Approach to Gynaecomastia

History

• Gynaecomastia
  • When did you first notice it?
  • What do you think caused it?
  • How is it affecting your life?
• Deficiency in serum androgens
  • Do you have a headache?
  • Have you noticed that you are bumping into things unintentionally?
  • Did you have any reading difficulties as a child? (Kleinfelter’s syndrome)
  • Have you noticed that you have less body hair than other men?
  • Do you have any problems with your sense of smell? (Kallman syndrome)
• Over-exposure to oestrogen
  • Have you noticed any lumps in your testicles?
  • Have you lost any weight?
  • Have you ever noticed any blood in your stool? (Peutz-Jehgers syndrome)
  • Have you used any bodybuilding steroids?
  • Do you use any hair products?
  • Are you currently sexually active?
  • How many partners do you have?
  • Does your partner use any vaginal lubricants?
  • Have you and your partner tried to start a family?
• Secondary gynaecomastia
  • Do you have any medical problems?
  • Have you noticed that you are increasingly tired?
  • How has your appetite been? (chronic kidney disease)
  • Have you noticed that your skin or eyes have changed colour?
  • Have you noticed any itching of the skin?
  • Have you noticed that the weather is unusually hot?
  • Do you ever notice your heart pounding?
  • Has there been any change in how often you pass motion?
• Drugs
  • Do you take any medication?
  • Have you ever been given a medication to make you pass urine, called spironolactone?
  • Have you ever taken a heart medicine called digoxin or amiodarone?
  • Have you ever taken any anti-depressants?
  • Do you use any recreational drugs?
• Breast cancer
  • Does anyone in your family have any medical conditions?
  • Does anyone in the family have breast cancer or ovarian cancer?

Examination

• Blood pressure (renal disease(
• General inspection
  • Loss of body hair
  • Height
  • Thyroid status
  • Icterus
• Breast examination
  • Gynaecomastia is felt as symmetric, firm glandular tissue under the nipple
  • Axillary lymph nodes
• Thyroid status
  • Proptosis, lid lag
  • Tremor
  • Pulse – rate and rhythm
  • Goitre
  • Pre-tibial myxedema
• Chronic liver disease
  • Palmar erythema
  • Scleral icterus
  • Spider naevi
  • Ascites
  • Splenomegaly from hypersplenism
• Offer:
  • Testicular examination
  • Visual fields (pituitary tumour)

Investigations

• Blood tests
  • Liver function tests, coagulation screen (chronic liver disease)
  • Renal function (chronic kidney disease)
  • Thyroid function tests
• Hormonal profile
  • Anterior pituitary screen (pituitary tumour)
  • Serum testosterone, FSH, LH
  • Serum oestrogen, human chorionic gonadotropin if recent breast enlargement (tumours)
• Breast ultrasound / mammogram if strong family history of breast cancer
• Testicular ultrasound

Management

• Patient education
• Withdrawal of the offending drug
• Treatment of the underlying cause (e.g. hyperthyroidism)
• Medical therapy for gynaecomastia usually possible if onset within two years (otherwise, fibrosis occurs)
  • Anti-oestrogen, e.g. tamoxifen
  • Testosterone therapy in men with hypogonadism
• Surgical removal of breast tissue

Summary

Sir, this patient has gynaecomastia, which has likely been caused by the combination of his underlying chronic liver disease and concurrent use of the diuretic spironolactone. Ox examination, there is palmar erythema, icterus, spider naevi and an ascitic abdomen. The liver is shrunken, and there is splenomegaly, consistent with cirrhosis. There is no associated lymphadenopathy, and nothing to suggest testicular failure or a testicular tumour. There is no family history of breast cancer.

In summary, this patient has gynaecomastia as a result of chronic liver disease and spironolactone use.