checkup condition
Gynecomastia ( besides spelled gynaecomastia ) [ a ] is the abnormal non-cancerous enlargement of one or both breasts in males due to the growth of breast tissue as a result of a hormone imbalance between estrogen and androgen. [ 4 ] [ 5 ] Gynecomastia can cause significant psychological straiten or disquiet. [ 6 ]
Reading: Gynecomastia – Wikipedia
Gynecomastia can be convention in newborn babies due to exposure to estrogen from the mother, in adolescents going through puberty, in older and/or corpulent men. [ 4 ] Most occurrences of gynecomastia do not require diagnostic tests. [ 4 ] [ 5 ] Gynecomastia may be caused by abnormal hormone changes, any condition that leads to an increase in the ratio of estrogens / androgens such as liver disease, kidney failure, thyroid disease and some non-breast tumors. Alcohol and some drugs can besides cause front expansion. [ 4 ] [ 7 ] other causes may include Klinefelter syndrome, metabolic dysfunction, or a natural decline in testosterone production. [ 4 ] [ 6 ] [ 8 ] This may occur tied if the levels of estrogens and androgens are both appropriate, but the ratio is altered. [ 7 ] Gynecomastia is the most common benign disorder of the male breast weave and affects 35 % of men, being most prevailing between the ages of 50 and 69. [ 5 ] [ 9 ] It is normal for up to 70 % of adolescent boys to develop gynecomastia. [ 6 ] Of these, 75 % decide within two years of onset without discussion. [ 10 ] If the condition does not resolve within 2 years, or if it causes embarrassment, annoyance or tenderness, treatment is warranted. [ 11 ] [ 12 ] Medical treatment of gynecomastia that has persisted beyond two years is much ineffective. Gynecomastia is different from “ pseudogynecomastia “, [ 5 ] [ 6 ] which is normally salute in men with fleshiness. [ 13 ] [ 14 ] Medications such as aromatase inhibitors have been found to be effective [ 15 ] and even in rare cases of gynecomastia from disorders such as aromatase surfeit syndrome or Peutz–Jeghers syndrome, [ 16 ] but surgical removal of the excess tissue can be needed to correct the condition. [ 17 ] In 2019, 24,123 male patients underwent the operation in the United States, accounting for a 19 % increase since 2000. [ 18 ]
definition [edit ]
Gynecomastia is the abnormal non-cancerous enlargement of one or both breasts in men due to the growth of breast tissue as a leave of a hormone asymmetry between estrogen and androgen. [ 4 ] [ 5 ] Gynecomastia is different from “ pseudogynecomastia “, [ 5 ] [ 6 ] which is defined as an surfeit of skin and/or adipose weave in the male breasts without the development of true female-like protrusive summit tissue ; [ 19 ] [ 20 ] pseudogynecomastia is normally present in men with fleshiness. [ 13 ] [ 14 ]
Signs and symptoms [edit ]
In gynecomastia there is typically enlargement of one or both breasts, symmetrically or asymmetrically, in a man. soft, compressible, and fluid breast weave is felt under the nipple and its surrounding skin in line to softer fatty tissue. [ 9 ] [ 21 ] Dimpling of the skin and nipple retraction are not typical features of gynecomastia. [ 9 ] Milky discharge from the nipple is not a distinctive find, but may be seen in a gynecomastic person with a prolactin secreting tumor. [ 7 ] An increase in the diameter of the areola and asymmetry of the chest of drawers are other possible signs of gynecomastia. [ 22 ] world with gynecomastia may appear anxious or stressed due to concerns about its appearance and the hypothesis of having breast cancer. [ 23 ] [ 24 ]
Causes [edit ]
Gynecomastia is thought to be caused by an alter proportion of estrogens to androgens mediated by an addition in estrogen production, a decrease in androgen production, or a combination of these two factors. [ 7 ] Estrogen acts as a growth hormone to increase the size of male breast tissue. [ 7 ] [ 23 ] The induce of gynecomastia is strange in around 25 % of cases. [ 21 ] [ 24 ] Drugs are estimated to cause 10–25 % of cases of gynecomastia. [ 25 ] lavender and tea tree oils have estrogenic and anti-androgenic effects and there have been reports of their use causing prepubescent gynecomastia. [ 26 ] [ 27 ] Certain health problems in men such as liver-colored disease, kidney failure, or gloomy testosterone can cause breast emergence in men. Drugs and liver disease are the most common causal agent in adults. [ 28 ] other medications known to cause gynecomastia include methadone ; aldosterone antagonists ( spironolactone and eplerenone ) ; HIV medicine ; cancer chemotherapy ; hormone treatment for prostate cancer ; heartburn and ulcer medications ; calcium distribution channel blockers ; antifungal medications such as ketoconazole ; antibiotics such as metronidazole ; tricyclic antidepressants such as amitriptyline ; and herbals such as lavender, tea corner petroleum, and dong quai. [ 4 ] The insecticide phenothrin possesses antiandrogen natural process and has been associated with gynecomastia. [ 29 ] [ 30 ]
physiologic [edit ]
