Gynaecomastia

Gynaecomastia is a common disease of the male breast where there is a benign glandular enlargement of that breast at some time in the male's life. It usually consists of the appearance of a flat pad of glandular tissue beneath a nipple which becomes tender at the same time. The development may be unilateral or bilateral. There is rarely a continued growth of the breast tissue; ordinarily the process is of brief duration and stops short of the production of permanent enlargement of the breast.

A great number of patients who suffer from this disease have a disturbance in the proper ratio of androgen and estrogen levels. The normal ratio of the two hormones in plasma is approximately 100:1. "The etiology of gynaecomastia in patients with a known documented cause appears to be related to increased estrogen stimulation, decreased testosterone levels, or some alteration of the estrogens and androgen so that the androgen-estrogen ratio is decreased"(Williams 373). From this information it was discovered that there is also a lower ratio of weaker adrenal androgens (delta 4-androstenedione and dehydroepiandrosterone) found in youths with this disease. It was once believed that there was an imbalance in the ratios of testosterone to estrogen or estradiol, but this is now known to be untrue.

There are three areas the can be attributed to the cause of gynaecomastia: physiologic, pathologic and pharmacologic. "Enlargement of the male breast can be a normal physiologic phenomenon at certain stages of life or the result of several pathologic states."(Isselbacher, 2037) In the case of physiologic gynaecomastia the disease can occur in a newborn baby, at puberty or at any time in a man's life. In the newborn, transient enlargement of the breast is due to the action of maternal and/or placental estrogens. The enlargement usually disappears within a few weeks. Adolescent gynaecomastia is common during puberty with the onset at the median age of 14. It is often asymmetrical and frequently tender. It regresses so that by the age of 20 only a small number of men have palpable vestiges of gynaecomastia in one or both the breasts. Gynaecomastia of the aging also occurs in otherwise healthy men. Forty percent or more of aged men have gynaecomastia. One explanation is the increase in age in the conversion of androgens to estrogens in extraglandular tissues. Drug therapy and abnormal liver functioning can also be causes of gynaecomastia in older men.

When the disease is pathologic the patient can have increased estrogen secretions, increased conversion of androgens to estrogens or decreased androgen activity due to a failure in protein receptors. Increased estrogen secretions are found in such diseases and disorders as Hermaphroditism, Kleinfelter's syndrome, congenital adrenal hyperplasia, and adrenal carcinoma or testicular tumors. In the second case some examples are adrenal carcinoma, liver disorders, malnutrition and thyroidtoxicosis. Decreased androgen activity can be found in complete testicular feminization, incomplete testicular feminization and Reifenstein's syndrome.

Many drugs can cause gynaecomastia by several mechanisms. The drugs can either act directly as estrogens or cause and increase in plasma estrogen levels. "Boys and young men are particularly sensitive to estrogen, and can develop gynaecomastia after the use of dermal ointments containing estrogen or after the ingestion of milk or meat from estrogen-treated animals."(Isselbacher, 2038) Some examples of drugs that may have cause gynaecomastia include Cannabinoids (methane and marijuana), Psychotropics (pheno-thiazine, butyrophenone and reserpine), Antihypertensives (reserpine, alpha-methyldopa and spironolactone), Cardiac (digitalis), Gastrointestinal (cimetidine, metoclopramide and domperidone), Antituburculous (isoniazid), Cytoxic (cyclophospha-mide, mustine, vincristine and mitotane) and Hormonal (sex steroids, gonadotropins and antiandrogens). Use of these drugs, however, will rarely cause gynaecomastia. In some instances, the feminization is due to effects of drugs on liver functions.

There are very few signs and symptoms that are associated with this disease. Signs may appear at any time in a male's life, although the most common time of onset is during puberty. At the first indication of the disease the patient will feel pain and tenderness in the breast area due to the rapid development of the breast. The breasts grow because of the enlargement of the glandular tissue. "The concentric arrangement of the connective tissue around the ducts is a characteristic feature of the active phase of gynaecomastia."(Delany, 67) The enlargement of the breast is usually bilateral but some cases have unilateral enlargement. In the case of unilateral enlargement, "Induration, fixation, or bloody discharge should raise the possibility of carcinoma."(Wyngaarden, 1450) Carcinoma is a cancerous growth of the epithelial tissues. It may be hard to distinguish true breast tissue from masses of adipose tissue without true enlargement (lipomastia). In such cases, a real case of gynaecomastia can be distinguished by mammography or by sonography.

Early gynaecomastia is characterized by "proliferation of both the fibroblastic stroma and the duct system, which elongates, buds, and duplicates. As the disease progresses, fibrosis and hyalinization are associated with the regression of epithelial proliferation." Eventually the number of ducts decreases, resolution occurs by reduction in size of epithelial content leaving temporary hyaline bands behind. (Isselbacher, 2037)

A satisfactory diagnosis can be made in only half or less of patients referred for gynaecomastia. This is a result of insufficient diagnostic techniques, causes that are still undefined and/or difficult to diagnose, or in some instances, gynaecomastia may be normal rather than due to a pathologic state. This disease should only be worked up only if there is a negative drug history, if the breast is tender (indicating rapid growth), or if the breast mass is larger than 4 cm in diameter. A decision to perform an endocrine evaluation depends on the clinical context. An example would be gynaecomastia associated with signs of under androgenization.

Obesity can often be confused with gynaecomastia. To prevent this, the doctor can palpate the breast to see if there is a lack of glandular elements that would indicate only obesity. Once the signs become evident, the doctor needs to assess the patient with a number of test to give a proper diagnosis since many other diseases and disorders are commonly involved. This can be done with a physical examination. The head and neck area may show signs of a pituitary tumor or goiter which is found in Graves disease. The skin and abdomen may reveal signs of liver failure and the

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