A Thread Devoted To Gynecomastia

[BBC3]

· Surgery is the only effective treatment option once gynaecomastia becomes fibrotic

INTERESTING.. I was going to just fire a thought here and then I read this last sentence.

I was going to say that my Gyno in my right tit SEEMS like it went away after removing the steroidal forces that cause it. From time to time I think so. But examining right NIP a bit ALWAYS comes back to my conclusion that not only did my right "BB" stay (duct development), but it has just enlarged, and now more central and deeper, larger. NOT CURRENTLY ENFLAMED or ACTIVE. Its like it has more potential than ever but totally dormant.. But present and none the less and POTENTIALLY bigger than ever. In fact. I believe that if I took the same steroid combo which caused it, THE PROOF will be that it will be bigger and more active that EVER before...

I just don't think TISSUE DEVELPMENT CAN BE UNDONE. At least not without a GREAT DEAL OF TIME...

There is also the question of whether or not DNA has been rewritten FOR EVER..!????!

SO WHAT do they mean by "Fibrotic" I wonder... It does not sound natural.. Do they mean "Tissue-Otic". And just convoluting "their" usual PATHETIC/SKEWED/BIASED/ SELF SERVING (and serving WHO) - "results"...?!

NICE DOGGY IN THE AVATAR..>!

Gynaecomastia

What you need to know
· Gynaecomastia typically results from an imbalance between the level or action of oestrogen and androgen
· Physiological gynaecomastia is common in newborns, adolescents, and older men and most do not require investigation
· Removal of the underlying cause often leads to resolution of gynaecomastia
· Early treatment with tamoxifen (unlicensed) is the most effective medical option in men with symptoms
· Surgery is the only effective treatment option once gynaecomastia becomes fibrotic

Thiruchelvam P, Walker JN, Rose K, Lewis J, Al-Mufti R. Gynaecomastia. BMJ 2016;354. Gynaecomastia | The BMJ

 

[BBC3]

And NOW you begin the GRASP the Full COMPREHENSION of a GOOD'Ol BLOW-JOB...!

IT RUNS DEEP.. And Corporate America knows better than none other...!

Yup, absolutely horrible what ''evidence'' was concealed in that matter. It's also equally an issue that the risks of the medication themselves were not weighed against the other medications which are equally effective and produce far less side-effects!

 

[Michael Scally MD]

Young DB. 6'6" United States Marine Seeks Treatment for Gynecomastia Only to Learn It Is All in His Head. Mil Med 2016;180(12):e1290-2. Military Medicine - International Journal of AMSUS

Growth Hormone (GH) excess is an uncommon cause of gynecomastia encountered in primary care. Adults with GH excess (acromegaly) have a 72% increase in mortality compared with the general population, which is reversible with early detection and intervention. Currently, however, the diagnosis of acromegaly is often delayed up to 12 years because of the subtle onset of symptoms. We present an active duty male diagnosed with acromegaly after presenting to his primary care provider with chronic gynecomastia. The most common cause of GH excess is a pituitary somatotroph adenoma; however, it is important to remember that magnetic resonance imaging of the pituitary does not distinguish between functioning and nonfunctioning tumors. Subsequently, the diagnosis of GH excess is based on biochemical studies, not imaging.

 

[Michael Scally MD]

Mieritz MG, Christiansen P, Jensen MB, et al. Gynaecomastia in 786 Adult Men - Clinical and Biochemical findings. European Journal of Endocrinology. Gynaecomastia in 786 Adult Men - Clinical and Biochemical findings

Objective - Gynaecomastia is a benign proliferation of glandular tissue of the breast, however, it is an important clinical observation because it can be the first symptom of an underlying disease. Some controversy exists concerning the clinical importance of an in-depth investigation of men who develop gynaecomastia. We hypothesize that a thorough work-up is required in adult men with gynaecomastia.

Design- All adult men (n=818) referred to a secondary level andrological department at Rigshospitalet in Copenhagen, Denmark in a four-year period (2008-2011) under the diagnosis of gynaecomastia (ICD-10: N62) were included.

Methods - Thirty-two men did not have gynaecomastia when examined were excluded; leaving 786 men for final analyses. They went through an andrological examination, ultra sound of the testicles and analysis of endogenous serum hormones levels.