Gynecomastia of boys going through puberty Both male and female newborns may show front development at birth or in the first weeks of animation. [ 31 ] During pregnancy, the placenta converts the androgenic hormones dehydroepiandrosterone ( DHEA ) and DHEA sulfate to the estrogenic hormones estrone and estradiol, respectively ; after these estrogens are produced by the placenta, they are transferred into the baby ‘s circulation, thereby leading to impermanent gynecomastia in the baby. [ 23 ] [ 32 ] In some infants neonatal milk ( besides known as “ hag ‘s milk “ ) can leak from the nipples. [ 21 ] The temp gynecomastia seen in newborn babies normally resolves after two or three weeks. [ 23 ] hormonal changes of puberty leads to Gynecomastia in adolescent boys. Gynecomastia occurs in many boys during early puberty to middle puberty. It normally goes away within 6 months to 2 years. [ 33 ] Gynecomastia in adolescents normally starts between the ages of 10 and 12 and normally goes away after 18 months. [ 23 ] Declining testosterone levels and an increase in the level of hypodermic fatty tissue seen as part of the normal aging process can lead to gynecomastia in older men. This is besides known as doddering gynecomastia. [ 23 ] Increased fatso tissue in these men leads to increased conversion of androgenic hormones such as testosterone to estrogens. [ 23 ] When the human torso is deprived of adequate nutrition, testosterone levels drop, while the adrenal glands continue to produce estrogens, thereby causing a hormonal asymmetry. [ 23 ] Gynecomastia can besides occur once normal nutriment is restarted ( this is known as refeeding gynecomastia ). [ 23 ]
Medicines [edit ]
[34] More than 90% of cases of gynecomastia with nonsteroidal antiandrogens including flutamide are mild to moderate.[35][36] An exceptional subject of extreme gynecomastia in a 63-year-old world, treated with the nonsteroid antiandrogen flutamide for prostate gland cancer. ( a ) With flutamide ; ( b-complex vitamin ) after discontinuance of flutamide.More than 90 % of cases of gynecomastia with nonsteroid antiandrogens including flutamide are mild to moderate. about 10–25 % of cases are estimated to result from the use of medications, known as nonphysiologic gynecomastia. [ 17 ] [ 24 ] Medications known to cause gynecomastia include cimetidine, ketoconazole, gonadotropin-releasing hormone analogues, human growth hormone, homo chorionic gonadotropin, 5α-reductase inhibitors such as finasteride and dutasteride, sealed estrogens used for prostate gland cancer, and antiandrogens such as bicalutamide, flutamide, and spironolactone. [ 7 ] [ 17 ] [ 37 ] [ 38 ] Medications that are credibly associated with gynecomastia include calcium groove blockers such as verapamil, amlodipine, and nifedipine ; risperidone, olanzapine, anabolic steroids, [ 17 ] [ 39 ] alcohol, opioids, efavirenz, alkylating agents, and omeprazole. [ 17 ] [ 29 ] Certain components of personal skin care products such as lavender necessity oil [ 40 ] or tea tree anoint and sealed dietary supplements such as ding quai and Tribulus terrestris have been associated with gynecomastia. [ 24 ]
chronic disease [edit ]
People with kidney failure are much malnourished, which may contribute to gynecomastia development. dialysis may attenuate malnutrition of kidney failure. additionally, many kidney failure patients experience a hormonal asymmetry due to the inhibition of testosterone production and testicular damage from high levels of urea besides known as uremia-associated hypogonadism. [ 24 ] [ 41 ] In individuals with liver-colored failure or cirrhosis, the liver-colored ‘s ability to by rights metabolize hormones such as estrogen may be impaired. additionally, those with alcoholic liver disease are far put option at risk for development of gynecomastia ; ethanol may directly disrupt the synthesis of testosterone and the presence of phytoestrogens in alcoholic drinks may besides contribute to a higher estrogen to testosterone ratio. [ 24 ] Conditions that can cause malabsorption such as cystic fibrosis or ulcerative colitis may besides produce gynecomastia. [ 24 ] A small symmetry of male gynecomastia cases may be seen with rare inherit disorders such as spinal anesthesia and bulbar brawny atrophy and the very rare aromatase excess syndrome. [ 42 ] [ 43 ]
Tumors [edit ]
testicular tumors such as Leydig cell tumors or Sertoli cell tumors [ 44 ] ( such as in Peutz–Jeghers syndrome ) [ 10 ] or human chorionic gonadotropin -secreting choriocarcinoma [ 29 ] may result in gynecomastia. other tumors such as adrenal gland tumors, pituitary gland tumors ( such as a prolactinoma ), or lung cancer, can produce hormones that alter the male–female hormone symmetry and campaign gynecomastia. [ 21 ] Individuals with prostate cancer who are treated with androgen loss therapy may experience gynecomastia. [ 45 ]
Pathophysiology [edit ]
