Natural Treatment Of Gynecomastia Exercise

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Aldosterone Antagonists

Aldosterone antagonists such as spironolactone, and eplerenone (Fig. 5-3) modulate vascular tone through a variety of mechanisms besides diuresis. Their potassium-sparing effects mediated through aldosterone antagonism, complement the potassium-wasting effects of more potent diuretics such as thiazide or loop diuretics. Patients with resistant hypertension (with or without primary aldosteronism) experience significant BP reductions with the addition of low-dose spironolactone (12.5-50 mg day) to diuretics, ACE inhibitors, and ARBs.68 Although functional in this circumstance, it is important to recognize their potential to enhance the risk for hyperkalemia when used in conjunction with ACE inhibitors, ARBs, and now potentially DRIs. This is particularly relevant for individuals with comorbidities associated with reduced renal function or those receiving either potassium supplements or NSAIDs. The most commonly used potassium-sparing diuretic is spironolactone however, eplerenone has...

Clinical Manifestations and Diagnosis

Clinically cirrhosis may be latent (5 to 10 percent of cases), well compensated, or active and decompensated. The clinical features depend on the underlying etiology and the appearance of the two cardinal manifestations, portal hypertension and hepatocellular failure. As cirrhosis usually evolves over a period of several years, the course may be intermittent with therapeutic intervention such as with corticosteroids or with temporary cessation of injury. During the early phase of disease, patients often present with nonspecific symptoms and signs including malaise, lethargy, anorexia, loss of libido, and weight gain. Incidental laboratory findings of abnormal liver function tests, positive hepatitis B serology and hypergammaglobulinemia, and incidental physical findings such as icterus, hepatomegaly, gynecomastia, and spider nevi may point to the presence of cirrhosis. With the progression of disease, portal hypertension and hepatocellular failure invariably supervene. These two...

Classification and symptoms of hypogonadism

Voice mutation will not occur. The frontal hairline will remain straight without lateral recession, beard growth is absent or scanty, the pubic hairline remains straight. Hemoglobin and erythrocytes will be in the lower normal to subnormal range. Early development of fine perioral and periorbital wrinkles are characteristic. Muscles remain underdeveloped. The skin is dry due to lack of sebum production and free of acne. The penis remains small, the prostate is underdeveloped. Spermatogenesis will not be initiated and the testes remain small. If an ejaculate can be produced it will have a very small volume. Libido and potency will not develop. A lack of testosterone occurring in adulthood cannot change body proportions, but will result in decreased bone mass and osteoporosis. Early-on lower backache and, at an advanced stage, vertebral fractures may occur. Once mutation has occurred the voice will not change again. Lateral hair recession and baldness...

Sex Chromosomal Abnormalities

Affected children have small, firm testes, and adult patients have azoospermia. y This disorder is a common cause of primary hypogonadism and male infertility. Although a male phenotype is typical, delayed or poorly developed secondary sex characteristics are present, and about half the patients have varying degrees of gynecomastia, androgen deficiency, and eunuchoid features. These patients tend to be tall and have long legs, and adults have an increased incidence of pulmonary disease, varicose veins, diabetes mellitus, and breast cancer. y Serum levels of follicle-stimulating hormone and luteinizing hormone are increased early in the second decade, whereas testosterone concentrations are normal to low. Plasma levels of estradiol are normal or high. Affected individuals have cognitive abnormalities including impaired auditory sequential memory with delayed language development and associated learning disorders. y There is a slight lowering of the mean IQ and an increased incidence of...

Today he presents to the clinic with bone pain and a serum PSA of 67 ngmL 67 mcglX

The combination of estramustine (280 mg three times a day, days 1-5) and do-cetaxel 60 mg m on day 2 every 3 weeks also improves survival in hormone-refractory metastatic prostate cancer.50 Estramustine causes a decrease in testosterone and a corresponding increase in estrogen therefore, the adverse effects of estramustine include an increase in thromboembolic events, gynecomastia, and decreased libido

Medical Management versus Operation

Inhibition of gastric acid secretion in many Z-E syndrome patients was made possible with the introduction of the H2 receptor antagonist cimetidine.18 Previously, TG had been necessary to achieve long-term survival of patients with Z-E syndrome. After cimetidine became available in 1977, some argued for medical management alone, claiming that the mortality for TG was inordinately high and finding and removing all gastrinoma tissue were unlikely.89 However, there were failures of medical management and antiandrogen side effects at high cimetidine doses (> 4.8 g day), such as breast tenderness, gynecomastia, and impotence in men, which continued to fuel the controversy. Some surgeons still favored TG when not all tumor could be removed.21 The introduction of two new H2 blockers, ranitidine and famotidine, which inhibited gastric acid secretion more effectively and did not have antiandrogen side effects, made medical therapy even more attractive.

