What is the pathology and management of gynecomastia?

Pathology and Management of Gynecomastia

Gynecomastia is defined as benign glandular breast tissue enlargement in males, caused by an imbalance between estrogen and androgen action, and requires a systematic approach for diagnosis and management based on etiology. 1

Pathophysiology

Gynecomastia develops due to:

• Hormonal imbalance: Increased estrogen action or decreased androgen action at breast tissue level 1, 2
• Key distinction: True gynecomastia involves glandular tissue proliferation, while pseudogynecomastia is fatty tissue deposition without glandular involvement 1

Common Causes

1. Physiologic causes:

   • Neonatal period (maternal hormones)
   • Puberty (transient hormonal fluctuations)
   • Aging/senescence (declining testosterone) 3, 4

2. Pathologic causes:

   • Medications:
     • Antipsychotics (via hyperprolactinemia) 1
     • Spironolactone (well-documented association) 1
     • 5-α reductase inhibitors (finasteride, dutasteride) 1
     • Phenytoin (affects hormone metabolism) 1
   • Medical conditions:
     • Hypogonadism
     • Hyperthyroidism
     • Cirrhosis
     • Renal insufficiency 2, 3
   • Tumors: Testicular tumors, adrenal tumors (rare) 2

Diagnostic Approach

1. Clinical assessment:

   • Differentiate true gynecomastia from pseudogynecomastia
   • Rule out male breast cancer (rare but important consideration) 1
   • Most cases can be diagnosed clinically without imaging 1

2. Laboratory evaluation (based on clinical suspicion):

   • Hormone levels: Testosterone, estradiol, prolactin
   • Liver and kidney function tests
   • Thyroid function tests 5

3. Imaging (when indicated):

   • Mammography or ultrasound to distinguish gynecomastia from malignancy
   • Testicular ultrasound if testicular tumor suspected 1

Management Strategy

1. Address Underlying Cause

• Discontinue contributing medications when possible 3
• Treat underlying medical conditions 2
• For medication-induced cases:
  • For antipsychotic-induced: Consider switching to prolactin-sparing alternatives (aripiprazole, clozapine, quetiapine) 1
  • For spironolactone-induced: Consider eplerenone (25-50 mg daily initially) or amiloride (10-40 mg daily) as alternatives 1

2. Observation and Reassurance

• Pubertal gynecomastia: Self-resolving in most cases, observation is appropriate 1, 4
• Recent-onset cases: May resolve with treatment of underlying cause 3

3. Medical Therapy

• For recent-onset, painful gynecomastia:
  • Selective estrogen receptor modulators may be beneficial in early proliferative phase (30% response rate) 1, 4
  • Not effective for chronic established cases (>12 months) 1
  • For hypogonadism: Testosterone replacement 2

4. Surgical Management

• Indications:

  • Long-standing gynecomastia (>12-24 months)
  • Failure of medical therapy
  • Significant psychological distress
  • Suspected malignancy 1

• Surgical options:

  • Liposuction (for predominant fatty component)
  • Direct excision (for predominant glandular tissue)
  • Combined approaches 1

Special Considerations

• Psychological impact: Gynecomastia can cause significant anxiety and psychosocial discomfort 5
• Malignancy risk: Male breast cancer is rare (<1% of all breast cancers) but should be considered, especially in older men (median age 63) 1
• Long-term effects: Untreated hyperprolactinemia may lead to bone mineral density loss 1

Common Pitfalls to Avoid

• Failing to distinguish true gynecomastia from pseudogynecomastia
• Overlooking medication causes
• Delaying treatment in cases causing significant psychological distress
• Attempting medical therapy in chronic established cases
• Missing rare but serious underlying causes like testicular tumors