Gynecomastia

The male has a scarce or atrophied mammary glandular tissue than in general. On certain occasions, this gland can increase in size in men due to a variety of causes, most of them benign and transitory and with an underlying imbalance between the levels of estrogens and androgens. When this occurs, the male is said to suffer from gynecomastia.

How is it produced?

Gynecomastia is due to an imbalance between estrogens and androgens, with an increase in the former and / or a decrease in the latter. This hormonal imbalance causes the mammary gland to proliferate and there is an increase in size and, consequently, a lump in the breast. Most cases of gynecomastia are physiological or of unknown cause, although there are several secondary causes of gynecomastia, the most frequent being induction by drugs.

Physiological or primary gynecomastia has three peaks of incidence throughout life:

• In newborns due to the passage of maternal estrogens through the placenta; usually disappears in less than a month.
• At puberty, due to a transient increase in estrogen levels; usually disappears in 1.5-3 years.
• In old age, due to an increase in fat tissue and a decrease in testosterone production; it does not usually go away.

Various causes of gynecomastia are:

• Tumors producing estrogens or their precursors, such as certain or adrenal, as well as less frequently lung, kidney or gastric tumors.
• Deficient hormonal function, with the consequent decrease in testosterone production, either at the testicular level caused by orchitis, viral infections, trauma or castration, or at the pituitary or hypothalamic level, where the hormones that regulate the production of testosterone and estrogens are released .
• Increased conversion of androgens to estrogens, caused by various diseases such as obesity, chronic liver disease, chronic kidney failure, hypothyroidism, or Klinefelter syndrome (a genetic disorder in which there are two copies of the X chromosome).
• Resistance to androgens or failures in their receptors, due to genetic causes or due to certain drugs or environmental factors.
• Drugs, the most common and generally reversible cause upon discontinuation of treatment. The most common drugs are:
• Hormonal treatments for prostate disease, such as finasteride or dutasteride.
• Adjuvant treatments such as bicalutamide and flutamide.
• diuretics such as spironolactone.
• Gastric protectors, especially cimetidine.
• Calcium antagonists to control blood pressure.
• Haloperidol.
• Certain drugs such as marijuana, amphetamines, heroin, or methadone.
• Steroidal anabolics such as those used for bodybuilding.

Symptoms

The basic symptom is the enlargement of the mammary gland in the male. It is not accompanied by discharge or axillary lymphadenopathy. It can be unilateral or bilateral, the latter being more frequent, and it is an increase in concentric size from the nipple, without retraction of the latter or skin changes, of rubbery consistency.

It can cause pain or make the breast more tender. If gynecomastia is secondary to another pathology, the patient will present symptoms of it, as in the case of thyroid problems, chronic kidney failure or chronic liver diseases.

Diagnosis

The diagnosis will be based on the clinical history and physical examination of the patient, and if necessary, a blood test will be performed with the determination of various hormones. In the interrogation, the patient should be asked about the evolution time, the presence or absence of pain and discharge (more typical of breast cancer), the use of drugs, drugs or anabolics, and the history of other pathologies that may be possible causes of gynecomastia, as well as a family history of it.

Both breasts should be explored to detect the masses. It is important to assess that it is rubbery in consistency and that it offers a certain resistance, unlike pseudogynecomastia caused by an increase in fatty tissue, and that it is not hard, unilateral, eccentric with respect to the nipple or that it causes retractions of the nipple or the skin. , which would lead to suspicion of breast cancer in men. Also, the armpits should be explored for lymphadenopathy and the abdomen, thyroid, and testes should be palpated.

The blood test will be performed if the medical history and examination do not facilitate the cause of the gynecomastia. In addition to a general analysis, several hormones such as estradiol, testosterone, prolactin, luteinizing hormone (LH) and chorionic gonadotropin (βHCG) will be measured. In the same way, the thyroid hormones, liver function and kidney function to rule out other possible causes.

Given the suspicion of a possible breast cancer in the man after the physical exploration An imaging test such as a mammogram or Doppler ultrasound can be performed, and if necessary a histological study using a fine needle aspiration puncture or FNA. Most of the histological studies of the masses causing gynecomastia are carried out after their surgical removal. Likewise, if gynecomastia of testicular, renal, hepatic, thyroid or pituitary causes is suspected, orafter imaging tests pertinent such as testicular or thyroid ultrasound, abdominal computed tomography (CT) or brain magnetic resonance imaging (MRI).

Treatment

When gynecomastia is physiological origin, is painless or of recent onset, the most advisable thing is to maintain an expectant attitude and monitor the evolution in a few months while waiting for its resolution. If there is a clear cause such as a drug, its withdrawal should be considered.

In the event that gynecomastia is painful, persistent or produces psychological problems, one can opt for pharmacological treatment using tamoxifen, danazol or raloxifene, being tamoxifen the most used and with a good response both to reduce the size of the breast and to improve discomfort and pain. If the pharmacological treatment does not obtain good results or there are significant psychological problems or the suspicion of breast cancer, surgical treatment will be used, removing the mass and analyzing it a posteriori to assess whether any further treatment should be performed. in case of breast cancer.

In those patients receiving adjuvant hormonal treatment for prostate cancer using bicalutamide or flutamide, preventive use of tamoxifen or even radiation therapy may be considered to prevent gynecomastia caused by these hormonal treatments.

Precautionary measures

There are no preventive measures for primary or physiological gynecomastia, but certain causes of secondary gynecomastia can be avoided, such as the use of certain medications or the use of drugs or anabolics.