Results - In 45% of men with adult onset of gynaecomastia (≥18 years) an underlying, and often treatable, cause could be detected. In men younger at onset an underlying cause for gynaecomastia could be detected in merely 7.7%.

The study is limited by the fact that we did not have access to investigate men who were referred directly by their GP to private clinics of plastic surgery, or who sought cosmetic correction without consulting their GP first.

Conclusions - Our study demonstrates the importance of a thorough examination, and provides a comprehensible examination strategy, to disclose underlying pathology leading to development of gynaecomastia in adulthood.

 

[Michael Scally MD]

Gynecomastia Classification for Surgical Management

BACKGROUND: Gynecomastia is a common deformity of the male breast, where certain cases warrant surgical management. There are several surgical options, which vary depending on the breast characteristics. To guide surgical management, several classification systems for gynecomastia have been proposed.

METHODS: A systematic review was performed to (1) identify all classification systems for the surgical management of gynecomastia, and (2) determine the adequacy of these classification systems to appropriately categorize the condition for surgical decision-making.

RESULTS: The search yielded 1012 articles, and 11 articles were included in the review. Eleven classification systems in total were ascertained, and a total of 10 unique features were identified:

(1) breast size,
(2) skin redundancy,
(3) breast ptosis,
(4) tissue predominance,
(5) upper abdominal laxity,
(6) breast tuberosity,
(7) nipple malposition,
(8) chest shape,
(9) absence of sternal notch, and
(10) breast skin elasticity.

On average, classification systems included two or three of these features. Breast size and ptosis were the most commonly included features.

CONCLUSIONS: Based on their review of the current classification systems, the authors believe the ideal classification system should be universal and cater to all causes of gynecomastia; be surgically useful and easy to use; and should include a comprehensive set of clinically appropriate patient-related features, such as breast size, breast ptosis, tissue predominance, and skin redundancy. None of the current classification systems appears to fulfill these criteria.

Waltho D, Hatchell A, Thoma A. Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System. Plast Reconstr Surg 2017;139(3):638e-48e. Gynecomastia Classification for Surgical Management: A Syst... : Plastic and Reconstructive Surgery

 

[Michael Scally MD]

Which patients with gynaecomastia require more detailed investigation?

Gynaecomastia may be due to medication, chronic liver or kidney disease, hypogonadism (primary or secondary to pituitary disease) or hyperthyroidism. Having excluded these aetiologies, it is imperative to be vigilant for underlying malignancy causing gynaecomastia.

These include human chorionic gonadotrophin-secreting testicular and extratesticular tumours, and oestrogen-secreting testicular tumours and feminising adrenal tumours.

Ali S., Jayasena C., Sam A. Which patients with gynaecomastia require more detailed investigation? Clin Endocrinol [Internet]. Available from: http://dx.doi.org/10.1111/cen.13526

 

[Michael Scally MD]

[OA] Managing Male Mammary Maladies

This review examines the symptoms, need for referral and management of the benign breast conditions which afflict males, together with the steps that are necessary to exclude or confirm male breast cancer.

The most common complaint is gynaecomastia, either true or pseudo, and the majority of these cases need reassurance without over-investigation.

Drugs that induce breast enlargement are described in order that, when possible, a medication switch can be made.

Men receiving endocrine therapy for prostate cancer may develop painful gynaecomastia and this can be relieved with tamoxifen.

All men with breast cancer need mammography as part of their work-up but this should not be used as a screening technique for symptomatic males.

Because of lack of lobular development, both cysts and fibroadenomas are very rare in men; but those with nipple discharge need referral and investigation as some will have underlying malignancy.

Fentiman IS. Managing Male Mammary Maladies. European journal of breast health 2018;14:5-9. Managing Male Mammary Maladies

 

[Michael Scally MD]

Quantitative CT Assessment of Gynecomastia in the General Population and in Dialysis, Cirrhotic, and Obese Patients

RATIONALE AND OBJECTIVES: Gynecomastia is the benign enlargement of the male breast because of proliferation of the glandular component. To date, there is no radiological definition of gynecomastia and no quantitative evaluation of breast glandular tissues in the general male population.

