Work Up Of Gynecomastia (slides)

Work up of gynecomastia Nilanjan Sengupta,MD,DM Assistant Professor Department of Endocrinology NRS Medical College Kolkata

Hormonal control of breast development • estradiol stimulates glandular cells • testosterone inhibits growth & differentiation • GH,cortisol,IGF1,insulin act permissively • thyroid hormones increase SHBG level • cortisol & prolactin lower T levels (hypothalamic & testicular effects)

Gynecomastia : the problem • common condition : not always pathological • pubertal gynecomastia : 65% by age 15 • 30% of normal military recruits have palpable breast tissue • 40% men (40-44y)have palpable breast tissue • upto 70% hospitalized patients (50-69y) have palpable breast tissue • upto 83% of hospitalized men with gynecomastia – breast tissue diameter <5cm

Physiological vs pathological gynecomastia • • • • •

challenging common association with obesity psedogynecomastia pathological arbitrarily defined : palpable tissue > 4cm >2cm & tender >2cm & increasing

Causes • • • • • •

estradiol excess testosterone deficiency estrogen – testosterone imbalance regulatory hormone excess drugs others

Aromatase associated causes of gynecomastia • • • • • •

obesity ageing aromatase excess syndrome (familial, sporadic) neoplasms (eutopic & ectopic productions) idiopathic thyrotoxicosis unifying feature of several causes- known & unknown of gynecomastia

Evaluation • whom to evaluate

• how to evaluate

Candidates needing evaluation • breast tenderness • rapid enlargement • eccentric, hard or irregular mass • lesion >4cm in diameter

Candidates not requiring evaluation • asymptomatic • stable • obese • <5cm

History • family history : familial aromatase excess, Peutz Zeghers syndrome, Carney complex • personal history : marijuana • time of onset • duration (beyond 12mo breast becomes irreversibly fibrotic) • rate of progression • pain • symptoms of androgen deficiency

History • drugs : finasteride, biculatamide, spironolactone, domperidone,βblockers, calcium channel blockers, amiodarone, diazepam, enalapril, metronidazole…….. • inadvertent estrogen exposure : industrial, coital exposure involving women using vaginal estrogen cream, from women using estrogen containing cosmetics

History • systemic diseases : CLD, CKD, diabetes • endocrinopathies : thyrotoxicosis, hypothyroidism, acromegaly, Cushing’s syndrome • psychological assessment : depression, social withdrawal, scholastic deterioration

Examination : local • presence or absence of breast disc • diameter of breast disc • to pinch the tissue between thumb & forefinger lateral to nipple; ability to flip an edge of tissue at the interface of normal & glandular tissue signifies gynecomastia • comparison of consistency with abdominal fat or fat in the axillary line • tenderness

Simon classification of gynecomastia Grade

Enlargement

Skin excess

I

small

absent

IIA

moderate

absent

IIB

moderate

present

III

large

present

Simon classification of gynecomastia • fatty, low grade breast without glandular tissue : suction assisted lipectomy (SAL), ultrasound assisted liposuction (UAL) • I : simple excision; SAL,UAL (adjunctive) • II : simple excision, + SAL • III : total mastectomy with free nipple grafting, modified radical mammoplasty

Examination : systemic • features of hypogonadism • asymmetrical testes (testicular tumor)* • probable systemic illnesses : may be too obvious *50% palpable; rest require ultrasound for detection

Investigations • to distinguish glandular tissue from fat mammography ultrasonography (less sensitive)

• to exclude neoplasm : excision biopsy

Biochemical investigations • • • • • • •

testosterone ad e l to g n di 17β estradiol r o acc r e h t r DHEAS fu d e ce o r p LH β hCG thyroid function test liver function test

Conclusion • to differentiate gynecomastia from lipomastia • to differentiate physiological from pathological gynecomastia • to separate gynecomastia that is relatively innocuous from those that connote serious underlying endocrinopathy or medical disorder

Conclusion • to assess patient’s attitude towards gynecomastia & psychological stress ,if any • work up should be judicious & purposeful : detailed work up may not be necessary or rewarding in many instances • if no apparent abnormality is detected, wait & watch policy may be adopted along with reassurance