Is a benign proliferation of the glandular tissue

of the male breast, is caused by an increase in

the ratio of estrogen to androgen activity. It
may be unilateral or bilateral and is diagnosed
on exam as a palpable mass of tissue at least
0.5 cm in diameter (usually underlying the
nipple).
 Conditions associated with gynecomastia
Physiologic
Neonatal
Pubertal
Involutional
Pathologic
Drugs
Idiopathic
Cirrhosis or malnutrition
Male hypogonadism - primary or secondary
Neoplasms
Testicular - germ cell, Leydig cell, Sertoli cell, sex cord
Adrenal - adenoma or carcinoma
Ectopic production of human chorionic gonadotropin
Hyperthyroidism
Renal disease and dialysis
Rare causes
Enzymatic defects of testosterone production*
Androgen-insensitivity syndromes*
True hermaphroditism*
Excessive extraglandular aromatase activity
 Persistent pubertal gynecomastia 25
percent
Drugs 10 to 25 percent
No detectable abnormality 25 percent
Cirrhosis or malnutrition 8 percent
Hypogonadism primary (8 percent),
secondary (2 percent)
Testicular tumors 3 percent
Hyperthyroidism 1.5 percent
Chronic renal insufficiency 1 percent
 True gynecomastia should be differentiated from
pseudogynecomastia, which refers to fat
deposition without glandular proliferation.
Gynecomastia must also be differentiated from
breast carcinoma, which is far less common.
The management of gynecomastia depends upon
a number of factors, including
its etiology,
duration,
severity, and
presence or absence of tenderness.
When gynecomastia persists beyond 12 months,
the breast glandular tissue has typically become
fibrotic, and medical therapy is unlikely to be
effective.
 Observation only
Drug therapy androgens, selective estrogen
receptor modulators, and aromatase
inhibitors
Surgery
PROSTATE CANCER
Tamoxifen
Anastrozole
Radiotherapy
Tamoxifen versus RT
Surgical intervention
 For most adolescents with gynecomastia, we
recommend observation only with reevaluation in
three to six months, because most will experience
spontaneous regression.
For boys with severe breast enlargement that is
confirmed to be glandular tissue and is causing
substantial tenderness and/or embarrassment, we
suggest a brief trial (three months) of a SERM. We
currently use tamoxifen (10 mg twice daily) because
there is inadequate experience with raloxifene in this
population. Patients and parents should be told that
these drugs are not approved for this purpose.
We suggest not using aromatase inhibitors, because
they do not appear to be effective
 For most men with gynecomastia, we suggest initial observation
only with follow-up reevaluation, especially in men with drug-
induced gynecomastia or men with an underlying treatable
disorder such as hypogonadism or hyperthyroidism, once the
drug has been stopped and/or the underlying disorder has been
treated.
For men in whom no cause can be identified and the
gynecomastia is tender and persists more than three months, we
suggest a brief trial (three to six months) of a SERM for relief of
tenderness. We currently use tamoxifen (10 mg twice daily)
because there is inadequate experience with raloxifene. Patients
should be told that SERMs are not approved for this purpose. We
suggest not using aromatase inhibitors, as they do not appear to
be effective .
In men with persistent gynecomastia (>one to two years) that the
patient finds troubling psychologically, we suggest surgery,
because the breast tissue has probably become fibrotic and
unresponsive to drug therapy .
 For prevention of gynecomastia in men with
advanced prostate cancer undergoing high dose
antiandrogen monotherapy, we suggest
tamoxifen therapy to reduce the risk of developing
gynecomastia . Prophylactic radiation is a
reasonable alternative for men who value the
convenience of a short-term radiation intervention
over the inconvenience and possible side effects of
a daily medication.
We suggest not using aromatase inhibitors for
prevention, because they do not appear to be
effective in this setting .
For men who have already developed gynecomastia
on antiandrogen therapy, we suggest
tamoxifen therapy (if it is of recent onset, and
likely to be in its proliferative phase) .