The aims of this study were to supply radiological-based measurements of breast glandular tissue in the general male population, to quantitatively assess the prevalence of gynecomastia according to age by decades, and to evaluate associations between gynecomastia and obesity, cirrhosis, and dialysis.

MATERIALS AND METHODS: This retrospective study included 506 men who presented to the emergency department following trauma and underwent chest-abdominal computed tomography. Also included were 45 patients undergoing hemodialysis and 50 patients with cirrhosis who underwent chest computed tomography. The incidence and size of gynecomastia for all the study population were calculated.

RESULTS: Breast tissue diameters of 22 mm, 28 mm, and 36 mm corresponded to 90th, 95th, and 97.5th cumulative percentiles of diameters in the general male population. Peaks of gynecomastia were shown in the ninth decade and in boys aged 13-14 years. Breast tissue diameter did not correlate with body mass index (r = -0.031). Patients undergoing hemodialysis and patients with cirrhosis had higher percentages (P < .0001) of breast tissue diameters above 22 mm, 28 mm, and 36 mm.

CONCLUSIONS: Breast tissue diameter is a simple and reliable quantitative tool for the assessment of gynecomastia. This method provides the ability to determine the incidence of gynecomastia by age in the general population. Radiological gynecomastia should be defined as 22 mm, 28 mm, or 36 mm (90th, 95th, and 97.5th percentiles, respectively). Radiological gynecomastia is not associated with obesity, but is associated with cirrhosis and dialysis.

Klang E, Kanana N, Grossman A, et al. Quantitative CT Assessment of Gynecomastia in the General Population and in Dialysis, Cirrhotic, and Obese Patients. Academic radiology 2018. http://www.academicradiology.org/article/S1076-6332(17)30486-5/abstract

 

[Michael Scally MD]

A Review of Unusual Benign and Malignant Male Breast Imaging Cases

· Men with breast symptoms create unique diagnostic challenges for a radiologist.
· Accurate clinical history with imaging can aid accurate male breast diagnosis.
· Ductal pathology is much more common than lobular pathology in men.

Male breast disease is uncommon. Men presenting with breast symptoms may represent unique diagnostic challenges for the radiologist, particularly if imaging findings are not classic for gynecomastia or carcinoma.

In this paper we review 10 unusual male breast cases, 5 benign and 5 malignant, including the radiologic findings, differential diagnosis, pathology and management.

Mango VL, Goodman S, Clarkin K, et al. The unusual suspects: A review of unusual benign and malignant male breast imaging cases. Clinical imaging 2017;50:78-85. http://www.clinicalimaging.org/article/S0899-7071(17)30262-0/abstract

 

[Michael Scally MD]

[OA] Efficiency of Imaging Modalities in Male Breast Disease

Objective: The purpose of this study is to present mammography and ultrasound findings of male breast lesions and to investigate the ability of diagnostic modalities in estimating the evolution of gynecomastia.

Materials and Methods: Sixty-nine male patients who admitted to Taksim and Bakirkoy Education and Research Hospitals and underwent mammography (MG) and ultrasonography (US) imaging were retrospectively evaluated. Duration of symptoms and mammographic types of gynecomastia according to Appelbaum's classifications were evaluated, besides the sonographic findings in mammographic types of gynecomastia.

Results: The distribution of 69 cases were as follows:
· gynecomastia 47 (68.11%),
· pseudogynecomastia 6 (8.69%)
· primary breast carcinoma 7 (10.14%),
· metastatic carcinoma 1 (1.4%),
· epidermal inclusion cyst 2 (2.8%),
· abscess 2 (2.8%),
· lipoma 2 (2.8%),
· pyogenic granuloma 1 (1.4%), and
· granulomatous lobular mastitis 1 (1.4%).

Gynecomastia patients who had symptoms less than 1 year had nodular gynecomastia (34.6%) as opposed to dendritic gynecomastia (61.5%) (p<0.01) based on mammography results according to Appelbaum's classifications. In patients having symptoms for 1 to 2 years, diffuse gynecomastia (70%) had a higher rate than the dendritic type (20%). Patients having the symptoms more than 2 years had diffuse gynecomastia (57.1%) while 42.9% had dendritic gynecomastia (p<0.001).

