CONCISE REVIEW FOR CLINICIANSGynecomastia: Pathophysiology, Evaluation, and Management
Section snippets
PATHOPHYSIOLOGY
The imbalance between estrogen action relative to androgen action at the breast tissue level appears to be the main etiology of gynecomastia.6 Elevated serum estrogen levels may be a result of estrogen-secreting neoplasms or their precursors (eg, Leydig or Sertoli cell tumors, human chorionic gonadotropin [hCG]—producing tumors, and adrenocortical tumors) but more commonly are caused by increased extragonadal conversion of androgens to estrogens by tissue aromatase (as occurs in obesity).
CLINICAL MANIFESTATIONS AND DIAGNOSIS
Careful history taking and physical examination (the relevant elements of which are presented in Table 1) often reveal that patients actually are presenting with pseudogynecomastia, which means accumulation of subareolar fat without real proliferation of glandular tissue. Examination of these patients reveals diffuse breast enlargement without a subareolar palpable nodule. These patients do not need additional work-up and only require reassurance. Gynecomastia is usually bilateral,3, 9 but
MANAGEMENT AND PROGNOSIS
Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended. Although evidence is lacking to support a recommendation for follow-up intervals, 6 months seems reasonable. Causative medications should be withdrawn or the underlying causative medical
CONCLUSION
The evaluation of gynecomastias can be complex. A step-wise approach that starts with careful history taking and physical examination may obviate the need for extensive work-up. Subsequent selective imaging and laboratory testing help exclude possible neoplasms and endocrinopathies. The etiology is usually benign.
CME Questions About Gynecomastia
- 1.
Which one of the following statements best describes a typical presentation of gynecomastia?
- a.
Unilateral peripheral mass
- b.
Painless bilateral hard and fixed masses
- c.
A mass associated with nipple discharge
- d.
Bilateral painful masses in an anxious adolescent
- e.
Bilateral masses with minimal axillary lymphadenopathy
- a.
- 2.
Which one of the following statements best describes the recommendations for gynecomastia evaluation?
- a.
Diagnostic work-up for gynecomastia is recommended if initial history and
- a.
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