Gynecomastia

Gynecomastia is the benign enlargement of male breast glandular tissue, commonly caused by an imbalance between estrogen and androgen activity. It can present unilaterally or bilaterally and may occur at any age.

Pathophysiology

Gynecomastia occurs when the ratio of estrogen (which stimulates breast tissue growth) to androgens (which inhibit this growth) increases. Several factors can contribute to this hormonal imbalance:

1. Increased Estrogen Production or Activity: Conditions like testicular tumors, adrenal tumors, or obesity (where peripheral aromatization of androgens to estrogens occurs) can elevate estrogen levels.
2. Reduced Androgen Production or Activity: Hypogonadism (e.g., Klinefelter syndrome), aging (which lowers testosterone), and certain systemic illnesses can decrease androgen levels.
3. Drugs/Medications: Some medications can either increase estrogen activity or reduce androgens. Examples include anti-androgens, anabolic steroids, antipsychotics, anti-ulcer medications (cimetidine), and some antibiotics.

Etiology

Gynecomastia can be classified based on the underlying cause:

1. Physiological Gynecomastia:
   • Neonatal: Maternal estrogen crosses the placenta, causing transient gynecomastia.
   • Pubertal: Common in adolescent boys due to hormonal fluctuations and often resolves within 6-24 months.
   • Senile: Age-related decrease in testosterone and relative increase in fat mass leading to more estrogen production.
2. Pathological Gynecomastia:
   • Endocrine Disorders: Conditions like hyperthyroidism, adrenal tumors, or androgen insensitivity syndrome.
   • Systemic Disorders: Liver cirrhosis (affecting hormone metabolism) or chronic kidney disease.
   • Medications and Substance Use: Includes antiandrogens, digoxin, spironolactone, alcohol, marijuana, and anabolic steroids.
   • Tumors: Testicular or adrenal tumors that alter hormonal balance.

Clinical Presentation

• Symptoms: Tender or painless palpable mass under the nipple-areolar complex. It may vary from a small nodule to a more prominent mass.
• Signs: Distinguishing between true gynecomastia (glandular tissue enlargement) and pseudogynecomastia (fat deposition) is key. Gynecomastia typically feels firm, rubbery, and concentric around the nipple, whereas pseudogynecomastia is softer.

Diagnosis

1. History and Physical Examination: Assess for any drug use, chronic illnesses, or signs of endocrine disorders.
2. Laboratory Tests:
   • Hormone levels (e.g., testosterone, estradiol, luteinizing hormone, follicle-stimulating hormone).
   • Thyroid function tests.
   • Liver and kidney function tests.
3. Imaging:
   • Ultrasound or Mammography: Used when physical findings are unclear or if malignancy is suspected.
   • Testicular Ultrasound: If a testicular mass is suspected.

Management

1. Observation: Physiological gynecomastia, especially during puberty, often resolves without treatment.
2. Medical Treatment:
   • Selective Estrogen Receptor Modulators (SERMs): Such as tamoxifen or raloxifene, reduce breast tissue growth.
   • Aromatase Inhibitors: Reduce the conversion of androgens to estrogens but are less commonly used.
   • Androgens: In cases of hypogonadism, testosterone replacement may be considered.
3. Surgical Treatment:
   • Liposuction: For fat-dominant gynecomastia (pseudogynecomastia).
   • Mastectomy: For glandular tissue removal in severe or long-standing cases.

Complications

• Psychological Impact: Anxiety, embarrassment, or social withdrawal due to appearance.
• Malignancy Risk: While rare, male breast cancer should be considered if there are atypical findings (e.g., unilateral hard mass, nipple discharge, or axillary lymphadenopathy).

Prognosis

Most cases of gynecomastia, especially physiological or mild cases, have a good prognosis with spontaneous resolution or minimal intervention. Pathological cases require addressing the underlying condition for effective management.

Conclusion

Gynecomastia is a common condition resulting from hormonal imbalance, with various etiologies and management options. A comprehensive approach to evaluation and treatment can help alleviate symptoms and address any underlying causes.