Side effects and acceptability

Possible side effects of hormonal male contraception might be caused by too high or too low testosterone levels or by additional substances. Decreased testicular volumes reflecting suppression of spermatogenesis is inherent to all hormonal methods, but is not considered a serious effect by the volunteers as long as sexual function remains unaltered. Weight gain is most likely an anabolic effect of testosterone. Due to the high peak serum testosterone levels caused by testosterone enanthate in the earlier studies, acne and mild gynecomastia could be observed in individual cases. Except for local skin reactions, side effects of GnRH analogues are mainly attributable to decreased testosterone levels, not sufficiently compensated for by testosterone supplementation. Sweating and in particular, nocturnal sweating is a feature of some added progestins (see Table 23.2).

Adrenocortical Carcinoma

Adrenocortical carcinoma is a rare malignant disease with a dismal prognosis and an estimated incidence of 0.5 cases per 1 million individuals per year.45 Patients with nonfunctioning tumors have manifestations attributable to a large abdominal mass. Forty percent to 70 of adrenocortical carcinomas are secretory,4546 and these patients usually present with clinical features of hormone excess. The clinical features depend on the predominant excess steroid production glucocorticoid-secreting tumors cause Cushing's syndrome androgen-secreting tumors lead to virilization mineralocorticoid-secreting tumors cause hypertension and hypokalemia and estrogen-secreting tumors result in gynecomastia and testicular atrophy in men and menstrual irregularities and precocious puberty in girls.45,46 Diagnosis is confirmed by elevated levels of urinary steroids. Eighty percent of patients demonstrate a suprarenal mass on CT scan.45-46 Pooled data from several institutions confirm that more than 60 of...

Antiandrogens Bicalutamide Flutamide and Nilutamide

Flashes, gynecomastia, and decreased libido. Flutamide tends to be associated with more diarrhea and requires three-times-daily administration, whereas bicalutamide is dosed once daily. Nilutamide may cause interstitial pneumonia and is associated with the visual disturbance of delayed adaptation to darkness. Initially, luteinizing hormone-releasing hormone (LHRH) agonists increase levels of leutinizing hormone and follicle-stimulating hormone, but testosterone and estrogen levels are decreased because of continuous negative-feedback inhibition. Major side effects are testicular atrophy, decreased libido, gynecomastia, and hot flashes. Leuprolide is well absorbed, with a terminal half-life of 2.9 hours, whereas goserelin has a terminal half-life of 4.9 hours. Goserelin is injected as a pellet under the skin, so subcutaneous injection of lidocaine prior to administration helps to decrease the pain associated with goserelin administration. Numerous dosage forms are available for...

The Written Physical Examination

Left Lower Abdominal Tenderness

Breasts Mild gynecomastia, L > R no masses or discharge present. Summary Mr. Henry is a 65-year-old man in no acute distress. Physical examination reveals systolic hypertension, retinal changes suggestive of sustained hypertension, a mild cataract in his right eye, a conductive hearing loss in his right ear, tonsillopharyngitis, and gynecomastia. Cardiac examination reveals aortic insufficiency. Peripheral vascular examination reveals possible atherosclerotic disease of the right carotid artery and mild venous disease of the lower extremities. The patient has a right, easily reducible inguinal hernia. A left-sided varicocele is present. Mild osteoarthritis of the hands is also present.

Mecanism Of Centripetal Lipid Accumulation Supraclavicular Fat And Face

Seborrhea and hirsutism may be present. In men the most common clinical manifestation of hyperprolactinemia is the progressive loss of libido and impo-tency. Oligospermia and other physical signs of hypogonadism (i.e., muscular hypotrophy, increased abdominal fat) are commonly reported. Galactorrhea or gynecomastia is present in 15 to 30 of male patients.2 Prolactinomas among men and postmenopausal women are often macroadenomas (> 1 cm), because changes in libido are not detected early. Hyperpro-lactinemia in both sexes can also be associated with anxiety, depression, fatigue, emotional instability, and hostility.10,11

Hyperprolactinemia and Prolactinomas

Hypersecretion of prolactin may be physiologic or pathologic in origin. Physiologic stimulators include exercise, pain, breast stimulation, sexual intercourse, general anesthesia, and pregnancy. Pathologic causes of hyperprolactinemia include prolactinomas, decreased dopaminergic inhibition of prolactin secretion through pharmacologic agents, and decreased clearance of prolactin. Early manifestation of prolactin hypersecretion is galactorrhea and menstrual irregularities, notably amenorrhea, in women and erectile dysfunction or loss of libido in men. Rarely, galactorrhea with gynecomastia can occur in men. These patients are at risk of developing osteoporosis secondary to hypogo-nadism as well as a result of the direct inhibitory effect of prolactin on bone formation. Galactorrhea is rarely found in postmenopausal women with hyperprolactinemia, in whom mass effect of prolactinomas may cause the principal

