Gynaecomastia

Section: Breast Curriculum: Curriculum, page 14

Definition

• True – Hyperplasia of stromal and ductal tissue of the male breast
  • Benign proliferation of the glandular component of male breast (≥ 2cm)
• Pseudo – Excess adipose tissue

Incidence

• Any age, up to 35% of males in lifetime
• Association with Klinefelter’s Syndrome
• Risk of Breast Ca approaches risk of female population

Clinical

• Concentric painful swelling
  • C.F Cancer, that presents as eccentric, usually painless mass
• Benign, usually reversible

Aetiology

• Imbalance in the ratio
• Relative hyperoestrogenism
  1. Decreased androgen production
  2. Increased oestrogen production
  3. Increased peripheral aromatisation

Classification

• 20% Primary/physiological
  • 3 Peaks - Neonatal, Puberty, Elderly (trimodal)
    • Neonatal - increased placental estrogen synthesis
    • Puberty - estrogen surge
    • Elderly - drop in testosterone production
• 35% Pathological – see table
• 25% Idiopathic
• 20% Drugs
  • Anti-Androgen/Inhibitors of Androgen synthesis:
    • Spironolactone
    • Finasteride
    • Cyproterone
  • Antibiotics
    • Isoniazid
    • Metronidazole
    • Ketoconazole
  • Anti-Ulcer Drugs
    • Omeprazole
  • Chemo Drugs
    • Methotrexate
    • Imatinib
  • Cardiovascular Drugs
    • ACE Inhibitors
    • Digoxin
    • Calcium Channel Blockers
    • Amiodarone
    • Statins
  • Drugs of Abuse
    • Alcohol
    • Marijuana
    • Amphetamines
    • Methadone
  • Hormones
    • Androgens
    • Anabolic Steroids
    • Oestrogens
    • Growth Hormone
  • Psychoactive Drugs
    • Diazepam
    • Haloperidol
    • Tricyclics
  • Other
    • Domperidone
    • Metoclopramide
    • Phenytoin

Pathological

• Decreased Oestrogen Clearance:
  • Cirrhosis
  • Haemochromatosis
  • Wilson’s Disease

Investigations

• Exclude Breast Ca or 2° pathological cause
• Hx + Exam (Breast, axilla, testes abdomen)
• LFTs and creatinine, AFP, β-HCG, Prolactin if rapidly growing, TFTs
• Triple assess if concerns for Ca +/- Testicular USS

Management

• Initial management
  • Adolescent boys
    • Observation as 80% will regress within 2 years
  • Adults
    • Assess for cause and treat
    • Observation after:
      • Exclusion of precipitating medication
      • Underlying medical disorders have been addressed
    • If present for > 1 year fibrosis is likely to be present and glandular tissue will not regress spontaneously therefore further management is indicated
• Treatment
  • Pharmacologic
    •  Effective in the early active phase of gynecomastia (for relief of tenderness and partial regression) but not in the late fibrotic stage (after 12 months)
    • Adolescent
      • Indication
        • Significant enlargement
        • Causing embarrassment
      • Treatment
        • 20mg daily of Tamoxifen
    • Adults
      • Indication
        • No identifiable cause
        • Breast tenderness that persists past 3 months
      • Treatment
        • 20mg daily of Tamoxifen
      • Hypogonadism
        • Treatment with testosterone therapy
  • Surgical
    • Indications
      • causing considerable psychological distress
      • Has persisted >12 months,
        • Non-tender, fibrotic stage has been reached.
  • Radiotherapy
    • Can be considered as prophylaxis in patient undergoing high-dose antiandrogen for prostate cancer

Gynaecomastia Management Algorithm