Gynecomastia

00:01 Welcome. In this talk we're going to discuss the entity of gynecomastia, which is male breast enlargement.

00:09 The epidemiology. It is actually reasonably common, especially in neonates and in elderly individuals.

00:15 And in most cases, this is minor breast tissue proliferation, that will regress spontaneously within months.

00:24 So, up to 90% of neonates, there will be some level of gynecomastia, even in the little boy infants, and this is due to residual estrogen from the mother, prior to delivery.

00:38 In adolescence, particularly going through puberty, there will be a transient kind of alteration, in levels of testosterone, which may give rise to a transient accumulation of breast tissue about half of adolescents.

00:54 And then in old men, there is a rising incidence of gynecomastia, largely just fatty tissue.

01:04 The pathophysiology of this overall, it is too much estrogen and not enough androgen.

01:10 And interestingly, because of what happens during normal fetal development, male breast tissue can't really make lobules.

01:22 So, there has been attrition, a totally atresia of the lobular architecture.

01:27 But normal male breast tissue does have ducts.

01:33 So, with elevated estrogen, you get proliferation of the ductular epithelium, not lobular epithelium, but even that little bit of proliferation of the ducts can give you gynecomastia.

01:45 In a quarter of cases we don't know what is underlying that.

01:50 But in most cases, we suspect that and can demonstrate that it's due to elevated estrogen levels.

01:57 Adrenal tumors, Kleinfelter syndrome, increased body fat content, which will increase estrogen synthesis or reduced estrogen metabolism as in cirrhosis, where you are not metabolizing any estrogen that has been made normally.

02:14 All will lead to gynecomastia.

02:16 Certain medications are associated with this.

02:19 And interestingly hyperthyroidism can be associated.

02:22 And in hyperthyroidism, you get an increased production by the liver of sex hormone binding globulin SHBG.

02:30 And with that, you bind up free testosterone.

02:34 You have lower levels of circulating testosterone, which may also manifest as gynecomastia.

02:41 The clinical presentation are palpable concentric.

02:45 Usually symmetric, firm, or rubbery.

02:48 Tissue, usually directly beneath their areola.

02:53 The diagnosis is a clinical history.

02:56 It's often associated with sexual dysfunction, if there's really estrogenic, overexpression.

03:02 There may be infertility. There may be hypogonadism. Not always.

03:07 And mainly what we'll see is, "Gee, I started to go through puberty. My voice started to change.

03:11 I started to get some hair growth and I started to develop breasts.

03:15 Am I going to turn into a girl?" No.

03:17 So, I think being able to also provide reassurance to your patients is going to be important.

03:22 The physical exam is going to be part of your diagnosis.

03:26 You really want to see kind of symmetric, bilateral, increases in breast mass to know that that's what you're dealing with.

03:34 For laboratory evaluation.

03:36 You'll want to do serum testosterone levels, clearly, You want to look at Estradiol.

03:40 You want to look at things coming out of the pituitary such as luteinizing hormone, and follicle stimulating hormone.

03:46 You also want to look at what's coming out of the hypothalamus.

03:49 and human chorionic gonadotropin.

03:52 That may actually be due to other tumors, say germ cell tumors of the testis.

03:59 So these are important things to rule out.

04:02 You will want to look at sex hormone binding globulin, SHBG.

04:06 You may want to do associated thyroid function tests.

04:10 Liver function tests to make sure that you're not dealing with cirrhosis or some sort of metabolic defect in the liver.

04:16 And then finally, rarely, you might do biopsy of the gynecomastic tissues.

04:23 In imaging, you may or may not do mammography.

04:26 You consider malignancy.

04:28 If the gynecomastia is unilateral, if it's ulcerative, fixed, it's hard.

04:34 It's not associated with the nipple, or the areola area, if it has bloody discharge, or if there's axillary lymphadenopathy.

04:43 So, treatment. In most cases, as I've already intimated, it goes away. It remits after six months.

04:49 The hormones sort themselves out.

04:52 And without estrogenic stimulation, you get regression of the epithelial proliferation within the ducts.

05:00 You want to treat any underlying cause.

05:02 So, if there's liver disease, you want to treat that.

05:04 If there is a germ cell tumor, you want to treat that.

05:07 If there's hyperthyroidism, treat that, et cetera.

05:10 The medical therapy may also involve testosterone replacement if there is some hypogonadism, for example, or you want to block estrogen effects, and in refractory cases or where the patient just feels that a cosmetic cure is very important, you do a subcutaneous mastectomy.

05:30 With that we've covered an interesting topic, reasonably common of gynecomastia.