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TOPICREVIEWGYNECOMASTIABrianLee,MD,2ndYrInternalMedicineResident,SirirajHospitalDefinitionofGynecomastiaTruegynecomastia:Pseudogynecomastia/lipomastia:benignenlargementofmalebreastduetoproliferationglandularcomponentsRubberyorfirmmoundoftissuethatisconcentricwiththenipple-areolarcomplexisfeltfatdepositionwithoutglandularproliferationBraunsteinG.NEnglJMed2007;357:1229-1237DifferentiationofGynecomastiafromPseudogynecomastiaandOtherDisordersbyPhysicalExaminationPrevalenceThreepeaksInfancy:60-90%.Duetohighmaternalestrogen.Normallyregressesover2-3weekperiod.Adolescence:48-64%.Peakat13-14yr.Normallyregressesin18mo.Oldermen:24-65%.Highestprevalencein50-80yr.EtiologiesDrugs:10-25%Idiopathic:25%Persistentpubertalgynecomastia:25%Cirrhosisormalnutrition:8%Primaryhypogonadism:8%Testiculartumors:3%SecondaryHypogonadism:2%Hyperthyroidism:1.5%Chronicrenalinsufficiency:1%Harrison’sPrinciplesofInternalMedicine,17thEd.Kronenberg:WilliamsTextbookofEndocrinology,11thed.Kronenberg:WilliamsTextbookofEndocrinology,11thed.Kronenberg:WilliamsTextbookofEndocrinology,11thed.BraunsteinG.NEnglJMed1993;328:490-495GlandularandPeripheralOriginsandInterrelationsofTestosterone,Androstenedione,Estrone,andEstradiolGYNECOMASTIAHowtoapproachBraunsteinG.NEnglJMed2007;357:1229-1237InterpretationofSerumHormoneLevelsandRecommendationsforFurtherEvaluationofPatientswithGynecomastiaTreatmentOptionsWatchfulWaitingMedicationsSurgeryTreatmentsWatchfulwaitingInhealthyadolescentwithnormalphysicalexam,includinggenitalia,reevaluatein6monthsGynecomastiaattributedtoamedicationshouldbestoppedandpatientreassessedafterstoppingmedicationRegressionwilloccurin85%ofpatientswithgynecomastiaduetovariouscausesTreatmentsMedicationsMaybeindicatedinpatientswithpersistentgynecomastia,eg.Laterpubertywithseverepain,tenderness,psychosocialissuesofembarrasment.ThreetypesofmedicationsAndrogens,SERMS,aromataseinhibitorsLimitedclinicaldataNoneareFDAapprovedforgynecomastiaAndrogensTestosteroneImprovesgynecomastiainhypogonadismNouseineugonadalmenMayworsengynecomastiaduetoaromatizationoftestosteronetoestradiolDihydrotestosterone(nonaromatizableandrogen)Idiopathicgynecomastia:decreaseinbreastvolumein75%ofpatients,resolutionin25%.Nonotedsideeffects;decreaseintendernesswithin1-2weeks.DanazolSignificantlyreducedbreasttendernessandsizeUselimtedbysideeffects:edema,weightgain,acne,nauseaandmusclecrampsAnti-estrogenClomiphenecitrateResponseratesof36-95%.Twomajorstudiesofpubertalgynecomastia:fewerthan1/2ofptshadmorethan20%decreaseinbreastvolumeorweresatisfiedwithresultsAnti-estrogen:SERMSevere,tenderorpainfulgynecomastiaDonotresultincompleteregressionofbreasttissue.Gynecomastiafor6-12monthsTamoxifen10-20mg/dSignificantreductioninpainandbreastsize,butnonehadcompleteremission.Sideeffects:epigastricdistressandnauseaRaloxifene60mg/dAromataseinhibitorsAnastrozoleNoclinicalbenefitforgynecomastia,comparablewithplaceboNotsuggestusingaromataseinhibitorsinboysinpubertalgynecomastiaSurgeryShouldbeconsideredinpatientswhodonotrespondtomedicaltherapyorwhohavelongstandinggynecomastia12months.Adolescents:onlyafteradulttesticularsizeOptionsIncludeLiposuctionDirectsurgicalexcision,orbothComplicationsPermanentnumbness,compromiseofbloodsupply,irregularcontour,hematoma,seroma,woundinfection.