Breast: Gynecomastia

Definition

• Gynecomastia: Benign Proliferation of Glandular Tissue in Men
• Pseudogynecomastia: Accumulation of Subareolar Fat without Glandular Proliferation
  • More Common in Obese Patients

Basics

• Caused by Estrogen/Androgen Imbalance
  • Relatively Increased Estrogen Production
  • Decreased Androgen (Testosterone) Production
• Trimodal Age Distribution:
  • Infancy
  • Puberty
  • Elderly
• Progression:
  • Early Stage (First 6 Months): Ductal Hyperplasia & Periductal Inflammation
    • Most Symptomatic & Most Treatable Time Period
  • Late Stage (After 12 Months): Fibrosis

Causes

• Medications:
  • ACE Inhibitors
  • Spironolactone
  • Cimetidine
  • Ketoconazole
  • HGH
  • HCG
  • Antiandrogens – Often Seen in Treatment of Prostate Cancer
• Drugs (Marijuana, Alcohol & Amphetamines)
• Liver Cirrhosis
• Malnutrition & Refeeding
• Hypogonadism
• Testicular Neoplasia
• Hyperthyroidism
• Chronic Kidney Disease

Presentation

• Bilateral
• Firm-Rubbery Tissue
• Symmetrical Shape
• Centrally-Located Deep to the Nipple-Areolar Complex
• Can Be Painful/Tender

Diagnosis

• Clinical Diagnosis
• Consider Imaging (Diagnostic Mammogram/US) if Unilateral, Uncertain or Concerned for Malignancy

Treatment

• Primary Treatment: Reassurance & Observation
  • Stop Offending Drugs
  • Treat Underlying Conditions
• Medical Therapy: Selective Estrogen Receptor Modulators (SERM/Tamoxifen) or Androgens (Only in Hypogonadism)
  • Consider if Conservative Measures Fail to Resolve After 3-6 Months
  • Avoid Aromatase Inhibitors – No Improvement Seen
• Surgical Intervention:
  • Indications:
    • Failure to Respond to Less Aggressive Measures
    • Longstanding (> 12 Months) in Fibrotic Stage
    • Significant Pain
    • Significant Psychological Distress
  • Surgery: Excision & Liposuction of Surrounding Tissue
    • Liposuction Alone is Insufficient – Removes Fat but Not Glandular Tissue