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Testosterone Replacement, Low T, HCG, & Beyond
Testosterone Side Effect Management
Gynecomastia Evaluation and Treatment: EAA clinical practice guidelines
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<blockquote data-quote="madman" data-source="post: 148807" data-attributes="member: 13851"><p><strong>ABSTRACT </strong></p><p><strong></strong></p><p><strong><span style="color: rgb(184, 49, 47)">Background</span></strong></p><p></p><p><em>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.</em></p><p></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">Objectives</span></strong></p><p></p><p><em>The aim was to provide clinical practice guidelines for the evaluation and management of GM.</em></p><p></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">Materials and methods</span></strong></p><p></p><p><em>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.</em></p><p></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">Results</span></strong></p><p></p><p><em>A set of five statements and fifteen clinical recommendations was formulated.</em></p><p></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">Conclusions</span></strong></p><p></p><p><em>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.</em></p><p></p><p></p><p></p><p></p><p><strong>SUMMARY OF STATEMENTS (S) AND RECOMMENDATIONS (R) </strong></p><p><strong></strong></p><p><strong><span style="color: rgb(184, 49, 47)"><em>S1. </em></span><em>Gynecomastia (GM) is a </em><span style="color: rgb(184, 49, 47)"><em>benign proliferation of glandular tissue of the breast in males.</em></span> </strong></p><p><em></em></p><p><em><strong><span style="color: rgb(184, 49, 47)">S2. </span><span style="color: rgb(0, 0, 0)">GM of infancy is a </span><span style="color: rgb(184, 49, 47)">common condition</span> that usually resolves <span style="color: rgb(184, 49, 47)">spontaneously</span>, typically within <span style="color: rgb(184, 49, 47)">the first year of life. </span></strong></em></p><p><em><strong><span style="color: rgb(184, 49, 47)"></span></strong></em></p><p><em><strong><span style="color: rgb(184, 49, 47)">S3.</span></strong> <strong><span style="color: rgb(0, 0, 0)">GM of puberty is a </span><span style="color: rgb(184, 49, 47)">common condition</span>, affecting approximately <span style="color: rgb(184, 49, 47)">50% of mid-pubertal boys</span>; in more than <span style="color: rgb(184, 49, 47)">90% of cases</span>, it resolves <span style="color: rgb(184, 49, 47)">spontaneously </span>within <span style="color: rgb(184, 49, 47)">24 months.</span></strong></em></p><p><em><strong><span style="color: rgb(184, 49, 47)"></span></strong></em></p><p><em><strong><span style="color: rgb(184, 49, 47)">S4. </span>The prevalence of <span style="color: rgb(184, 49, 47)">GM in adulthood</span> increases with <span style="color: rgb(184, 49, 47)">increasing age</span>; proper investigation may reveal <span style="color: rgb(184, 49, 47)">an underlying pathology</span> in approximately <span style="color: rgb(184, 49, 47)">45–50%</span> of the cases. </strong></em></p><p><em><strong></strong></em></p><p><em><strong><span style="color: rgb(184, 49, 47)">S5.</span></strong> </em><strong><em>Male breast cancer is </em><span style="color: rgb(184, 49, 47)"><em>rare</em></span><em>; GM should not be considered a </em><span style="color: rgb(184, 49, 47)"><em>premalignant condition</em></span><em>. </em></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>INTRODUCTION—DEFINITION </strong></p><p></p><p><em><strong>Gynecomastia (GM) is a </strong></em><span style="color: rgb(184, 49, 47)"><strong><em>benign proliferation of glandular tissue of the breast in men.</em></strong></span><strong><em> The term is derived from the Greek words ‘gyneka’ (woman) and ‘mastos’ (breast). GM can be <span style="color: rgb(184, 49, 47)">unilateral or bilateral</span>, most commonly <span style="color: rgb(184, 49, 47)">the latter </span>(Nuttall, 1979; Mieritz et al., 2017). GM has to be distinguished from <span style="color: rgb(184, 49, 47)">pseudogynecomastia (i.e., lipomastia)</span>, which is characterized by <span style="color: rgb(184, 49, 47)">excess fat deposition</span> without <span style="color: rgb(184, 49, 47)">glandular proliferation.