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Attention should be paid to the symmetry and smoothness of the glandular tissue; unusual firmness, asymmetry, or an eccentric location not centered beneath the areola , fixation to the skin or chest wall, nipple retraction, bleeding or nipple discharge, ulceration, or associated lymphadenopathy should all suggest the possibility of breast carcinoma 23 and should lead to biopsy or excision.

In two reported series of men with gynecomastia, the cause was determined to be physiological i. Therapy Asymptomatic men with long-standing breast enlargement do not require treatment; reassurance is often all that is required. In men with an identifiable underlying disorder e. Similarly, if the gynecomastia is believed to be due to a medication or recreational drug, withdrawal of that agent should lead to at least some improvement over a period of a few months.

If the breast enlargement has been present for more than 1 yr, complete regression is less likely, due to the predominance of dense fibrous tissue 13 , Teenage boys with pubertal gynecomastia can usually be observed, with the expectation that the gynecomastia will spontaneously resolve over 1—2 yr in most cases Gynecomastia related to dialysis or refeeding is also generally self-limited, and reassurance may be sufficient treatment 27 , In some men with hypogonadism of short duration, testosterone replacement may lead to the resolution or improvement of associated gynecomastia 29 , However, because testosterone can be aromatized to estradiol, it may worsen the breast enlargement in some cases, and the patient should be warned of this possibility.

Antiestrogens have been increasingly used in recent years to decrease the stimulatory effect of estrogens on the male breast. Tamoxifen and raloxifene, which block the estrogen receptor, and aromatase inhibitors such as anastrozole have all been used with varying degrees of success in the treatment of gynecomastia. Although studies of their effects have been limited, there appears to be reasonable evidence supporting the utility of tamoxifen 31 — 35 and some evidence that raloxifene is approximately as useful as tamoxifen Neither tamoxifen nor raloxifene has been associated with significant side effects in the majority of patients 31 — In contrast, anastrozole was no better than placebo in a randomized, double-blind trial in patients with pubertal gynecomastia Anastrozole was successfully used to reduce the estrogen excess and breast enlargement in a patient with familial aromatase excess 37 , a patient with a feminizing Sertoli cell tumor 38 , and two hypogonadal men with gynecomastia induced by testosterone therapy It should be noted that none of these drugs have been approved for the treatment of gynecomastia.

For men with gynecomastia due to androgen deprivation therapy for prostate cancer, prophylactic radiation therapy directed at the breast has been somewhat successful in preventing new-onset gynecomastia 40 — Tamoxifen has also been used successfully in this situation 43 and appears to be superior to both radiotherapy 44 and anastrozole 45 , Daily administration of tamoxifen was shown to be more efficacious than weekly dosing Surgery to remove the breast tissue has been widely used in the treatment of gynecomastia.

It should probably be performed by highly experienced surgeons to achieve the best cosmetic result. Excision with or without liposuction has been successfully used 48 , Surgical treatment of pubertal gynecomastia should generally be postponed until the completion of puberty to minimize the possibility of postoperative regrowth of breast tissue.

Figure 1 illustrates a suggested scheme for the evaluation and treatment of gynecomastia. Suggested algorithm for the management of gynecomastia.

Narula and H. Therefore, universal application of imaging seems unlikely to be cost-effective. In one study of male breast mammography, all of the men diagnosed with breast cancer also had physical findings that were suspicious for malignancy It is certainly true that asymptomatic men with incidentally discovered palpable breast tissue generally need only a careful history and physical examination and do not usually benefit from laboratory testing.

Factors that bear on this question include the potential seriousness of a positive laboratory finding e. The perceived need to practice defensive medicine undoubtedly contributes, as well. Unfortunately, there is no consensus on this matter. The issue may particularly arise in older men, in whom palpable breast tissue is a common incidental finding.

Although hypogonadism is also common in this age group, it is not clear whether serum testosterone should be measured in all such individuals if they are truly asymptomatic i.

There would appear to be little clear benefit from testosterone treatment in the absence of symptoms, so I do not routinely obtain screening laboratory tests in such patients. In the realm of therapy, medical treatment has its own controversies.

It has not yet been clearly established whether tamoxifen and raloxifene are of equal benefit, although it seems reasonably clear that both are more effective than aromatase inhibitors 36 , 45 , Surgical therapy is generally agreed to be the most effective means of restoring the normal contour of the breast, but many different techniques and approaches are in current use and are likely to be influenced by the degree of breast enlargement as well as the proportion of glandular and fibrous tissue vs.

In addition, not all patients treated surgically are pleased with the results Returning to the Case Our patient developed tender bilateral breast enlargement in the setting of recent cytotoxic chemotherapy for lymphoma. There was no evidence of thyroid, renal, or hepatic disease. His compensated primary hypogonadism was most likely a consequence of his cancer chemotherapy. Literature reports suggest that many although not all such patients with chemotherapy-induced gynecomastia will have spontaneous recovery of Leydig cell function over several months, with gradual improvement or disappearance of the breast enlargement and tenderness 30 , 65 — Alternatively, he could be offered testosterone supplementation or tamoxifen therapy, with a good chance that his gynecomastia would decrease in size and tenderness because his breast enlargement had been present for only a few months.

After an extensive discussion of all these options, he chose to forego active treatment, opting for continued observation. Over the next 6 months, his serum testosterone LH and FSH returned to mid-normal, and his breasts were no longer tender or enlarged.

This patient is in many ways typical of the sort of patient seen by endocrinologists for gynecomastia. Although his history suggested the ultimate cause, it was important to rule out other underlying diseases and neoplasms and then to offer the patient the appropriate therapeutic modalities from which to choose. Conclusions Patients with asymptomatic palpable breast tissue need only a careful history and physical examination; most of these patients have either persistent pubertal gynecomastia or age-related gynecomastia.

Patients with symptomatic gynecomastia need, in addition to a careful history and physical examination, appropriate screening laboratory tests to detect underlying disorders and guide therapy. Most such cases have a benign etiology or are idiopathic. Underlying causes should be corrected, when possible; medical therapy or surgery can be offered to patients with persistent symptoms.


Endocrine Pathophysiology / Edition 2





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