GYNECOMASTIA

Dr. Yusri, Sp.B

 Clinical Problem
• Asymptomatic gynecomastia  enlargement of
the glanduler tissue of the breast in man
• Histologic  dilated ducts with periductal
fibrosis, stromal hyalinization and increased
subareolar fat
• Symptom of pain and tenderness  hyperplasia
of the ductal epithelium, infiltration of the
periductal tissue w/ inflamatory cells and
increased subareolar fat
 Pathophysiologic
• Imbalance between free estrogen and free
androgen actions in the breast tissue
• Thi imbalance  multiple mechanism
 Diagnosis
• Determine wheter the enlarged breast tissue or
mass is gynecomastia
• Pseudogynecomastia  increased subareolar
fat without enlargement of the breast glandular
component
• Breast carcinoma
• Gynecomastia :
– The tissue is soft, elastic, or firm (not hard)
– Affected area  concentric to the nipple-areolar
complex
– 50% bilateral
– Tenderness may be present (<6 months duration)
– Mammography  90% sensitivity and specificity
 Evaluation
• Review all medication
– Herbal products
– Sex steroids hormone
– Antiandrogen (Th/ Prostate cancer)
– Spironolactone
– Cimetidine
– Cancer chemotherapy : ankylating agent
– Phenitoin, Metoclopramide
• Physiologic pubertal gynecomastia (13-14 y.o, last for 6
months  regress)
5%  persistent gynecomastia
• Klinefelter’s Syndrome, Familial or sporadic excessive
aromatase activity, incomplete androgen insensitifity,
Feminizing testicular or Adrenal tumor and
Hyperthyroidism
• Drug abbuse  alcohol, marijuana, opioids
• Lab :
– hCG
– LH
Circardian
– Testosterone rhythem
– Estradiol
To determine the cause of asymptomatic
gynecomastia in adult without a history
suggestive of an underlying pathologic cause
Long standing aymptomatic gybecomastia 
fibrotic stage  minimal approach
 Treatment
• Specific cause can be indentified and treated
during the painfull prolifertaive phase  there
may be regression
• Gynecomastia > 1 year  unlikely to regress
substantially, either spontaneously or with
medical therapy  present of fibrosis
• Surgical subcutaneous mastectomy
• Ultrasound-assisted liposuction
• Suction-assisted lipectomy
 Treatment
• During the rapid, proliferative phase  breast pain and
tenderness :
– Testosterone (Px hypogonadism)
– Dihydrotestosterone
– Danazol
– Clomiphene citrate
– Tamoxifen
– Testolactone
• SERM Tamoxifen : 20 mg daily for up to 3 months
(efective but not approved)
– Randomized and Non-randomized CT : 80% regress, 60%
complete regress
– Retrospective : 78% complete regress, as compared w/ Danazol
(40%)
• Aromatase inhibitor (anastrozole)  not efective
 Conclusions & Recommendations
• Asymtomatic gynecomastia : History taking and
Physical Exam
– Pubertal Gynecomastia
– Drug-induced causes
– Underlying Pathologic process
• Hormonal evaluation  acute onset painful
gynecomastia without an obvious cause
• Acute stage of gynecomastia  Trial of
Tamoxifen, 20 mg per day, up to 3 months
• If not regressed by 1 year or long-standing
gynecomastia  Surgical
• Px who are troubles by their appearance 
Surgical