Severe Gynecomastia

What is Gynecomastia?

Gynecomastia in short can be described as the enlargement of male breast as a result of proliferation of the glandular component comprised in the breast. Clinically, Gynecomastia appears as a firm or rubbery mass protruding concincrally, emanating from the nipple. The mass is normally bilateral but unilateral Gynecomastia is also known. Incidents of fat deposits without any glandular proliferation are also known and are termed as pseudogynecomastia. Severe Gynecomastia is a condition that occurs irrespective of age. It results in male breasts that can be as large as cup C or D in comparison to women. It has been observed that men with sever Gynecomastia live with limited social activity and are depressed or embarrassed about the condition. Large breasts are perceived by many people as lack of masculinity and hence men with such condition tend to avoid circumstances where they need to expose their breasts.

Frequency of Sever Gynecomastia

It has been found that this condition is quite common in infancy, adolescence and all ages of men. However, it is known that infants have a high rate (60% – 90%) of transient Gynecomastia due to high levels of estrogen secretion by mothers during pregnancy. The next high risk (4% – 69%) f severe Gynecomastia occurs during puberty due to transient increase of estradiol concentration on the sunset of puberty (10 years – 12 years of age). Regression is known to happen in about one and a half years and does not normally persist beyond the age of 17. The next peak (24% – 65%) occurs in older men due to decreased secret of testosterone and is very prevalent.

Causes of severe Gynecomastia

Gynecomastia can be pathologic or physiologic. Physiological type occurs more in newborns, infants, adolescents or older men, whereas pathologic Gynecomastia is caused by hormonal imbalances or drug use and can be caused in anyone. Decreased production of testosterone or increased production of estrogen causes pathological Gynecomastia. Decreased production of testosterone can happen due to the following conditions:

Klinefelter syndrome

Pituitary tumors

Congenital anorchia

Viral orchitis

Testicular trauma

Kallmann syndrome OR

Testicular torsion

Many malignancies occurring in the human body also increase the hCG serum resulting in the cause of Gynecomastia. The maligannacies could have gastric carcinoma, lung cancer, hepatoma or renal cell carcinoma. Renal failure, Malnutrition, hyperthyroidism, androgen insensitivity syndrome and alpha-reductase deficiency syndrome are also known to contribute to the cause.

The contribution of drug use to severe Gynecomastia can be classified as following:
Estrogen enhancing drugs like digitalis, diethylstilbestrol, phytoestrogens or estrogen-contaminated food and estrogen containing cosmetics

Use of drugs that promote estrogen synthesis like clomiphene, gonadotropins, phenytoin or exogenous testosterone

Drugs that can inhibit synthesis of testosterone like metronidazole, ketoconazole, cisplatin, cimetidine, spironolactone, finasteride, flutamide, finasteride or etomidate

However it is necessary to understand that drugs in the same class do not contribute to gynecomastia to the same extent. In order to evaluate the actual causes of severe Gynecomastia, it is essential to evaluate the medical history of a patient. The essential points are

a. Please note the age at which the onset of Gynecomastia was observed and the duration.

b. Inquire about the recent changes in nipple size and the occurrence of pain or discharge from the nipples.

c. Make sure to find out if the patient has a history of trauma to the testicles, mumps, alcohol use or use of any drugs.

d. The family medical history relating to Gynecomastia is an important consideration.

e. Medical history of the patient with regard to sexual dysfunction, hypogonadism (impotence or decreased libido and strength).

f. Examine the physical factors like examination of breasts with regard to size and consistency, presence of discharge or any axillary lymphadenopathy.

g. Examine size of testicles with regard to size and consistency. Observe for presence of nodules or any asymmetry.

h. Signs of feminization like enunchid habitus and hair distribution.

i. Also check for any chronic thyroid, liver or renal dysfunctions or diseases.

Severe Gynecomastia is perfectly curable over time.

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