Gynecomastia Evaluation and Treatment: EAA clinical practice guidelines

Buy Lab Tests Online

madman

Super Moderator
ABSTRACT

Background


Gynecomastia (GM) is a benign proliferation of the glandular tissue of the breast in men. It is a frequent condition with a reported prevalence of 32–65%, depending on the age and the criteria used for definition. GM of infancy and puberty are common, benign conditions resolving spontaneously in the majority of cases. GM of adulthood is more prevalent among the elderly and proper investigation may reveal an underlying pathology in 45–50% of cases.


Objectives

The aim was to provide clinical practice guidelines for the evaluation and management of GM.


Materials and methods

A literature search of articles in English for the term ‘gynecomastia’ was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.


Results

A set of five statements and fifteen clinical recommendations was formulated.


Conclusions

The purpose of GM assessment should be the detection of underlying pathological conditions, reversible causes (administration/abuse of aggravating substances), and discrimination from other breast lumps, particularly breast cancer. Assessment should comprise a thorough medical history and physical examination of the breast and genitalia (including testicular ultrasound). A set of laboratory investigations may integrate the evaluation: testosterone (T), estradiol (E2), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), follicular stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactin, human chorionic gonadotropin (hCG), alpha-fetal protein (AFP), liver and renal function tests. Breast imaging may be used whenever the clinical examination is equivocal. In suspicious lesions, core needle biopsy should be sought directly instead. Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with GM. T treatment should be offered to men with proven T deficiency. The use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), and non-aromatizable androgens is not justified in general. Surgical treatment is the therapy of choice for patients with long-lasting GM.




SUMMARY OF STATEMENTS (S) AND RECOMMENDATIONS (R)

S1. Gynecomastia (GM) is a benign proliferation of glandular tissue of the breast in males.


S2. GM of infancy is a common condition that usually resolves spontaneously, typically within the first year of life.

S3.
GM of puberty is a common condition, affecting approximately 50% of mid-pubertal boys; in more than 90% of cases, it resolves spontaneously within 24 months.

S4.
The prevalence of GM in adulthood increases with increasing age; proper investigation may reveal an underlying pathology in approximately 45–50% of the cases.

S5.
Male breast cancer is rare; GM should not be considered a premalignant condition.




INTRODUCTION—DEFINITION


Gynecomastia (GM) is a benign proliferation of glandular tissue of the breast in men. The term is derived from the Greek words ‘gyneka’ (woman) and ‘mastos’ (breast). GM can be unilateral or bilateral, most commonly the latter (Nuttall, 1979; Mieritz et al., 2017). GM has to be distinguished from pseudogynecomastia (i.e., lipomastia), which is characterized by excess fat deposition without glandular proliferation. GM is a common condition with a prevalence that varies widely between 32 and 65%, depending on the age of the subjects studied and the criteria used for GM definition (Braunstein, 2007). GM shows three discrete peaks throughout a man’s lifespan: the first peak is observed during infancy, the second during puberty, and the third in middle-aged and elderly men (Nachtigall, 1965; Knorr & Bidlingmaier, 1975; Nuttall, 1979). The purpose of the assessment of GM should be the detection of underlying pathological conditions and the discrimination from other breast lumps that mimic GM, particularly breast cancer.




CONCLUSIONS


GM is a common condition associated with benign hormonal processes of maturation of the male adolescent in the majority of cases. On the other hand, GM of the elderly is more often associated with underlying pathological conditions. The assessment of GM should aim at the detection of such conditions or the administration/abuse of aggravating substances as well as the exclusion of the very rare male breast cancer. The cornerstones of assessment are thorough medical history and physical examination including the breast and genitalia (supported by testicular ultrasound). Laboratory investigations may reveal underlying systematic disorders, whereas the role of breast imaging is still debated: Core needle biopsy should be sought in any clinically suspicious breast lesion. Watchful waiting and reassurance are reasonable options after underlying pathology, or the administration/abuse of substances associated with GM has been excluded or treated. The use of medical regimens, including SERMS, AIs, or DHT, still lacks substantial evidence to recommend their generalized use, while surgical treatment remains the therapy of choice for patients with long-lasting GM.