</span> GM is a common condition with a prevalence that varies widely between <span style="color: rgb(184, 49, 47)">32 and 65%</span>, depending on the <span style="color: rgb(184, 49, 47)">age of the subjects</span> studied and the <span style="color: rgb(184, 49, 47)">criteria</span> used for GM definition (Braunstein, 2007). GM shows <span style="color: rgb(184, 49, 47)">three discrete peaks</span> throughout a man’s lifespan: <span style="color: rgb(184, 49, 47)">the first peak is observed during infancy</span>, <span style="color: rgb(44, 130, 201)">the second during puberty</span>, and <span style="color: rgb(26, 188, 156)">the third in middle-aged and elderly men </span>(Nachtigall, 1965; Knorr & Bidlingmaier, 1975; Nuttall, 1979). The purpose of the assessment of GM should be the <span style="color: rgb(184, 49, 47)">detection of underlying pathological conditions </span>and the <span style="color: rgb(184, 49, 47)">discrimination </span>from other breast lumps that <span style="color: rgb(184, 49, 47)">mimic GM</span>, particularly <span style="color: rgb(184, 49, 47)">breast cancer.</span></em></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>CONCLUSIONS </strong></p><p></p><p><span style="color: rgb(0, 0, 0)"><em><strong>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.</strong></em></span> <span style="color: rgb(0, 0, 0)"><em><strong>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 </strong></em></span><strong><em>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.</em></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>Table 1 Causes of gynecomastia</strong></p><p><strong></strong></p><p><strong>Cause</strong></p><p><strong></strong></p><p><strong><span style="color: rgb(184, 49, 47)">Physiological and idiopathic </span></strong></p><p><strong></strong></p><p><strong><em>• Neonatal/infancy </em></strong></p><p><em><strong>• Pubertal </strong></em></p><p><strong><em>• Middle or advanced age </em></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong><span style="color: rgb(184, 49, 47)">Pathological </span></strong></p><p><strong></strong></p><p><strong><em>• Medications </em></strong></p><p><em><strong>• Primary testosterone deficiency (particularly Klinefelter syndrome) </strong></em></p><p><em><strong>• Secondary testosterone deficiency </strong></em></p><p><em><strong>• Hyperthyroidism</strong></em></p><p><em><strong>• Neoplasms</strong></em></p><p><em><strong>• Testicular: originating from germ (secreting forms), Leydig or Sertoli cells</strong></em></p><p><em><strong>• Adrenal: androgen- or estrogen-secreting tumors </strong></em></p><p><em><strong>• Ectopic production of hCG </strong></em></p><p><em><strong>• Hepatic causes, malnutrition </strong></em></p><p><em><strong>• Renal causes </strong></em></p><p><em><strong>• Rare causes </strong></em></p><p><em><strong>• Enzymatic defects of testosterone production </strong></em></p><p><em><strong>• Androgen insensitivity syndromes </strong></em></p><p><em><strong>• True hermaphroditism</strong></em></p><p><em><strong>• Excessive extra-glandular aromatase activity </strong></em></p><p><strong><em>• Environmental polluting substances</em></strong></p></blockquote><p></p>
