Gynecomastia is an endocrine system disorder in which a noncancerous increase in the size of male breast tissue occurs. Gynecomastia is benign enlargement of the male breast caused by proliferation of glandular breast tissue
Pseudogynecomastia is Enlargement of the male breast, as a result of increased fat deposition is called Pseudogynecomastia.
Some of the causes are:
• Persistent pubertal gynecomastia
• Drugs :Common drugs includes Spironolactone, Cimetidine, Ketoconazole, Estrogens and estrogen agonists, human chorionic gonadotropin (hCG), antiandrogens, gonadotropin-releasing hormone (GnRH) agonists, and 5- alpha-reductase inhibitors.
• No detectable abnormality (idiopathic)
• Cirrhosis or malnutrition
• Hypogonadism
• Testicular tumors
• Hyperthyroidism
• Chronic renal insufficiency
Sign and symptoms are:
• Gynecomastia usually manifests as a palpable, discrete button of tissue radiating from beneath the nipple and areola.
• Gynecomastia feels “gritty” when the breast is pinched between the thumb and forefinger.
• Fatty tissue (Pseudogynecomastia), unlike gynecomastia, will not cause resistance until the nipple is reached.
Examination findings are:
• The examination is performed by having the patient lie on his back with his hands behind his head. The examiner then places his or her thumb and forefinger on each side of the breast and slowly brings them together
• Gynecomastia is appreciated as a concentric, rubbery-to-firm disk of tissue, often mobile, located directly beneath the areolar area.

Diagnostic evaluation:
History: Age, Duration of the gynecomastia, Presence of pain, Use of drugs including recreation drugs e.g. Alcohol, Presence of symptoms suggestive of pathological cause, Symptoms of hypogonadism – reduced libido, erectile dysfunction, Systemic disease: Hepatic, Renal, Endocrine disease. (Thyrotoxicosis, Cushing syndrome).
Physical examination of Breasts:
Pinch breast tissue between thumb and forefinger distinguish from fat
Measure glandular tissue diameter. Assess testicular size
Baseline investigations
-Serum testosterone,Serum estradiol, LH and FSH,Prolactin, hCG,Liver function tests.
Additional investigations
-If testicular tumour is suspected, e.g. raised estradiol/hCG, testicular USG.
-If adrenal tumour is suspected, e.g. markedly raised estradiol: abdominal CT or MRI scan.
-If breast malignancy is suspected: mammography; FNAC/tissue biopsy.
-If lung cancer is suspected, e.g. raised hCG: chest radiograph.
-Other investigations, depending on clinical suspicion, e.g. renal or thyroid function.
Management :
Medical treatment:
The underlying disease should be corrected if possible, and offending drugs should be discontinued. ER antagonists (tamoxifen, 10 to 20 mg daily, or raloxifene, 60 mg daily) are effective in treating pubertal and adult gynecomastia and preventing gynecomastia induced by androgen deprivation therapy.
With long standing gynecomastia (more than 1 year), surgical reduction mammoplasty (i.e. removal of breast tissue with or without periareolar adipose tissue) is necessary if breast enlargement is severe, painful, socially embarrassing or disfiguring.

Radiation therapy:
Low-dosage external beam radiation therapy (900 cGy or less) is effective, but less effective than tamoxifen, for prevention of gynecomastia due to anti-androgen monotherapy for prostate cancer.




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