Gynecomastia Key Point

• Although breast cancer is an uncommon cause of breast enlargement in men, this diagnosis must be ruled out because the prognosis is worse for men diagnosed with breast cancer than for women.

Gynecomastia refers to a benign enlargement of the male breast resulting from proliferation of breast glandular tissue. When the male breast is enlarged from adipose tissue, it is called lipomastia or pseudogynecomastia and is not caused by proliferation of breast tissue. Gynecomastia can be unilateral or bilateral, or it can be asymmetric. Any palpable breast tissue in men is abnormal except for three physiologic situations: transient gynecomastia of the newborn (caused by maternal or placental estrogens), pubertal gynecomastia (observed in 40%-70% of adolescent boys, resolving by age 18), and gynecomastia that occasionally occurs in older adult men (resulting from changes in estrogen and androgen metabolism). Gynecomastia can also be iatrogenic as a result of some medications.

Gynecomastia occurs as concentric, palpable glandular tissue beneath the areola that is not fixed to underlying structures. Prevalence is highest in men 50 to 80 years old and generally presents as bilateral. The cause of pathologic gyneco-mastia is a relative or absolute increase in circulating estrogen compared with androgen. Careful history (including drugs, legal and illegal) and physical examination can usually rule out Klinefelter's syndrome, androgen insensitivity syndrome, and testicular tumors (Griffin and Wilson, 1995) (Table 35-6).

Breast cancer is very uncommon in men but does occur, and generally the prognosis is much worse for men than for women diagnosed with breast cancer. Typically, breast cancer will present as a painless, central breast lump that may advance to pain, bloody discharge, and skin ulceration. Diagnosis is confirmed by biopsy (Wise et al., 2005).

Treatment of nonphysiologic gynecomastia involves removal of the offending drug or correction of the underlying condition, either of which usually results in regression of the glandular breast tissue. If the gynecomastia persists, a trial of antiestrogen therapy may be considered. Gynecomas-tia present for more than 1 year will undergo fibrosis and usually will not respond to medications. Surgical correction is required for alleviation of symptoms.

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