. PMID 31099174.
  7. ↑ 7.0 7.1 Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID doi.org/10.1210/jc.2010-1720 Check |pmid= value (help).
  8. ↑ 8.0 8.1 Gruntmanis U, Braunstein GD (2001). "Treatment of gynecomastia". Curr Opin Investig Drugs. 2 (5): 643–9. PMID 11569940.
  9. ↑ Khan HN, Blamey RW (2003). "Endocrine treatment of physiological gynaecomastia". BMJ. 327 (7410): 301–2. doi:10.1136/bmj.327.7410.301. PMC 1126712. PMID 12907471.
  10. ↑ 10.0 10.1 Johnson RE, Murad MH (2009). "Gynecomastia: pathophysiology, evaluation, and management". Mayo Clin Proc. 84 (11): 1010–5. doi:10.1016/S0025-6196(11)60671-X. PMC 2770912. PMID 19880691.
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