With sonographic examination patients who had symptoms less than 1 year had higher rates of dendritic gynecomastia (92.3%) than noduler type (1.9 %). Patients having symptoms for 1 to 2 years had more dentritic gynecomastia (70%) than diffuse type (30%). Patients having symptoms more than 2 years had diffuse gynecomastia (57.1%) comparable to dendritic gynecomastia (42.9 %).

Conclusion: Diagnostic imaging modalities are efficient tools for estimation of gynecomastia evolution as well as the diagnosis of other male breast diseases. There seems to be an incongruity between duration of clinical complaints and diagnostic imaging classification of gynecomastia. The use of these high resolution US findings may demonstrate an early phase fibrosis especially in patients visualized by mammography as with nodular phase.

Sarica O, Kahraman AN, Ozturk E, Teke M. Efficiency of Imaging Modalities in Male Breast Disease: Can Ultrasound Give Additional Information for Assessment of Gynecomastia Evolution? European journal of breast health 2018;14:29-34. Efficiency of Imaging Modalities in Male Breast Disease: Can Ultrasound Give Additional Information for Assessment of Gynecomastia Evolution?

 

[Michael Scally MD]

Ultrasound Imaging of Male Breast

The principles of diagnostics and the approaches to breast pathology treatment in men are based on knowledge obtained in the process of diagnosis and treatment of women with similar breast pathology. High efficacy of ultrasound in diagnosis of breast carcinoma in men is the result of high sensitivity (86.9%) and specificity (85.3%).

It allows assessing the areas, which are inaccessible to mammography, such as retromammary space, regions of lymph drainage, and the relation of a tumor to the skin and nipple. In the first visit, the correct diagnosis of cancer is established in 20–52% of male patients. The most difficult is the diagnostics of breast cancer comorbid to gynecomastia, which is observed in 12–40% of patients.

The image of normal male breast is rather constant and does not depend on age and cyclic physiological features. Gynecomastia is the most common pathologic condition, which accounts for 74% of all processes developing in male breast. A typical feature of gynecomastia is its central location under the nipple. Physiological gynecomastia exhibits three age peaks: in newborn, in puberty, and in senile period. Gynecomastia may periodically accompany diabetes and other diseases.

Palpable benign breast masses in men may be represented with tumors (lipoma, fibroadenoma, atheroma, schwannoma, angiolipoma, intraductal papilloma, cyst) or inflammatory lesions (mastitis, subareolar sepsis, abscess, posttraumatic hematoma, adipose necrosis, tuberculosis, syphilis, intramammary lymph nodes, etc.). Breast cancer in men is a rare disease, discussed in the chapter in detail.

Sencha AN, Patrunov Y. Ultrasound Imaging of Male Breast. In: Sukhikh GT, Sencha AN, eds. Multiparametric Ultrasound Diagnosis of Breast Diseases. Cham: Springer International Publishing; 2018:223-63. Ultrasound Imaging of Male Breast

 

[Michael Scally MD]

Statin Medications and the Risk of Gynecomastia

Objective - Case reports have suggested an increased risk of gynecomastia with HMG‐CoA reductase inhibitors (i.e. statins). A recent meta‐analysis also found that statins decrease circulating testosterone levels in men. We investigated whether statin use was associated with an increased risk of gynecomastia.

Design - Case control study.

Patients - A cohort of patients from a random sample of 9,053,240 US subjects from the PharMetrics Plus™ health claims database from 2006 to 2016 was created.

Measurements - New cases of gynecomastia requiring at least two ICD‐9 codes were identified from the cohort and matched to 10 controls by follow‐up time and age using density‐based sampling. Rate ratios (RRs) for past users of statins were computed using conditional logistic regression adjusting for alcoholic cirrhosis, hyperthyroidism, testicular cancer, Klinefelter syndrome, obesity, hypogonadism, hyperprolactinemia and use of spironolactone, ketoconazole, H2 receptor antagonists (H2 blockers), risperidone, testosterone and androgen deprivation therapy.

Results - Our cohort included 6,147 cases of gynecomastia and 61,470 corresponding matched controls. The adjusted RR for current, recent and past statin use with respect to gynecomastia was 1.19 (1.04‐1.36), 1.38 (1.15‐1.65) and 1.20 (1.03‐1.40) respectively.

