Gynaecomastia

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Example Management | References

Definition

Gynaecomastia is the benign enlargement of male breast glandular tissue. It is distinct from pseudogynaecomastia, which involves fat deposition without glandular proliferation.

Aetiology

The causes of gynaecomastia can include:

• Physiological: Neonatal (due to maternal oestrogens), puberty (transient imbalance between oestrogen and testosterone), ageing (decline in testosterone production).
• Pathological: Hormonal imbalances (e.g., hypogonadism, hyperthyroidism), liver disease, renal failure, testicular tumours.
• Medications: Anti-androgens (e.g., spironolactone), antipsychotics, certain antibiotics, anti-ulcer drugs (e.g., cimetidine), recreational drugs (e.g., alcohol, marijuana).
• Idiopathic: No identifiable cause in some cases.

Pathophysiology

Gynaecomastia results from an imbalance between oestrogen and androgen activity in the male breast tissue:

• Increased oestrogen production or activity
• Decreased androgen production or activity
• Increased availability of breast tissue receptors for oestrogens

Risk Factors

• Adolescence
• Older age
• Use of certain medications (e.g., anti-androgens, antipsychotics)
• Chronic illnesses (e.g., liver disease, renal failure)
• Substance use (e.g., alcohol, marijuana)
• Hormonal disorders (e.g., hypogonadism, hyperthyroidism)

Signs and Symptoms

Common signs and symptoms of gynaecomastia include:

• Enlargement of the breast tissue, typically bilateral but can be unilateral
• Breast tenderness or sensitivity
• Palpable, firm glandular tissue beneath the areola
• Emotional or psychological distress due to changes in physical appearance

Investigations

• Clinical history and physical examination
• Hormonal assays: Serum testosterone, oestrogen, LH, FSH, prolactin, and hCG levels to assess for hormonal imbalances
• Liver function tests: To evaluate for liver disease
• Renal function tests: To assess for renal failure
• Thyroid function tests: To check for hyperthyroidism
• Ultrasound of the testes: To rule out testicular tumours
• Mammography or ultrasound of the breast: To differentiate between gynaecomastia and breast malignancy, especially in unilateral cases

Management

Primary Care Management

• Observation: Many cases of pubertal gynaecomastia resolve spontaneously within 6-12 months.
• Education: Informing patients about the benign nature of the condition and potential causes.
• Reassurance: Providing reassurance to patients, especially adolescents, about the temporary nature of the condition in most cases.
• Medication review: Identifying and discontinuing any medications that may be contributing to the condition, in consultation with the prescribing physician.
• Referral: To an endocrinologist if there are signs of hormonal imbalances, or to a surgeon for persistent or severe cases causing significant distress or discomfort.

Specialist Management

• Hormonal therapy: Anti-oestrogens (e.g., tamoxifen) or aromatase inhibitors (e.g., anastrozole) may be used in persistent cases.
• Surgery: Reduction mammoplasty for severe or long-standing gynaecomastia that does not respond to medical therapy.
• Treatment of underlying conditions: Addressing any primary conditions such as hypogonadism or hyperthyroidism.

Example Management for Gynaecomastia

An adolescent male presenting with bilateral breast enlargement and tenderness is diagnosed with pubertal gynaecomastia. The patient is reassured that the condition is common and usually resolves spontaneously within a year. A follow-up appointment is scheduled in six months to monitor progress. If the condition persists or worsens, hormonal assays and further investigations will be conducted to rule out underlying causes. The patient and his parents are educated about the benign nature of the condition and the importance of avoiding medications or substances that could exacerbate gynaecomastia.

References

1. NICE. (2024). Gynaecomastia: Management and Treatment. Retrieved from NICE
2. NHS. (2023). Gynaecomastia. Retrieved from NHS
3. British Association of Dermatologists (BAD). (2022). Guidelines for the Management of Gynaecomastia. Retrieved from BAD
4. American Society of Plastic Surgeons (ASPS). (2021). Management of Gynaecomastia. Retrieved from ASPS

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