[QUOTE="madman, post: 148807, member: 13851"] [B]ABSTRACT [COLOR=rgb(184, 49, 47)]Background[/COLOR][/B] [I]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.[/I] [B][COLOR=rgb(184, 49, 47)]Objectives[/COLOR][/B] [I]The aim was to provide clinical practice guidelines for the evaluation and management of GM.[/I] [B][COLOR=rgb(184, 49, 47)]Materials and methods[/COLOR][/B] [I]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.[/I] [B][COLOR=rgb(184, 49, 47)]Results[/COLOR][/B] [I]A set of five statements and fifteen clinical recommendations was formulated.[/I] [B][COLOR=rgb(184, 49, 47)]Conclusions[/COLOR][/B] [I]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.[/I] [B]SUMMARY OF STATEMENTS (S) AND RECOMMENDATIONS (R) [COLOR=rgb(184, 49, 47)][I]S1. [/I][/COLOR][I]Gynecomastia (GM) is a [/I][COLOR=rgb(184, 49, 47)][I]benign proliferation of glandular tissue of the breast in males.[/I][/COLOR][I] [/I][/B] [I] [B][COLOR=rgb(184, 49, 47)]S2. [/COLOR][COLOR=rgb(0, 0, 0)]GM of infancy is a [/COLOR][COLOR=rgb(184, 49, 47)]common condition[/COLOR] that usually resolves [COLOR=rgb(184, 49, 47)]spontaneously[/COLOR], typically within [COLOR=rgb(184, 49, 47)]the first year of life. S3.[/COLOR][/B] [B][COLOR=rgb(0, 0, 0)]GM of puberty is a [/COLOR][COLOR=rgb(184, 49, 47)]common condition[/COLOR], affecting approximately [COLOR=rgb(184, 49, 47)]50% of mid-pubertal boys[/COLOR]; in more than [COLOR=rgb(184, 49, 47)]90% of cases[/COLOR], it resolves [COLOR=rgb(184, 49, 47)]spontaneously [/COLOR]within [COLOR=rgb(184, 49, 47)]24 months. S4. [/COLOR]The prevalence of [COLOR=rgb(184, 49, 47)]GM in adulthood[/COLOR] increases with [COLOR=rgb(184, 49, 47)]increasing age[/COLOR]; proper investigation may reveal [COLOR=rgb(184, 49, 47)]an underlying pathology[/COLOR] in approximately [COLOR=rgb(184, 49, 47)]45–50%[/COLOR] of the cases. [COLOR=rgb(184, 49, 47)]S5.[/COLOR][/B] [/I][B][I]Male breast cancer is [/I][COLOR=rgb(184, 49, 47)][I]rare[/I][/COLOR][I]; GM should not be considered a [/I][COLOR=rgb(184, 49, 47)][I]premalignant condition[/I][/COLOR][I]. [/I] INTRODUCTION—DEFINITION [/B] [I][B]Gynecomastia (GM) is a [/B][/I][COLOR=rgb(184, 49, 47)][B][I]benign proliferation of glandular tissue of the breast in men.[/I][/B][/COLOR][B][I] The term is derived from the Greek words ‘gyneka’ (woman) and ‘mastos’ (breast). GM can be [COLOR=rgb(184, 49, 47)]unilateral or bilateral[/COLOR], most commonly [COLOR=rgb(184, 49, 47)]the latter [/COLOR](Nuttall, 1979; Mieritz et al., 2017). GM has to be distinguished from [COLOR=rgb(184, 49, 47)]pseudogynecomastia (i.e., lipomastia)[/COLOR], which is characterized by [COLOR=rgb(184, 49, 47)]excess fat deposition[/COLOR] without [COLOR=rgb(184, 49, 47)]glandular proliferation.[/COLOR] GM is a common condition with a prevalence that varies widely between [COLOR=rgb(184, 49, 47)]32 and 65%[/COLOR], depending on the [COLOR=rgb(184, 49, 47)]age of the subjects[/COLOR] studied and the [COLOR=rgb(184, 49, 47)]criteria[/COLOR] used for GM definition (Braunstein, 2007). GM shows [COLOR=rgb(184, 49, 47)]three discrete peaks[/COLOR] throughout a man’s lifespan: [COLOR=rgb(184, 49, 47)]the first peak is observed during infancy[/COLOR], [COLOR=rgb(44, 130, 201)]the second during puberty[/COLOR], and [COLOR=rgb(26, 188, 156)]the third in middle-aged and elderly men [/COLOR](Nachtigall, 1965; Knorr & Bidlingmaier, 1975; Nuttall, 1979). The purpose of the assessment of GM should be the [COLOR=rgb(184, 49, 47)]detection of underlying pathological conditions [/COLOR]and the [COLOR=rgb(184, 49, 47)]discrimination [/COLOR]from other breast lumps that [COLOR=rgb(184, 49, 47)]mimic GM[/COLOR], particularly [COLOR=rgb(184, 49, 47)]breast cancer.[/COLOR][/I] CONCLUSIONS [/B] [I][B][/B][/I] [COLOR=rgb(0, 0, 0)][I][B]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.[/B][/I][/COLOR][I][B] [/B][/I][COLOR=rgb(0, 0, 0)][I][B]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 [/B][/I][/COLOR][B][I]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.[/I] Table 1 Causes of gynecomastia Cause [COLOR=rgb(184, 49, 47)]Physiological and idiopathic [/COLOR] [I]• Neonatal/infancy [/I][/B] [I][B]• Pubertal [/B][/I] [B][I]• Middle or advanced age [/I] [COLOR=rgb(184, 49, 47)]Pathological [/COLOR] [I]• Medications [/I][/B] [I][B]• 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 [/B][/I] [B][I]• Environmental polluting substances[/I][/B] [/QUOTE]
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Gynecomastia Evaluation and Treatment: EAA clinical practice guidelines
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