Conclusions - Statin use is associated with an increased risk of developing gynecomastia. Clinicians should be cognizant of this effect and educate patients accordingly.

Skeldon Sean C, Carleton B, Brophy J, Sodhi M, Etminan M. Statin Medications and the Risk of Gynecomastia. Clinical Endocrinology 2018. https://doi.org/10.1111/cen.13794

 

[Michael Scally MD]

The Role of Expression of Estrogen and Progesterone Receptors in Idiopathic Gynecomastia Etiology

To conclude, the obtained results may indicate that men with idiopathic gynecomastia present primary “overexpression” of ER and PR This thesis may be supported by the fact that in many cases of idiopathic gynecomastia antiestrogens appear to be effective in an unknown mechanism. Additionally, these findings may pave the way for further researches on effective pharmacotherapy in this condition and explain a mechanism of its efficacy.

Kasielska-Trojan A, Danilewicz M, Antoszewski B. The role of expression of estrogen and progesterone receptors in idiopathic gynecomastia etiology. The breast journal 2019. https://onlinelibrary.wiley.com/doi/abs/10.1111/tbj.13221

 

[Michael Scally MD]

Baumann K. Gynecomastia - Conservative and Surgical Management. Breast care (Basel, Switzerland) 2018;13:419-24. Gynecomastia - Conservative and Surgical Management

Gynecomastia is defined as a unilateral or bilateral persistent benign mammary gland enlargement in men. Prevalence of asymptomatic gynecomastia is up to 65%. True gynecomastia must be distinguished from pseudogynecomastia. Typically, in true gynecomastia, a solid tissue mass is palpable below the nipple-areolar complex. Malignant changes such as male mammary carcinoma must always be ruled out.

The causes of gynecomastia are diverse. An imbalance of female to male hormones triggers the onset of the disease. This imbalance can be caused by endogenous diseases like hyperthyroidism, chronic liver disease, primary or secondary gonadal failure, androgen resistance syndromes, medication, and drug abuse. A series of heart or hypertension medications can also trigger gynecomastia. A basic requirement of proper therapy planning is knowledge of the triggers and possible drug therapy options. Inquiring about the patient's lifestyle and medication history is essential.

Drug therapy with tamoxifen may be considered at an early stage. For gynecomastia persisting over 12 months, surgical excision is the treatment of choice, and there are several surgical options available depending on the grade of the gynecomastia. A thoughtful approach to managing this condition can lead to high patient satisfaction.

 

[Michael Scally MD]

Risk of Gynecomastia with Users of Proton Pump Inhibitors

INTRODUCTION: Proton pump inhibitors (PPI) are commonly prescribed for many gastrointestinal diseases. A number of case reports have linked PPIs to gynecomastia in men, but large epidemiologic studies are lacking.

OBJECTIVE: To quantify the risk of gynecomastia with PPIs in male patients.

METHODS: Using the PharMetrics Plus() health claims database from the United States, a retrospective cohort study of new PPI users and new amoxicillin users from 2006 to 2016 was conducted. Diagnosis of gynecomastia was identified by the International Classification for Diseases, 9th edition (ICD-9) and 10th edition (ICD-10) codes. Cases were defined as patients with two codes for gynecomastia within 90 days, with the first code as the event code.

Hazard ratios (HRs) were computed by adjusting for alcoholic cirrhosis, hyperthyroidism, testicular cancer, Klinefelter syndrome, and obesity; as well as the use of ketoconazole, risperidone, spironolactone, and androgen deprivation therapy. A sensitivity analysis defining exposure with two PPI prescriptions was also undertaken.

RESULTS: There were 389 cases of gynecomastia diagnosed among 220,791 new PPI users, and 996 gynecomastia cases diagnosed among 837,740 new amoxicillin users. The crude HR for PPI use compared to amoxicillin use was 1.70 (95% confidence interval (CI): 1.461-1.976). The adjusted HR for the sensitivity analysis was 1.299 (95% CI: 1.146-1.473). The adjusted HR was 1.4795 (95% CI: 1.2431-1.7609) for patients over 50 years old and 1.324 (95% CI: 1.1133-1.5745) for patients 50 years old or younger.

