Gynecomastia: Etiologies, Diagnosis, and Management
Gynecomastia: Etiologies, Diagnosis, and Management
Gynecomastia typically is discovered upon routine physical examination and is usually asymptomatic; however, some patients may present with complaints of pain, tenderness, psychosocial distress caused by cosmetic concerns, or fear of malignancy. Given the broad differential, a comprehensive clinical examination with a diagnostic workup is occasionally required (Fig.).
(Enlarge Image)
Figure.
Diagnostic algorithm for gynecomastia.
History and physical examination should form the basis of any investigation into gynecomastia. If the patient is symptomatic, then physicians should inquire about the duration of symptoms and presence of nipple discharge, overlying skin changes, or firm masses. Symptoms such as weight loss or presence of a testicular mass should prompt concern and further diagnostic testing. Patients with macromastia (breast tissue >5 cm), rapidly progressive gynecomastia, persistent mastodynia, or other evidence of malignancy (eg, palpable, fixed, peripheral lymph nodes >1.5 cm) should undergo further evaluation with breast imaging.
Gynecomastia itself is not a risk factor for malignancy, with the exception of patients with Klinefelter syndrome. Breast cancer should be considered in patients with asymmetric enlargement of the breast or in those with other risk factors.
A review of patients' prescription and over-the-counter medications/vitamin and herbal supplements is necessary. Specific questions should be asked regarding topical preparations, growth hormones, anabolic steroids, and use of alcohol and/or illicit recreational drugs (eg, marijuana, heroin, amphetamines). Although some studies have associated marijuana use with gynecomastia, others have not found a similar link. Patients may not volunteer information regarding these medications unless asked about them directly, and when speaking with an adolescent, it is prudent to conduct parts of the interview without parent(s) in the room. When alone, the adolescent may be more apt to admit to over-the-counter medication use or use of illicit drugs, such as marijuana or anabolic steroids.
Physical examination requires palpation of the breast tissue, with assessment of symmetry and consistency. Eccentric, immobile, and firm masses are suggestive of malignancy or other causes and require diagnostic workup. Skin examination for nipple discharge, retraction, or peau d'orange is reason for concern. A testicular examination is also necessary to determine the presence of any masses.
Diagnostic Considerations
Gynecomastia typically is discovered upon routine physical examination and is usually asymptomatic; however, some patients may present with complaints of pain, tenderness, psychosocial distress caused by cosmetic concerns, or fear of malignancy. Given the broad differential, a comprehensive clinical examination with a diagnostic workup is occasionally required (Fig.).
(Enlarge Image)
Figure.
Diagnostic algorithm for gynecomastia.
History and physical examination should form the basis of any investigation into gynecomastia. If the patient is symptomatic, then physicians should inquire about the duration of symptoms and presence of nipple discharge, overlying skin changes, or firm masses. Symptoms such as weight loss or presence of a testicular mass should prompt concern and further diagnostic testing. Patients with macromastia (breast tissue >5 cm), rapidly progressive gynecomastia, persistent mastodynia, or other evidence of malignancy (eg, palpable, fixed, peripheral lymph nodes >1.5 cm) should undergo further evaluation with breast imaging.
Gynecomastia itself is not a risk factor for malignancy, with the exception of patients with Klinefelter syndrome. Breast cancer should be considered in patients with asymmetric enlargement of the breast or in those with other risk factors.
A review of patients' prescription and over-the-counter medications/vitamin and herbal supplements is necessary. Specific questions should be asked regarding topical preparations, growth hormones, anabolic steroids, and use of alcohol and/or illicit recreational drugs (eg, marijuana, heroin, amphetamines). Although some studies have associated marijuana use with gynecomastia, others have not found a similar link. Patients may not volunteer information regarding these medications unless asked about them directly, and when speaking with an adolescent, it is prudent to conduct parts of the interview without parent(s) in the room. When alone, the adolescent may be more apt to admit to over-the-counter medication use or use of illicit drugs, such as marijuana or anabolic steroids.
Physical examination requires palpation of the breast tissue, with assessment of symmetry and consistency. Eccentric, immobile, and firm masses are suggestive of malignancy or other causes and require diagnostic workup. Skin examination for nipple discharge, retraction, or peau d'orange is reason for concern. A testicular examination is also necessary to determine the presence of any masses.
Source...