Gynecomastia

Gynaecomasty is no disease sui generis, but a symptom which may underlie different causes. Steroidal substances, above all oestrogens play a dominating role in these cases. Diagnostic and therapeutic measures must comply with the known causal factors. The gynaecomasty during puberty exhibits a high spontaneous retrogression rate. Only seldom an operative correction becomes necessary.     

Gynecomastia.

Gynecomastia is common and may be asymptomatic. In most cases, a thorough history and physical examination, along with limited laboratory investigations, can help to exclude breast malignancy and serious underlying endocrine or systemic disease. Careful clinical observation may be all that is required in many cases, because gynecomastia often resolves spontaneously. Because gynecomastia is usually caused by an imbalance of androgenic and estrogenic effects on the breast, medical therapy may include antiestrogens, androgens, or aromatase inhibitors. Surgery is useful in the management of patients with long-standing symptomatic gynecomastia or when medical therapy is not successful.     

Gynecomastia and cirrhosis of the liver

Hepatic cirrhosis is frequently listed as a cause of gynecomastia. We found previously that in hospitalized men the prevalence of gynecomastia was correlated with body mass index and with age. The mean body mass index and the prevalence of gynecomastia in the cirrhotic subjects (nonedematous) did not differ from those in the overall population. Because more severely cirrhotic subjects with ascites, peripheral edema, or both usually are thin, we examined 18 more severely cirrhotic subjects and 18 nonobese (mean body mass index, 20.9 +/- 0.6 kg/m2), age-matched control subjects for the prevalence of palpable gynecomastia. Total testosterone, free testosterone, total estrogen, and estradiol concentrations also were measured. Fifty percent of the control subjects had gynecomastia. Breast tissue diameter was correlated with body mass index. The prevalence of gynecomastia in the cirrhotic subjects was 44%. In these subjects no significant correlation was noted between breast tissue diameter and body mass index, presumably because the body mass index was increased owing to fluid retention. The results could not be accounted for based on medications. Serum free testosterone concentrations were lower in the cirrhotic patients than in the controls (0.11 +/- 0.02 vs 0.22 +/- 0.03 nmol/L). The total estrogen-free testosterone ratio was higher in cirrhotic patients (10.3 +/- 2.5 vs 2.6 +/- 0.5), as was the estradiol-free testosterone ratio (2.2 +/- 0.7 vs 0.5 +/- 0.1). These ratios did not differ significantly in cirrhotic subjects with and without gynecomastia. Therefore, these data indicate that factors other than the estrogen-testosterone ratio are playing a role in the development of gynecomastia in both cirrhotic subjects and controls or that breast tissue sensitivity to an elevated estrogen-testosterone ratio is highly varible.     

Gynecomastia after chemotherapy for lymphoma

Although development of gynecomastia in a patient with cancer may indicate persistence or regrowth of a tumor, we studied three patients with lymphoma in whom development of gynecomastia during or after chemotherapy did not portend a poor outcome. In all patients, serum testosterone levels were normal, serum luteinizing hormone (LH) levels were high-normal or elevated, and serum follicle-stimulating hormone (FSH) levels were clearly elevated. The serum estradiol level of one patient was elevated at the onset of gynecomastia, but it fell to normal as the gynecomastia resolved spontaneously over a three-month period during which the patient received no chemotherapy. In a second patient, gynecomastia resolved over a period of eight months while the patient continued on maintenance chemotherapy, and he remains clinically well in remission 21/2 years after onset of gynecomastia. In the third patient, gynecomastia developed while the patient was in complete remission and off of all therapy, and it remained unchanged for the duration of a 21/2-year remission without therapy. Gynecomastia after chemotherapy for lymphoma is not an ominous prognostic sign and does not necessarily indicate the need for alteration of the treatment regimen.     

Gynecomastia in a hospitalized male population

Two hundred fourteen hospitalized adult men, aged 27 to 92, were examined for the presence of palpable gynecomastia. The overall prevalence was 65 percent. Gynecomastia was bilateral in all but 11 subjects. The prevalence was greatest in the 50 to 69-year-old group (72 percent). It was lower in the 70- to 89-year-old (47 percent, p less than 0.01) and the 30- to 49-year-old (54 percent, p less than 0.05) groups. The prevalence of gynecomastia increased with body mass index. More than 80 percent of those with a body mass index of 25 kg/m2 or greater had gynecomastia. The diameter of breast tissue also increased with increasing body mass index (r = 0.52, p less than 0.001). The decreased prevalence of gynecomastia after the seventh decade could be explained by the lower body mass index in this group. The youngest group did not have a lower body mass index; an independent age factor appeared to be present. Because of the high overall prevalence of gynecomastia, independent effects of diseases or medications could not be determined. It is concluded that palpable bilateral gynecomastia is present in most older men, is correlated with the amount of body fat, and does not require clinical evaluation unless symptomatic or of recent onset.     

Gynecomastia and sexual impotence associated with methotrexate treatment

Methotrexate (MTX) is the disease modifying antirheumatic drug most frequently used for rheumatoid and psoriatic arthritis (PsA). Several reports associate sexual dysfunction to MTX use. We describe 2 cases of sexual impotence and gynecomastia in patients with PsA treated with MTX. Although the mechanism underlying MTX induced sexual dysfunction is unknown, the potential consequences should be taken in account in view of the steady increase in the number of patients.