CONCLUSION: This large retrospective cohort study suggests that patients who used PPIs are at higher risk of developing gynecomastia. Clinicians may want to convey this information to male patients who require long-term PPI therapy.

He B, Carleton B, Etminan M. Risk of Gynecomastia with Users of Proton Pump Inhibitors. Pharmacotherapy 2019. https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1002/phar.2245

 

[Michael Scally MD]

Surgical Management of Gynecomastia: A Review of the Current Insurance Coverage Criteria

BACKGROUND: Gynecomastia is a common condition that can be corrected with surgical excision of the breast tissue. Unlike the policies available for reduction mammaplasty in women, gynecomastia policies are variable and not based on strong scientific evidence.

This study reviews U.S. insurance policies for coverage of gynecomastia surgery and compares these policies to the guidelines put forth by the American Society of Plastic Surgeons.

METHODS: Sixty U.S. insurance companies were selected based on their market share value. Medicare was also evaluated. The policy for each company was identified using a Web-based search or by contacting the company directly. Policies were reviewed to abstract coverage criteria. All information gathered was compared to national recommendations.

RESULTS: Of the 61 companies evaluated, 38% did not have a well-defined policy for gynecomastia surgery and assessed each request on a case-by-case basis with no defined criteria. The remaining 62% of providers held a defined policy.

Companies often required thorough documentation of breast size, body mass index, extent and duration of symptoms, and prior treatments, but requirements varied between insurers.

Many of these policies were limited in their coverage, e.g. they would cover tissue excision but not liposuction. Fourteen companies would consider of coverage for patients younger than 18 years.

CONCLUSIONS: Coverage of gynecomastia surgery varies across insurers. Insurance company considerations do not often align with patient concerns and physician recommendations on gynecomastia and its treatment options. Coverage criteria should be reevaluated and universally established, to expand access to care and improve treatment efficiency.

Rasko YM, Rosen C, Ngaage LM, et al. Surgical Management of Gynecomastia: A Review of the Current Insurance Coverage Criteria. Plastic and reconstructive surgery 2019;143:1361-8. https://journals.lww.com/plasreconsurg/fulltext/2019/05000/Surgical_Management_of_Gynecomastia__A_Review_of.16.aspx

 

[Michael Scally MD]

EAA Clinical Practice Guidelines-Gynecomastia Evaluation and Management

BACKGROUND: Gynecomastia (GM) is a benign proliferation of the glandular tissue of the breast in men. It is a frequent condition with a reported prevalence of 32-65%, depending on the age and the criteria used for definition. GM of infancy and puberty are common, benign conditions resolving spontaneously in the majority of cases. GM of adulthood is more prevalent among the elderly and proper investigation may reveal an underlying pathology in 45-50% of cases.

OBJECTIVES: The aim was to provide clinical practice guidelines for the evaluation and management of GM.

MATERIALS AND METHODS: A literature search of articles in English for the term 'gynecomastia' was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS: A set of five statements and fifteen clinical recommendations was formulated.

CONCLUSIONS: The purpose of GM assessment should be the detection of underlying pathological conditions, reversible causes (administration/abuse of aggravating substances), and the discrimination from other breast lumps, particularly breast cancer. Assessment should comprise a thorough medical history and physical examination of the breast and genitalia (including testicular ultrasound).

A set of laboratory investigations may integrate the evaluation: testosterone (T), estradiol (E2), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), follicular stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactin, human chorionic gonadotropin (hCG), alpha-fetal protein (AFP), liver and renal function tests. Breast imaging may be used whenever the clinical examination is equivocal. In suspicious lesions, core needle biopsy should be sought directly instead.

Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with GM. T treatment should be offered to men with proven T deficiency. The use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs) and non-aromatizable androgens is not justified in general. Surgical treatment is the therapy of choice for patients with long-lasting GM.

Summary of Statements (S) and Recommendations (R)

· S1. Gynecomastia (GM) is a benign proliferation of glandular tissue of the breast in males.

· S2. GM of infancy is a common condition that usually resolves spontaneously, typically within the first year of life.

· S3. GM of puberty is a common condition, affecting approximately 50% of mid‐pubertal boys; in more than 90% of cases, it resolves spontaneously within 24 months.