Table 1 Causes of gynecomastia

Cause

Physiological and idiopathic

• Neonatal/infancy

• Pubertal
• Middle or advanced age


Pathological

• Medications

• Primary testosterone deficiency (particularly Klinefelter syndrome)
• Secondary testosterone deficiency
• Hyperthyroidism
• Neoplasms
• Testicular: originating from germ (secreting forms), Leydig or Sertoli cells
• Adrenal: androgen- or estrogen-secreting tumors
• Ectopic production of hCG
• Hepatic causes, malnutrition
• Renal causes
• Rare causes
• Enzymatic defects of testosterone production
• Androgen insensitivity syndromes
• True hermaphroditism
• Excessive extra-glandular aromatase activity

• Environmental polluting substances
 

Attachments

Defy Medical TRT clinic doctor

madman

Super Moderator
Figure 1 Gynecomastia of puberty: (A) at the age of 14 years and (B) at the age of 15.5 years. Spontaneous regression of breast enlargement is observed with associated progression of virilization (courtesy of Dr. G. Kanakis).
Screenshot (189).png
 

madman

Super Moderator
Figure 2 The action of different hormones on breast tissue. Androgen receptor has an inhibitory effect on the development of breast cells, whereas other receptors have a stimulatory effect. A: androgen; AR: androgen receptor; E: estrogen; ER: estrogen receptor; Pg: progestogen; PgR: progestogen receptor; Prl: prolactin; IGF-1: insulin-like growth factor-1; IGF-1R: insulin-like growth factor-1 receptor. Reprinted by permission from: Springer Nature Customer Service Centre GmbH, Nat Rev Endocrinol, Gynaecomastia—pathophysiology, diagnosis and treatment. Narula & Carlson (2014).
Screenshot (188).png
 

madman

Super Moderator
Figure 3 Causes of gynecomastia with an adult debut in men with no substance abuse. Reprinted by permission from: Bioscientifica Limited, European journal of Endocrinology, Gynaecomastia in 786 adult men: clinical and biochemical findings, Mieritz et al. (2017).
Screenshot (190).png
 

madman

Super Moderator
Screenshot (192).png

Causal role in GM by the level of evidence. A: proved causal role; B: highly probable role; and C: significant association could not be established (includes categories C and D of the original publication). Modified from: Krause (2012). ACE, angiotensin-converting enzyme; GH, growth hormone; HAART, highly active anti-retroviral therapy; hCG, human chorionic gonadotropin.
 

madman

Super Moderator
Figure 4 Clinical and biochemical workup of adult men presenting with breast development. AAS: anabolic androgenic steroid; ALP: alkaline phosphatase; ALT: alanine aminotransferase; E2: estradiol; IGF-1: insulin-like growth factor-1, LH: luteinizing hormone; SHBG: sex hormone-binding globulin; T: testosterone; T3: triiodothyronine; T4: thyroxine; TSH: thyroid-stimulating hormone. Reprinted by permission from: Bioscientifica Limited, European journal of Endocrinology, Gynaecomastia in 786 adult men: clinical and biochemical findings, Mieritz et al. (2017) (modified).
Screenshot (193).png
 

madman

Super Moderator
Figure 5 Technique and findings in breast palpation. Reprinted by permission from Massachusetts Medical Society, The New England Journal of Medicine, Gynecomastia, Braunstein (2007).
Screenshot (195).png
 

Nelson Vergel

Founder, ExcelMale.com
 

Nelson Vergel

Founder, ExcelMale.com
 
Buy Lab Tests Online
Defy Medical TRT clinic

Sponsors

enclomiphene
nelson vergel coaching for men
Discounted Labs
TRT in UK Balance my hormones
Testosterone books nelson vergel
Register on ExcelMale.com
Trimix HCG Offer Excelmale
Thumos USA men's mentoring and coaching
Testosterone TRT HRT Doctor Near Me

Online statistics

Members online
8
Guests online
6
Total visitors
14

Latest posts

bodybuilder test discounted labs
Top