diease

Gynaecomastia


OVERVIEW OF Gynaecomastia :

Gynecomastia is an increase in the amount of breast gland tissue in boys or men, caused by an imbalance of the hormones estrogen and testosterone. Gynecomastia can affect one or both breasts,  both enlargement of the breast can occur unevenly.


CAUSES :

Natural hormone changes:

The hormones testosterone and estrogen which plays a vital role in  control of sex characteristics in both men and women. Testosterone controls male traits, such as muscle mass and body hair. Estrogen controls female traits, including the growth of breasts.

Most people think of estrogen as an exclusively female hormone, but men also produce it — though normally in small quantities. Male estrogen levels that are too high or are out of balance with testosterone levels can cause gynecomastia.

Gynecomastia in infants:

More than half of male infants are born with enlarged breasts due to the effects of their mother's estrogen. Generally, the enlarged breast tissue goes away within two to three weeks after birth.

Gynecomastia during puberty:

Gynecomastia caused by hormone changes during puberty is relatively common. In most cases, the swollen breast tissue will go away without treatment within six months to two years.

Gynecomastia in adults:

The prevalence of gynecomastia peaks again between the ages of 50 and 69. At least 1 in 4 men in this age group is affected.

medications:

A number of medicines can lead to gynaecomastia. These include:

Anti-androgens used to treat an enlarged prostate, prostate cancer and other conditions. Examples include flutamide, finasteride and spironolactone

Anabolic steroids and androgens, which are prescribed by doctors for certain conditions or are sometimes used illegally by athletes to build muscle and enhance performance.

AIDS medications. Gynecomastia can develop in men who are HIV-positive and receiving a treatment regimen called highly active antiretroviral therapy. Efavirenz is more commonly associated with gynecomastia than are other HIV medications.

Anti-anxiety medications, such as diazepam (Valium).

Tricyclic antidepressants.

Antibiotics.

Ulcer medications, such as the over-the-counter drug cimetidine

The drugs used in the Cancer treatment.

Heart medications, such as digoxin and calcium channel blockers.

Stomach-emptying medications, such as metoclopramide .

Drugs and alcohol

Substances that can cause gynecomastia include:

  • Alcohol
  • Amphetamines, used to treat attention-deficit/hyperactivity disorder
  • Marijuana
  • Heroin
  • Methadone)

Age related disorder:

Hypogonadism:

Conditions that interfere with normal testosterone production, such as Klinefelter syndrome or pituitary insufficiency, can be associated with gynecomastia.

Aging:

 Hormone changes that occur with normal aging can cause gynecomastia, especially in men who are overweight.

Tumors:

Some tumors, such as those involving the testes, adrenal glands or pituitary gland, can produce hormones that alter the male-female hormone balance.

Hyperthyroidism:

 In this condition, the thyroid gland produces too much of the hormone thyroxine.

Kidney failure:

 About half the people being treated with dialysis experience gynecomastia due to hormonal changes.

Liver failure and cirrhosis:

 Changes in hormone levels related to liver problems and cirrhosis medications are associated with gynecomastia.

Malnutrition and starvation:

When your body is deprived of adequate nutrition, testosterone levels drop while estrogen levels remain the same, causing a hormonal imbalance. Gynecomastia can also happen when normal nutrition resumes.

Herbal causes:

Plant oils, such as tea tree or lavender, used in shampoos, soaps or lotions have been associated with gynecomastia. This is probably due to their weak estrogenic activity.


PATHOPHYSIOLOGY :

It results from the imbalance between the actions of estrogen and androgens at the breast tissue. Breast enlargement can result from the enlargement of the glandular breast tissue that is the chest adipose tissue and skin or either of the combination. Similar in females the estrogen hormone in the males promotes the enlargement of the breast.  In addition to directly stimulating the male breast tissue growth, estrogens can indirectly decreases the secreation of the testosterone by suppressing lutenizing hormone secretion resulting in decreased secretion of testosterone by suppressing lutenizing hormone. This leads to deterioration in the testicular testosterone secreation.

Estrogens can increases the blood levels of the protein called as the sex hormone binding protein sex hormone binding globulin which binds to the free testosterone and blocks the action of the testosterone in the enlargement of the male breast tissue.  Primary hypogonadism indicating an intrinsic problem with the testes in males leads to decreased testosterone synthesis and also increases the conversion of testosterone to the estradiol which leads to the gynaecomastic appearance. Klinefelter syndrome is a good example becauses it causes the hypogonadism which in turn increases the chances for the gynaecomastia. Central hypogonadism ( indicates the problem with the brain)

Central hypogonadism that is indicating a problem with the brain leads to decreased production and release of leutinizing hormone which leads to decreased production of testosterone and estradiol in the testes.

Individuals who have cirrhosis or chronic liver disease may develop gynaecomastia foe several reasons. Cirrhotics tends to have increased secretion of the androgenic hormone androstenedione from the adrenal glands, increased conversion of this hormone into various types of estrogen and increased levels of SHBg which leads to decreased blood levels of free testosterone. Hyperthyroidism can also lead to the development of the gynaecomastia. Hence resolving the hyperthyroidism might reduces the chances for gynaecomastia.

 


COMMON CLINICAL SIGNS AND SYMPTOMS :

Swollen breast tissue

Breast enlargement

Discharge from the breast

Swelling

Pain or tenderness on palpation


DIAGNOSTIC :

The diagnosis is based on the following procedure.

Blood tests:

Blood tests are not indicated in those with fatty breast enlargement, physiological pubertal or senile changes as identified drug cause or a clinically apparent cancer.

Renal function

Liver function test

Thyroid function test

Hormone profile:

 Estradiol

Testosterone

Prolactin

Beta hCG level

Alpha fetoprotein

Lutenizing hormone

LH and testosterone low – indicates testicular failure

LH and testosterone both low- indicates increase in estrogen.

LH and testosterone both high- androgen resistance or neoplasm secreting gonadotropins.

Chromosomal karyotyping may be needed.

Ultrasonography or mammography of breasts in all doubtful cases or unilateral breast enlargement is needed.
ultrasonography is indicated if there is a raised beta hCG or AFP

 

Biopsy:

The biopsy is used to indicate and it reveals if any severity arises.


TREATMENT AND PROGNOSIS :

The treatment is by the following drugs:

Tamoxifen

Anastrozole

Liposuction:

The surgery removes the fatty tissue in the breast.

Masectomy:

This surgery removes the breast itself

 


PROGNOSIS :

The prognosis is good and the recovery rate id 86% when appropriate treatment is given.


PREVENTION :

The main mode of prevention is by removing the triggering factors.


Medicines used in the Treatment :

Tamoxifen

Anastrazole