· S4. The prevalence of GM in adulthood increases with increasing age; proper investigation may reveal an underlying pathology in approximately 45–50% of the cases.

· S5. Male breast cancer is rare; GM should not be considered a premalignant condition.

The following recommendations are divided into ‘strong’, denoted by the number 1 and associated with the terminology ‘we recommend’, and ‘weak’ denoted by the number 2 and associated with the phrase ‘we suggest’. The grading of the quality of evidence is denoted as follows: ⊕○○○ for very low‐quality evidence; ⊕⊕○○ for low quality; ⊕⊕⊕○ for moderate quality; and ⊕⊕⊕⊕ for high quality.

· R1. The presence of an underlying pathology should be considered in GM of adulthood. We recommend that the identification of an apparent reason for GM in adulthood, including the use of medication known to be associated with GM, should not preclude a detailed investigation (1 ⊕⊕⊕○).

· R2. We suggest that the initial screening to rule out lipomastia, obvious breast cancer, or testicular cancer might be performed by a general practitioner or another non‐specialist (2 ⊕○○○).

· R3. We recommend that in those cases where a thorough diagnostic workup is warranted, it should be performed by a specialist (1 ⊕○○○).

· R4. We recommend that the medical history should include information on the onset and duration of GM, sexual development and function, and administration or abuse of substances associated with GM (1 ⊕⊕⊕○).

· R5. We recommend that the physical examination should detect signs of under‐virilization or systemic disease (1 ⊕⊕⊕⊕).

· R6. We recommend that breast examination should confirm the presence of palpable glandular tissue to discriminate GM from lipomastia (pseudo‐gynecomastia) and rule out the suspicion of malignant breast tumor (1 ⊕⊕⊕⊕).

· R7. We recommend that the physical examination should include the examination of the genitalia to rule out the presence of a palpable testicular tumor and to detect testicular atrophy (1 ⊕⊕⊕⊕).

· R8. We recommend that genitalia examination is aided by a testicular ultrasound, as the detection of a testicular tumor by palpation has low sensitivity (1 ⊕⊕○○).

· R9. We suggest that a set of evaluations may include T, E2, SHBG, LH, FSH, TSH, prolactin, hCG, AFP, and liver and renal function tests (2 ⊕⊕○○).

· R10. We suggest that breast imaging may offer assistance, where the clinical examination is equivocal (2 ⊕⊕○○).

· R11. We suggest that, if the clinical picture is suspicious for a malignant lesion, core needle biopsy should be performed (2 ⊕⊕○○).

· R12. We recommend watchful waiting after treatment of underlying pathology or discontinuation of the administration/abuse of substances associated with GM (1 ⊕⊕○○).

· R13. We recommend that T treatment should be offered only to men with proven testosterone deficiency (1 ⊕⊕⊕○).

· R14. We do not recommend the use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), or non‐aromatizable androgens in the treatment of GM in general (1 ⊕⊕○○).

· R15. We suggest surgical treatment only for patients with long‐lasting GM, which does not regress spontaneously or following medical therapy. The extent and type of surgery depend on the size of breast enlargement, and the amount of adipose tissue (2 ⊕⊕○○).

Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines-gynecomastia evaluation and management. Andrology 2019. https://onlinelibrary.wiley.com/doi/abs/10.1111/andr.12636

 

[Michael Scally MD]

[OA] An Unusual Cause Of Gynaecomastia

Summary: Beta-human chorionic gonadotropin (betahCG) is normally produced by syncytiotrophoblasts of the placenta during pregnancy and aids embryo implantation. However, it is also secreted in varying amounts in non-pregnant conditions commonly heralding a neoplastic process.

We present a case of 50-year-old man, who presented with bilateral gynaecomastia with elevated testosterone, oestradiol, suppressed gonadotropins with progressively increasing levels of human chorionic gonadotropin (hCG).

Biochemical and radiological investigations including ultrasonography of testes, breast tissue, MRI pituitary and CT scan full body did not identify the source of hCG. FDG PET scan revealed a large mediastinal mass with lung metastasis. Immunostaining and histological analysis confirmed the diagnosis of primary choriocarcinoma of the mediastinum. It is highly aggressive and malignant tumor with poor prognosis. Early diagnosis and management are essential for the best outcome.

