Gynecomastia pathophysiology
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Pathophysiology
Pathogenesis
- The exact pathogenesis of [disease name] is not fully understood.
OR
- It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
- [Pathogen name] is usually transmitted via the [transmission route] route to the human host.
- Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
- [Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
- The progression to [disease name] usually involves the [molecular pathway].
- The pathophysiology of [disease/malignancy] depends on the histological subtype.
Genetics
- [Disease name] is transmitted in [mode of genetic transmission] pattern.
- Genes involved in the pathogenesis of [disease name] include [gene1], [gene2], and [gene3].
- The development of [disease name] is the result of multiple genetic mutations.
Associated Conditions
Gross Pathology
- On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
Microscopic Pathology
- On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
The condition can occur physiologically in neonates, in adolescents,adults and in the elderly. In adolescent boys the condition is a source of distress, but for the large majority of boys whose pubertal gynecomastia is not due to obesity, the breast development shrinks or disappears within a couple of years [1]. The common type of gynecomastia in males undergoing pueberty is idiopathic in nature.One should be aware that several causes of gynecomastia have significant sequela and need to be ruled out ethier by history and or laboratory examinations prior to treatment of the disorder. The most common presentation of gynecomastia is idiopathic in nature. It is important to note that pituitary and adrenal tumors can result in gynecomastia. In addition several other endocrinological disorders such as klinefelters syndrome can be associated with gynecomastia and should be ruled out in pre pubertal individuals.Male breast cancer although rare needs to be considered in the differential diagnosis, particularly in cases that are of rapid onset and are unilateral in nature. Several types of exogenously injested substances , most notably steroids, can result in gynecomastia. Breast prominence can result from hypertrophy of breast tissue, chest adipose tissue and skin, and is typically in combination. Two types of tissue : glandular ,breast tissue , and fat ,adipose cells,compose the tissue in the breast. Optimal treatment needs to be directed at correction of the glandular and fatty tissue along with the skin envelope in each patient. As the relative volumes of the aforementioned components of the breast differ from individual to individual a patient specific treament plan needs to be established in all cases.The treatment plan in addition to correction of the obvious physical manifestations of the disease may need to be combined with an appropriate medical workup to establish and if necessary treat any concomitant disorder. [2] [3].
Physiologic gynecomastia occurs in neonates, at or before puberty and with aging. Many cases of gynecomastia are idiopathic, meaning they have no clear cause. Potential pathologic causes of gynecomastia are: medications including hormones, increased serum estrogen, decreased testosterone production, androgen receptor defects, chronic kidney disease, chronic liver disease, HIV,[4] and other chronic illness. Gynecomastia as a result of spinal cord injury and refeeding after starvation has been reported.[5] In 25% of cases, the cause of the gynecomastia is not known.
Medications cause 10-20% of cases of gynecomastia in post-adolescent adults. These include cimetidine, omeprazole, spironolactone, imatinib mesylate, finasteride and certain antipsychotics. Some act directly on the breast tissue, while others lead to increased secretion of prolactin from the pituitary by blocking the actions of dopamine (prolactin-inhibiting factor/PIF) on the lactotrope cell groups in the anterior pituitary. Androstenedione, used as a performance enhancing food supplement, can lead to breast enlargement by excess estrogen activity. Medications used in the treatment of prostate cancer, such as antiandrogens and GnRH analogs can also cause gynecomastia. Marijuana use is also thought by some to be a possible cause; however, published data is contradictory.[6]
Increased estrogen levels can also occur in certain testicular tumors, and in hyperthyroidism. Certain adrenal tumors cause elevated levels of androstenedione which is converted by the enzyme aromatase into estrone, a form of estrogen. Other tumors that secrete hCG can increase estrogen. A decrease in estrogen clearance can occur in liver disease, and this may be the mechanism of gynecomastia in liver cirrhosis. Obesity tends to increase estrogen levels.[7][8]
Decreased testosterone production can occur in congenital or acquired testicular failure, for example in genetic disorders such as Klinefelter Syndrome. Diseases of the hypothalamus or pituitary can also lead to low testosterone. Abuse of anabolic androgenic steroids (AAS) has a similar effect. Mutations to androgen receptors, such as those found in Kennedy disease can also cause gynecomastia.
Although stopping these medications can lead to regression of the gynecomastia, surgery is sometimes necessary to eliminate the condition.
Repeated topical application of products containing lavender and tea tree oils among other unidentified ingredients to three prepubescent males coincided with gynecomastia; it has been theorised that this could be due to their estrogenic and antiandrogenic activity. However, other circumstances around the study are not clear, and the sample size was insignificant so serious scientific conclusions cannot be drawn.[9]
References
- ↑ Adolescent gynecomastia
- ↑ Braunstein, GD (1993). "Gynecomastia". N Engl J Med. 328 (7): 490–5. PMID 8421478. Unknown parameter
|month=ignored (help) - ↑ Allee, Mark R (2006-11-15). "Gynecomastia". WebMD, Inc. (emedicine.com). Retrieved 2007-05-20.
- ↑ Peyriere, H (1999). "Report of gynecomastia in five male patients during antiretroviral therapy for HIV infection". AIDS. 13 (15): 2167–9. PMID 10546872. Unknown parameter
|month=ignored (help); Unknown parameter|coauthors=ignored (help) - ↑ Heruti, RJ (1997). "Gynecomastia following spinal cord disorder". Arch Phys Med Rehabil. 78 (5): 534–7. PMID 9161376. Unknown parameter
|month=ignored (help); Unknown parameter|coauthors=ignored (help) - ↑ Thompson D, Carter J. "Drug-induced gynecomastia". Pharmacotherapy. 13 (1): 37–45. PMID 8094898.
- ↑ Glass, AR (1994). "Gynecomastia". Endocrinol Metab Clin North Am. 23 (4): 825–37. PMID 7705322. Unknown parameter
|month=ignored (help) - ↑ Braunstein, GD (1999). "Aromatase and Gynecomastia". Endocr Relat Cancer. 6 (2): 315–24. PMID 10731125. Unknown parameter
|month=ignored (help) - ↑ Henley D, Lipson N, Korach K, Bloch C (2007). "Prepubertal gynecomastia linked to lavender and tea tree oils". N Engl J Med. 356 (5): 479–85. PMID 17267908.