Gynecomastia with Case

00:01 Let's go on to a case A 48-year old man has come to see you for breast tenderness and enlargement over the past year.

00:08 His medical history's significant for hypertension and heart failure which was diagnosed one year ago.

00:15 His medications include bisoprolol, lisinoprol and spironolactone.

00:21 He's noticed no change in his libido over the past year.

00:24 On physical examination, vital signs are normal, his BMI is 30.

00:30 There is bilateral areolar tenderness with firm concentric glandular enlargement.

00:35 Thyroid, testes and liver exams are normal.

00:40 What is the most likely cause of this condition? His libido is unchanged, he's overweight with a BMI of 30 which approaches obesity and also has bilateral gynecomastia He's taking an anti androgen for the same length of time that his abnormal breast enlargement has been present So one should immediately focus on spironolactone as the cause here.

01:06 Spironolactone is an agent that is used for heart failure as a 2nd or 3rd line agent but can be and is indeed probably the most common cause of medication-induced gynecomastia.

01:21 Essentially, as an anti-androgen, the gynecomastia due to spironolactone is due to an imbalance between estrogen and free androgen actions on the breat tissue.

01:32 Gynecomastia from spironolactone can increase the aromatisation of testosterone to estradiol, decrease the testosterone production by the testes and displace testosterone from sex hormone binding globulin thereby increasing its metabolic clearance rate.

01:48 It acts an anti-androgen by binding to androgen receptors and displacing the binding of testosterone and dihydotesterone to their receptors Causes of gynecomastia are divided into those caused by medications, and other causes.

02:04 By far the most common is spironolactone, however it can be seen with cimetidine which patients take for peptic ulcers, with protease inhibitors in HIV patients, patents with heart failure who take digoxin, patients who use ketoconazole as an antifungal agent, calcium channel blockers and ACE inhibitors which are used for high blood pressure, tricyclic antidepressants and selective serotonin reuptake inhibitors Non-medication causes include smoking marijuana, malnutrition, cirrhosis, hypogonadism, testicular germ cell tumors, hypothyroidism and chronic kidney disease.