Learning Points: High betahCG in a male patient or a non-pregnant female suggests a paraneoplastic syndrome. In the case of persistently positive serum hCG, exclude immunoassay interference by doing the urine hCG as heterophilic antibodies are not present in the urine.

Non-gestational choriocarcinoma is an extremely rare trophoblastic tumor and should be considered in young men presenting with gynaecomastia and high concentration of hCG with normal gonads.

A high index of suspicion and extensive investigations are required to establish an early diagnosis of extra-gonadal choriocarcinoma. Early diagnosis is crucial to formulate optimal management strategy and to minimize widespread metastasis for best clinical outcome.

Rehman T, Hameed A, Beharry N, Du Parcq J, Bano G. An unusual cause of gynaecomastia in a male. Endocrinology, diabetes & metabolism case reports 2019. An unusual cause of gynaecomastia in a male in: Endocrinology, Diabetes & Metabolism Case Reports Volume 2019 Issue 1 (2019)

 

[Michael Scally MD]

The Drugs That Mostly Frequently Induce Gynecomastia

AIMS: Drug-induced gynecomastia accounts for up to 25% of cases of gynecomastia. The objective of the present study was to provide a comprehensive overview of drug-induced gynecomastia on the basis of spontaneously reported adverse drug reactions (ADRs) in the French national pharmacovigilance database (FPVD).

METHODS: We performed a case – noncase study of drug-induced gynecomastia. Cases corresponded to reports of gynecomastia recorded in the FPVD between 1 January 2008 and 31 December 2015. The noncases corresponded to all other spontaneously reported ADRs recorded in the FPVD during the same period. Data were expressed as the reporting odds ratio (ROR) and its 95% confidence interval.

RESULTS: Of the 255,354 ADRs recorded in the FPVD between 1 January 2008 and 31 December 2015, 327 (0.31%) of relevant cases of gynecomastia and 106,800 noncases were analyzed. The RORs were statistically significant for 54 active compounds mentioned 429 times in cases of gynecomastia.

A single drug was involved in 59% of cases. The most frequently implicated drug classes were antiretrovirals (23.5%), diuretics (15.5%), proton pump inhibitors (11.9%), HMG-CoA reductase inhibitors (9.1%), neuroleptics and related drugs (6.5%), calcium channel blockers (6.3%), and 5-alpha reductase inhibitors (4%).

CONCLUSIONS: A comprehensive analysis of a national pharmacovigilance database highlighted the main drug classes suspected of inducing gynecomastia. A physiopathological mechanism (a hormone imbalance with elevated estrogen levels) is known or suspected for most of the drugs involved in gynecomastia. However, we noticed a lack of harmonization in the summary of product characteristics for original vs. generic medicines.

Batteux B, Llopis B, Muller C, et al. The drugs that mostly frequently induce gynecomastia: A national case – noncase study. Therapie 2019. https://www.sciencedirect.com/science/article/pii/S0040595719300988?via%3Dihub

 

[Michael Scally MD]

J&J Hit With $8 Billion Jury Award Over Antipsychotic Drug [Gynecomastia]
J&J Hit With $8 Billion Jury Award Over Antipsychotic Drug

A Philadelphia jury on Tuesday ordered Johnson & Johnson JNJ -0.99% to pay $8 billion in damages to a Maryland man who said his use of J&J’s antipsychotic Risperdal as a child caused enlarged breasts and the company failed to properly warn of this risk.

It was the biggest award to date among more than 13,000 lawsuits against J&J alleging that Risperdal caused a condition called gynecomastia in boys, which involves enlargement of breast tissue. The lawsuits generally claim that J&J was aware of the risk of this side effect, but understated the risk to doctors.

The latest verdict stems from a lawsuit filed by Nicholas Murray, who said his use of Risperdal between 2003 and 2008 caused gynecomastia. In 2015, a Philadelphia jury awarded Mr. Murray $1.75 million in damages, which a judge reduced to $680,000, but the judge had barred the jury from awarding punitive damages at that time.

An appeals court later overturned the judge’s decision on punitive damages, clearing the way for the punitive-damages phase of the trial to start in September, ending with Tuesday’s verdict.