Complications of chemotherapy

A number of case reports of unusual complications following chemotherapy for testicular cancer exist. Osteonecrosis of the femoral head was reported in three testicular cancer patients following BEP chemotherapy and treatment with the commonly prescribed antiemetic ondansetron, a serotonin receptor antagonist, in conjunction with dexamethasone 101 . Bilateral spontaneous pneumothorax was reported after implementation of a salvage chemotherapy regimen 102 . One case of gynecomastia has been reported in a young man in complete remission with normal values of beta-human chorionic gonadotropin (BHCG) following BEP combination chemotherapy 103 . This postchemotherapy gynecomastia resolved spontaneously over an 8-month time period.

Generalized androgen insensitivity in humans

Partial Androgen Insensitivity Syndrome

Partial impairment of AR function is usually associated with partial androgen insensitivity syndrome (PAIS). The considerable variability in the degree of impaired AR activity accounts for a wide clinical spectrum of external underviril-ization observed in PAIS. This may range from a female habitus with only a small degree of virilization as partial fusion of labioscrotal folds and minimal enlargement of the clitoris to patients with considerable degree of virilization with male habitus, gynecomastia, female pattern of secondary hair distribution, and genital malformations such as hypospadias (Hiort etal. 1993 1996 Holterhus etal. 1997 2000). Phenotype of external genitalia may be graded according to the scale of Sinnecker etal. (1997) (Fig. 3.3). The minimal androgen insensitivity syndrome (MAIS) describes individuals with a normal male habitus without genital malformation with only a slight masculin-ization deficit such as high pitched voice and gynecomastia associated with sub- or...

Ascites In Pathophysiology In Book

Portal Vein Anatomy

Changes in steroid hormone production, as well as changes in the conversion and handling of steroids are also prominent features of cirrhosis. These changes can result in decreased libido, gynecomastia (development of breast tissue in men), testicular atrophy, and features of feminization in male patients. Another deleterious effect of changes in sex hormone metabolism is the development of spider angiomata (nevi). Spider angiomata are vascular lesions found mainly on the trunk. The lesion has a central arteriole (body) surrounded by radiating legs. When blanched, the lesions fill from the center body outward toward the legs. Spider angiomata are not specific to cirrhosis, but the number and size do correlate with disease severity, and their presence relates to risk of variceal hemorrhage.12

What are some of the side effects of hormonal therapy and how are they treated

Breast Swelling and Tenderness (Gynecomastia) Antiandrogens may cause swelling and tenderness in the breast area (gynecomastia). This can affect one or both breasts and can range from mild sensitivity to ongoing pain. About one-half of men taking antiandro-gens will develop breast swelling and between 25 and 75 will note some breast tenderness. Gynecomastia is not as common in men who have had an orchiectomy or in those who are on combination therapy (an LHRH agonist or antagonist and an anti-androgen). A single dose of radiation to the breasts can decrease the risk of developing gynecomastia but is only effective if the radiation is given the first month of the hormone therapy. If gynecomastia has already developed then radiation treatment is not helpful. Tamoxifen, a medication that is used to treat breast cancer, can help in treating gynecomastia in men taking antiandrogens. It can't be used in those men who are taking estrogens (DES) to treat prostate cancer as the tamoxifen stops...

What are the 5alpha reductase inhibitors

Asymptomatic men with a PSA < 3.0 ng ml who are regularly screened with PSA or who are anticipating undergoing annual PSA screening for early detection of prostate cancer may benefit from a discussion of both the benefits of 5-alpha reductase inhibitors for 7 years for the prevention of prostate cancer and the potential risks (2-4 increase in reported erectile dysfunction and gynecomastia (enlarged and or painful breasts), and decrease in ejaculate volume in those receiving finasteride in the study compared to those receiving placebo).

