work up of gynecomastia (slides)
TRANSCRIPT
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Work up of gynecomastia
Nilanjan Sengupta,MD,DMAssistant Professor
Department of EndocrinologyNRS Medical College
Kolkata
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Hormonal control of breast development
• estradiol stimulates glandular cells
• testosterone inhibits growth & differentiation
• GH,cortisol,IGF1,insulin act permissively
• thyroid hormones increase SHBG level
• cortisol & prolactin lower T levels (hypothalamic & testicular effects)
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Gynecomastia : the problem
• common condition : not always pathological• pubertal gynecomastia : 65% by age 15• 30% of normal military recruits have palpable
breast tissue• 40% men (40-44y)have palpable breast tissue• upto 70% hospitalized patients (50-69y) have
palpable breast tissue• upto 83% of hospitalized men with gynecomastia
– breast tissue diameter <5cm
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Physiological vs pathological gynecomastia
• challenging• common• association with obesity• psedogynecomastia• pathological arbitrarily defined : palpable tissue > 4cm >2cm & tender >2cm & increasing
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Causes
• estradiol excess
• testosterone deficiency
• estrogen – testosterone imbalance
• regulatory hormone excess
• drugs
• others
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Aromatase associated causes of gynecomastia
• obesity• ageing• aromatase excess syndrome (familial, sporadic)• neoplasms (eutopic & ectopic productions)• idiopathic• thyrotoxicosis
unifying feature of several causes- known & unknown of gynecomastia
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Evaluation
• whom to evaluate
• how to evaluate
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Candidates needing evaluation
• breast tenderness
• rapid enlargement
• eccentric, hard or irregular mass
• lesion >4cm in diameter
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Candidates not requiring evaluation
• asymptomatic
• stable
• obese
• <5cm
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History
• family history : familial aromatase excess, Peutz Zeghers syndrome, Carney complex
• personal history : marijuana• time of onset • duration (beyond 12mo breast becomes
irreversibly fibrotic)• rate of progression• pain• symptoms of androgen deficiency
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History
• drugs : finasteride, biculatamide, spironolactone, domperidone,βblockers, calcium channel blockers, amiodarone, diazepam, enalapril, metronidazole……..
• inadvertent estrogen exposure : industrial, coital exposure involving women using vaginal estrogen cream, from women using estrogen containing cosmetics
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History
• systemic diseases : CLD, CKD, diabetes
• endocrinopathies : thyrotoxicosis, hypothyroidism, acromegaly, Cushing’s syndrome
• psychological assessment : depression, social withdrawal, scholastic deterioration
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Examination : local
• presence or absence of breast disc• diameter of breast disc• to pinch the tissue between thumb &
forefinger lateral to nipple; ability to flip an edge of tissue at the interface of normal & glandular tissue signifies gynecomastia
• comparison of consistency with abdominal fat or fat in the axillary line
• tenderness
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Simon classification of gynecomastia
Grade Enlargement Skin excess
I small absent
IIA moderate absent
IIB moderate present
III large present
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Simon classification of gynecomastia
• fatty, low grade breast without glandular tissue : suction assisted lipectomy (SAL), ultrasound assisted liposuction (UAL)
• I : simple excision; SAL,UAL (adjunctive)
• II : simple excision, + SAL
• III : total mastectomy with free nipple grafting, modified radical mammoplasty
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Examination : systemic
• features of hypogonadism
• asymmetrical testes (testicular tumor)*
• probable systemic illnesses : may be too obvious
*50% palpable; rest require ultrasound for detection
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Investigations
• to distinguish glandular tissue from fat
mammography
ultrasonography (less sensitive)
• to exclude neoplasm : excision biopsy
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Biochemical investigations
• testosterone
• 17β estradiol
• DHEAS
• LH
• β hCG
• thyroid function test
• liver function test
proceed further according to lead
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Conclusion
• to differentiate gynecomastia from lipomastia
• to differentiate physiological from pathological gynecomastia
• to separate gynecomastia that is relatively innocuous from those that connote serious underlying endocrinopathy or medical disorder
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Conclusion
• to assess patient’s attitude towards gynecomastia & psychological stress ,if any
• work up should be judicious & purposeful : detailed work up may not be necessary or rewarding in many instances
• if no apparent abnormality is detected, wait & watch policy may be adopted along with reassurance
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