This patient has bilateral gynaecomastia. Palpable breast tissue is found in approximately one third of all
adult males and in two thirds of pubertal boys. Localised discomfort may be the principle symptom but the
cosmetic appearance is usually the main concern, particularly in adolescents.
Most cases of gynaecomastia occur at times of physiological hormonal change. Such physiological gynaecomastia
occurs in the neonatal and pubertal periods and also in old age. Neonatal gynaecomastia is due to the
trans-placental passage of maternal oestrogen and may be associated with a nipple discharge known as 'witch's
milk'. It usually resolves during the first few weeks of life. Pubertal gynaecomastia is the commonest male
breast lesion. It can be either unilateral or bilateral. Reassurance is often the only treatment that is
required. The lesion will generally settle spontaneously but may persist for months or years. Senile
gynaecomastia can be difficult to differentiate from the pseudo- gynaecomastia due to general adiposity
increasingly seen in old age.
Only one third of patients with gynaecomastia will have a pathological cause. Gynaecomastia can be due to:
- Primary testicular failure - anorchia, Klinefelter's syndrome or bilateral cryptorchidism.
- Acquired testicular failure - mumps, irradiation.
- Secondary testicular failure - hypopituitarism. isolated gonadotrophin deficiency.
- Endocrine tumours - testicular, adrenal, pituitary.
- Non-endocrine tumours - bronchial carcinoma, lymphoma, hypernephroma.
- Hepatic disease - alcoholic cirrhosis, haemochromotosis.
- Drugs - oestrogen agonists (spironolactone), hyperprolactinaemia (phenothiazines), Testosterone target
cell inhibitors (cimetidine, cyproterone acetate)
The cause is often self evident from a full history and examination. The testes should always be examined.
Useful investigations may include a chest x-ray, full blood count and liver function test. If there is suspicion
of a testicular tumour then ultrasound should be requested. Hormonal assays may confirm endocrinopathies. Male
breast cancer is rare accounting for only 1% of all breast tumours and 0.2% of all male malignancies. It should
be considered in all unilateral breast lesions and fine needle aspiration cytology and male mammograms performed
if there is any diagnostic doubt.
Most gynaecomastia is minor, does not require surgical intervention and the patient can be appropriately
reassured. If it is painful or embarrassing surgery can be considered. The breast disc can usually be excised
through a circumareolar incision along the lower border of the areola. The use of a suction drain is advisable
to prevent post-operative haematoma formation. This can usually be removed after 24 hours. The concavity
resulting from excision of the breast disc tends to fill over time but numbness of the nipple is not uncommon.
Excision of all of the breast disc is required to prevent recurrence.
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