Gynaecomastia
Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management
Definition
Gynaecomastia is the benign enlargement of male breast tissue due to an imbalance between oestrogen and androgen activity.
Aetiology
- Physiological: neonatal, pubertal, and age-related (senescent) gynaecomastia.
- Endocrine disorders: hypogonadism, hyperthyroidism, adrenal tumours.
- Medication-induced: spironolactone, digoxin, anti-androgens, anabolic steroids.
- Systemic diseases: chronic liver disease, chronic kidney disease.
- Neoplasms: testicular tumours, oestrogen-secreting tumours.
Pathophysiology
- Oestrogen stimulates breast tissue proliferation, while androgens inhibit it.
- Gynaecomastia results from an increase in the oestrogen-to-androgen ratio.
- It may be transient (e.g., pubertal) or persistent due to underlying pathology.
Risk Factors
- Adolescence and ageing.
- Use of medications affecting hormonal balance.
- Chronic liver or kidney disease.
- Testicular or adrenal tumours.
- Obesity (increased peripheral oestrogen conversion).
Signs and Symptoms
- Breast: palpable, firm, symmetrical, and centrally located breast tissue.
- Pain or tenderness: may be present, particularly in early stages.
- Testicular examination: assess for masses or signs of hypogonadism.
- Systemic symptoms: signs of liver failure, hyperthyroidism, or malignancy.
Investigations
- Serum testosterone and LH/FSH: assess for hypogonadism.
- Oestradiol levels: elevated in oestrogen-secreting tumours.
- Liver and renal function tests: to evaluate for chronic disease.
- Thyroid function tests: to rule out hyperthyroidism.
- Testicular ultrasound: to assess for testicular tumours.
- Mammography: indicated if malignancy is suspected.
Management
1. Treat Underlying Cause:
- Medication-induced: consider discontinuing or substituting causative drugs.
- Hypogonadism: testosterone replacement therapy if indicated.
- Hyperthyroidism: manage with appropriate thyroid treatment.
2. Medical Management:
-
Note: the following information is for awareness only, as management is carried out by a specialist/MDT.
- Selective oestrogen receptor modulators (SERMs): tamoxifen may be used for persistent or painful gynaecomastia.
- Aromatase inhibitors: anastrozole may reduce oestrogen levels in certain cases.
3. Surgical Management (specialist management):
- Mastectomy: for persistent or severe cases where medical therapy fails.
4. Referral:
- Endocrinology: if hormonal imbalance is suspected.
- Surgery: if surgical intervention is required for persistent cases.
- Oncology: if testicular or adrenal malignancy is suspected.