Osteosclerotic Myeloma

One or more additional features of the POEMS syndrome often are observed, but in many cases, these are not prominent and must be carefully sought. Hepatomegaly may be found in up to 50 percent of patients, whereas lymphadenopathy and splenomegaly are less common. Manifestations of endocrinopathy include diabetes mellitus, hypothyroidism, impotence, gynecomastia, testicular atrophy, amenorrhea, hyperprolactinemia, and hyperestrogenemia. Skin changes include hyperpigmentation, thickening of the skin, hypertrichosis, skin angiomas, clubbing, and white nails. Some skin changes are suggestive of scleroderma. Peripheral edema, ascites and pleural effusions may also be seen. POeMs syndrome, sometimes referred to as Crow-Fukase syndrome, is not unique to osteosclerotic myeloma. It has been observed in multiple myeloma, Waldenstrom's macroglobulinemia, and angiofollicular lymph node hyperplasia, also referred to as Castleman's disease.y

Clinical management

Seminoma most commonly presents as a painless testicular mass in the fourth decade of life 13 . Distant to the primary tumor, metastases may manifest particularly as a palpable mass of the abdomen or neck, gynecomastia with or without tenderness, and respiratory symptoms, such as shortness of breath or, less commonly, hemoptysis. It is a well-recognized phenomenon of testicu-lar cancer that the interval between the onset of symptoms and diagnosis is often prolonged. A combination of factors, including patient embarrassment and delays in investigation owing to such factors as treatment of presumptive epididy-mitis, postpone the correct diagnosis by 3 months on average 14,15 .

Aldosteronomas

Once the diagnosis is confirmed, medical control of hypertension and correction of hypokalemia should be instituted at least several weeks prior to adrenalectomy. The most effective medication for management of hyperaldosteronism is spironolactone, a competitive antagonist of the aldosterone receptor (4). Side effects of spironolactone include hyperkalemia, sexual dysfunction, gynecomastia, gastrointestinal disturbances, and metabolic acidosis (12). Alternative medications include potassium sparing diuretics, calcium channel blockers, or converting enzyme inhibitors (11). Adrenalectomy improves or cures hypertension in approximately 90 of patients (13).

Phenotype

Gynecomastia may be caused by increased estradiol levels during testosterone therapy, especially under testosterone enanthate injections. After initiation of androgen therapy and consecutive decrease of estradiol serum levels, gynecomastia usually disappears. If gynecomastia preexists due to an increased estradiol testosterone ratio in hypogonadal men, it may decrease during adequate testosterone therapy. However, in severe cases mastectomy by an experienced plastic surgeon maybe required.

Renal disease

Men with chronic renal failure exhibit many features of classical androgen deficiency including gynecomastia, impotence, testicular atrophy, impaired spermato-genesis and infertility as well as somatic disorders of bone, muscle and other androgen-responsive tissues (Handelsman 1985 Handelsman and Dong 1993 Handelsman and Liu 1998). Yet there is little information on androgen replacement therapy in patients with end-stage renal disease, during dialysis or after renal transplantation. Only a single randomised controlled study has examined androgen replacement therapy in uremic men (van Coevorden et al. 1986). Nineteen regularly hemodialysed men were randomised to receive either oral testosterone undecanoate (240 mg daily) or placebo for 12 weeks. Although libido and sexual activity increased, hemoglobin was unchanged and no other androgen effects on bone, muscle, cognition and well-being were reported. Future studies examining physiological replacement therapy using testosterone patches...

Potential risks

Gynecomastia, related to the conversion of testosterone to estradiol in peripheral tissues, mainly fat tissue, which is relatively increased in elderly men, is a not uncommon but benign side-effect in elderly men, especially in the obese. This side-effect is probably less frequent when avoiding exposure to largely supraphysiological serum levels of testosterone. Testosterone causes some sodium and water retention (Wilson 1988), this cannot cause a problem, except in patients with congestive heart failure, hypertension or renal insufficiency. Hepatotoxicity is very rare when non-oral routes of administration of testosterone are used.

Synopsis

Are there any deformities of the thoracic cage such as kyphoscoliosis, straight-back syndrome, pectus excavatum, shield chest, or bamboo spine Are there any surgical scars (thoracotomy, pacemaker, intravenous access site, or vascular surgery) Are the ribs or sternum still intact Are there any venous collaterals on the chest wall to suggest Superior Vena Cava (SVC) syndrome Is there gynecomastia

Male Hypogonadism

Male hypogonadism is defined as inadequate gonadal function manifested by deficiency in gametogenesis or secretion of gonadal hormones. Primary hypogonadism is caused by dysfunction in the testes from either chromosomal or acquired disorders (Box 35-8). Secondary hypogonadism is caused by an abnormality of the hypothalamic-pituitary axis. Males may present with infertility, decreased testicular size, changes in libido, impotency, gynecomastia, delayed puberty, or a combination of these (Swerdloff and Wang, 2004). Klinefelter's syndrome is the most common genetic cause of male infertility. It is caused by a chromosomal aberration, most often 47,XXY. Phenotypic males can present with small firm testicles, infertility, tall height, long legs, gynecomastia, and varying symptoms of androgen deficiency and undervir-ilization. Treatment is replacement of testosterone to prevent the sequelae of androgen deficiency.

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