GYNECOMATIA male breast enlargement

*Excess estrogen action * Increased Estrogen / androgen ratio

True gynecomastia : glandular breast tissue >4 cm often tender distinguished from excess adipose tissue *firmer *fibrous-like cords.

Pubertal causes high estradiol to testosterone ratio and estrone to adrenal androgens ( Eearlier rise in estrogen than testostrone) Local formation of estrogen ?

Gynecomastia of Aging _ Decreases testosterone _ increase peripheral aromatization Exclusion: * take medications * concurrent disorders

Physiologic Gynecomastia Gynecomastia in newborn Adolescent gynecomastia Gynecomastia of aging Testostrone deficiency Congenital defects Congenital anorchia Klinefelter's Androgen resistance testosterone synthesis Secondary testicular failure viral orchitis, trauma, castration, neurologic, granulomatous, renal failure

Increased estrogen production : * Increased testicular estrogen secretion Testicular tumors Bronchogenic carcinoma & other tumors producing hCG True hermaphroditism * Increased extraglandular aromatase liver tumors, adrenal tumors, inherited disorder.

* Increased substrate for aromatase increased androstenedione for extraglandular estrogen formation CAH hyperthyroidism adrenal tumors Low catabolism of androstenedione liver disease liver disease Obesity increased aromatization of androgen precursors to estrogens.

Drugs Estrogens, drugs act like estrogen diethylstilbestrol, estrogen-containing cosmetics, birth control pills, digitalis, estrogen-contaminated foods, phytoestrogens) Drugs enhance endogenous estrogen formation gonadotropins, clomiphene Drugs inhibit testosterone synthesis or action (ketoconazole, metronidazole, cimetidine, etomidate, alkylating agents, cisplatin, flutamide, spironolactone) Drugs that act by unknown mechanisms (busulfan, isoniazid, methyldopa, calcium channelblocking agents, captopril, tricyclic antidepressants, penicillamine, diazepam, marijuana, heroin)

Idiopathic Gynecomastia 3/4 of cases

work-up 1. careful drug history 2.physical examinati on asymmetrical testes raise the possibility of testicular tumors small testes bilaterally suggests testicular insufficiency karyotype to exclude Klinefelter syndrom..

3. Evaluation of liver function. 4. endocrine work-up LH and testosterone. DHEAS & urinary 17 ketosteroids (elevated in adrenal states) plasma estradiol hCG elevated with testicular tumors

more extensive evaluation: –recent onset –rapid growth –tender tissue

The relative risk of breast cancer is increased in men with gynecomastia

TREATMENT primary cause can be corrected, breast enlargement usually subsides over several months. long duration surgery is the most effective therapy. psychologic cosmetic problemscontinued growth or tenderness, suspected malignancy Indications for surgery include severe psychologic or cosmetic problems, continued growth or tenderness, or suspected malignancy. antiestrogens tamoxifen (20 mg/d) reduces pain and breast size ( in two-thirds). Aromatase inhibitors in early proliferative phase. testolactone, anastrazole, letrozole, or fromestane

Medical management is successful when is gynecomastia recent onset  Testosterone administration inconsistent effects in Klinefelter but cause dramatic improvement in other forms of testicular failure (e.g., anorchia, viral orchitis ).  tamoxifen and clomiphene.  Aromatase inhibitor  Danazol weak androgen inhibits gonadotropin secretion.  dihydrotestosterone