It is caused by excess estrogen action and is usually the result of an increased estrogen-to-androgen ratio.

Gynecomastia occurs as a normal physiologic phenomenon in the newborn (due to transplacental transfer of maternal and placental estrogens), during puberty (high estrogen-to-androgen ratio in early stages of puberty), and with aging (increased fat tissue and increased aromatase activity), but it can also result from pathologic conditions associated with androgen deficiency or estrogen excess.

The prevalence of gynecomastia increases with age and body mass index (BMI), likely because of increased aromatase activity in adipose tissue. Medications that alter androgen metabolism or action may also cause gynecomastia. The relative risk of breast cancer is increased in men with gynecomastia, although the absolute risk is relatively small.

Increased estrogen levels associated with puberty, liver disease, drugs, and endocrine abnormalities can lead to proliferation of breast tissue in men.1

 

True gynecomastia is associated with glandular breast tissue that is >4 cm in diameter and often tender. Glandular tissue enlargement should be distinguished from excess adipose tissue: glandular tissue is firmer and contains fibrous-like cords.

Gynecomastia is defined as a transient or permanent noninflammatory enlargement of the male breast [Braunstein GD. Gynecomastia. N Engl J Med. 1993;328:490–495].

Physical examination reveals a finely lobulated often tender subareolar mass that is mobile on the chest wall.

[ Increased nipple sensitivity is frequently noted by the patient.] The mass may be small and unilateral, or gynecomastia can develop bilaterally to the dimensions of the female breast. Hard masses or those with fixation to the skin or chest wall must be excised to exclude carcinoma.

 CLINICAL OCCURRENCE: Idiopathic gynecomastia frequently appears at puberty and is usually unilateral. Hormonal stimulation with estrogens causes bilateral enlargement after castration, and in Cushing syndrome, hyperthyroidism, and testicular choriocarcinoma. Breast enlargement may also occur in liver cirrhosis.

Refeeding gynecomastia occurs when patients with severe malnutrition are first fed. Gynecomastia may occur in association with leukemia, lymphoma, pulmonary carcinoma, familial lumbosacral syringomyelia, and Graves disease. Among the drugs occasionally causing gynecomastia are digitalis, isoniazid, spironolactone, phenothiazine, and diazepam.

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GYNECOMASTIA

Breast development is controlled by circulating estrogens. Increased estrogen levels associated with puberty, liver disease, drugs, and endocrine abnormalities can lead to proliferation of breast tissue in men. Gynecomastia is defined as a transient or permanent noninflammatory enlargement of the male breast [Braunstein GD. Gynecomastia. N Engl J Med. 1993;328:490–495]. Physical examination reveals a finely lobulated often tender subareolar mass that is mobile on the chest wall. Increased nipple sensitivity is frequently noted by the patient. The mass may be small and unilateral, or gynecomastia can develop bilaterally to the dimensions of the female breast. Hard masses or those with fixation to the skin or chest wall must be excised to exclude carcinoma. CLINICAL OCCURRENCE: Idiopathic gynecomastia frequently appears at puberty and is usually unilateral. Hormonal stimulation with estrogens causes bilateral enlargement after castration, and in Cushing syndrome, hyperthyroidism, and testicular choriocarcinoma. Breast enlargement may also occur in liver cirrhosis. Refeeding gynecomastia occurs when patients with severe malnutrition are first fed. Gynecomastia may occur in association with leukemia, lymphoma, pulmonary carcinoma, familial lumbosacral syringomyelia, and Graves disease. Among the drugs occasionally causing gynecomastia are digitalis, isoniazid, spironolactone, phenothiazine, and diazepam.

 

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Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.

 

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Question 1 of 1

A 58-year-old man is seen in his primary care physician’s office for evaluation of bilateral breast enlargement. This has been present for several months and is accompanied by mild pain in both breasts. He reports no other symptoms. His other medical conditions include coronary artery disease with a history of congestive heart failure, atrial fibrillation, obesity, and type 2 diabetes mellitus. His current medications include lisinoprilspironolactonefurosemide, insulin, and digoxin. He denies illicit drug use and has fathered three children. Examination confirms bilateral breast enlargement with palpable glandular tissue that measures 2 cm bilaterally. Which of the following statements regarding his gynecomastia is true?

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The correct answer is D. You answered A.

The answer is D. (Chap. 411) Gynecomastia is a relatively common complaint in men and may be caused by either obesity with adipose tissue expansion in the breast or by an increased estrogen-to-androgen ratio in which there is true glandular enlargement, as in this case. If the breast is unilaterally enlarged or if it is hard or fixed to underlying tissue, mammography is indicated. Alternatively, if cirrhosis or a causative drug is present, these may be adequate explanations, particularly when gynecomastia develops later in life in previously fertile men. If the breast tissue is >4 cm or there is evidence of very small testes and no causative drugs or liver disease, a search for alterations in serum testosterone, LH, FSH, estradiol, and human chorionic gonadotropin (hCG levels) should be undertaken. An androgen deficiency or resistance syndrome may be present, or an hCG-secreting tumor may be found. In this case, spironolactone is the likely culprit, and it may be stopped or switched to eplerenone and gynecomastia reassessed.

 

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