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Breast tissue enlargement in men and pubertal boys is very common. Not unusual for a teenager to arrive with his parents to discuss this issue. Gynaecomastia is derived from Greek -mastos means women and Gynae we all know is a woman. This chart on Gynaecomastia on A4Medicine explains the pathophysiology and causes of gynaecomastia. A brief assessment is followed by some practical management tips. Which investigations to order are mentioned and currently, we do not have a guideline on management of gynaecomastia. Use of Tamoxifen is discussed with evidence of benefit in the Nottingham study

Benign proliferation of glandular breast tissue in men characterized by presence of rubbery or firm mass extending concentrically from the nipples Common – up to 35 % of men Most common disorder of male breast Can occur at any age but ↑ common in older men
Peak in pubertal boys Oestrogens are major hormones responsible for proliferation of breast tissue in both sexes whereas testosterone is a potent inhibitor of breast growth
 Can result from hormone imbalance- either an excess of oestrogens or oestrogen precursors or a reduction in androgens or impairment of their actions

Presentation-Presents usually with a swelling of the breast , often unilateral Can be tender ( proliferation of glandular tissue ) sometimes painful Size can vary from a small amount of extra tissue around nipple to prominent breasts Teenagers – body perception and self image are very important at this age and breast enlargement can be quite distressing Secondary gynaecomastia can present with associated symptoms for eg thyrotoxicosis , liver disease or renal disease

history-Age of onset and duration Any change in nipple size , pain , discharge H/O mumps , testicular trauma Illicit drug use 
( particularly in younger men explore illicit drug use and body building supplements ) Family history of gynaecomastia ( 58 % of patients with persistent pubertal gynaecomastia have a +ve family history ) H/o sexual dysfunction , infertility or hypogonadism Medications

Examination-Thorough examination of breasts
○ palpate all areas including nipple
○ compare and note uni or bilateral
○ use thumb and index finger- place over 
the outer and inner breast margins brought
 together in pinching movement
○ a diameter of under 2 cm is considered
to be within normal limits ; above 2 cm is consistent with gynaecomastia
○ concentric enlargement around areola or discoid mass underneath areola
 Check for nipple discharge or 
axillary lymphadenopathy

 Offer testicular examination
○ if h/o suggestive of hypogonadism
○ any suggestion of testicular mass
 General physical examination to look
for signs of hyperthyroidism 
liver disease and hypogonadism
 Check BMI and assess secondary sexual characters Refer urgently to
 r/o breast cancer if 
 unusual mass , distorted nipples or areola , skin abnormality or axillary lymphadenopathy 
found If testicular mass noticed arrange urgent US + refer Urology Cancer is 
diagnosed in about
 1 % of cases of gynaecomastia

Medical management will be ineffective if fibrosis has occurred
 In UK Danazol is licenced but use is limited due to weight gain which may exacerbate the condition
 Tamoxifen is the most widely used medical treatment
○ not licenced
○ improves breast pain and is more effective when gynaecomastia is < 4 cm
○ Nottingham used @ 20 mg/daily for physiological gynaecomastia duration 6-12 weeks- conclusion effective treatment for physiological gynaecomastia , especially lump type

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