pathology : A large glandular bulk of male breast tissue, surgically removed The causes of common gynecomastia stay uncertain, but are thought to result from an asymmetry between the actions of estrogen and androgens at the breast tissue. [ 8 ] [ 17 ] Breast prominence can result from enlargement of glandular breast tissue, chest adipose tissue ( fat ) and clamber, and is typically a combination. [ 29 ] As in females, estrogen stimulates the growth of breast weave in males. [ 7 ] In accession to immediately stimulating male front weave growth, estrogens indirectly decrease secretion of testosterone by suppressing luteinizing hormone secretion, resulting in decrease testicular secretion of testosterone. [ 7 ] Furthermore, estrogens can increase blood levels of the protein sex hormone-binding globulin ( SHBG ), which binds free testosterone ( the active shape ) leading to decreased action of testosterone in male breast tissue. [ 7 ] basal hypogonadism ( indicating an intrinsic trouble with the testes in males ) leads to decreased testosterone synthesis and increase conversion of testosterone to estradiol potentially leading to a gynecomastic appearance. [ 23 ] Klinefelter syndrome is a luminary example of a disorder that causes hypogonadism and gynecomastia, and has a higher hazard of breast cancer in males ( 20–50 times higher than males without the perturb ). [ 46 ] Central hypogonadism ( indicating a problem with the mind ) leads to decreased product and free of luteinizing hormone ( LH, a stimulatory signal for endogenous steroid hormone hormone synthesis ) which leads to decrease production of testosterone and estradiol in the testes. [ 23 ] Individuals who have cirrhosis or chronic liver disease may develop gynecomastia for respective reasons. Cirrhotics tend to have increased secretion of the androgenic hormone androstenedione from the adrenal glands, increased conversion of this hormone into assorted types of estrogen, [ 7 ] and increased levels of SHBG, which leads to decreased blood levels of free testosterone. [ 23 ] approximately 10–40 % of individuals with Graves ‘ disease ( a coarse shape of hyperthyroidism ) experience gynecomastia. [ 23 ] Increased conversion of testosterone to estrogen by increase aromatase activeness, [ 7 ] increased levels of SHBG and increased production of testosterone and estradiol by the testes due to lift levels of LH cause the gynecomastia. Proper treatment of the hyperthyroidism can lead to the resoluteness of the gynecomastia. [ 23 ] Medications are known to cause gynecomastia through several different mechanisms. These mechanisms include increasing estrogen levels, mimicking estrogen, decreasing levels of testosterone or other androgens, blocking androgen receptors, increasing prolactin levels, or through nameless means. [ 23 ] High levels of prolactin in the blood ( which may occur as a result of certain tumors or as a side impression of certain medications ) has been associated with gynecomastia. [ 23 ] A high gear level of prolactin in the rake can inhibit the release of gonadotropin-releasing hormone and consequently campaign central hypogonadism. [ 7 ] [ 23 ] Receptors for prolactin and other hormones including insulin-like growth factor 1, insulin-like growth divisor 2, luteinizing hormone, progesterone, and human chorionic gonadotropin have been found in male breast tissue, but the shock of these diverse hormones on gynecomastia development is not well understand. [ 7 ]
diagnosis [edit ]
To diagnose gynecomastia, a exhaustive history and physical examination are obtained by a doctor. significant aspects of the physical examination include evaluation of the male breast weave with palpation to evaluate for breast cancer and pseudogynecomastia ( male breast weave expansion entirely due to overindulgence fatso weave ), evaluation of penile size and development, evaluation of testicular development and an assessment for masses that raise intuition for testicular cancer, and proper development of secondary arouse characteristics such as the total and distribution of pubic and underhand hair. [ 7 ] Gynecomastia normally presents with bilateral interest of the breast weave but may occur unilaterally deoxyadenosine monophosphate good. [ 24 ] A review of the medications or illegal substances an individual takes may reveal the induce of gynecomastia. [ 24 ] Recommended lab investigations to find the underlie induce of gynecomastia include tests for aspartate transaminase and alanine transaminase to rule out liver disease, serum creatinine to determine if kidney damage is show, and thyroid-stimulating hormone levels to evaluate for hyperthyroidism. If these initial testing ground tests fail to uncover the cause of gynecomastia, then extra tests to evaluate for an underlying hormonal libra due to hypogonadism or a testicular tumor should be checked including entire and free levels of testosterone, luteinizing hormone, follicle stimulating hormone, estradiol, serum beta human chorionic gonadotropin ( β-hCG ), and prolactin. [ 24 ] high levels of prolactin are rare in people with gynecomastia. [ 24 ] If β-hCG levels are abnormally high gear, then ultrasound of the testicles should be performed to check for signs of a hormone-secreting testicular tumor. [ 24 ] Markers of testicular, adrenal, or other tumors such as urinary 17-ketosteroid or serum dehydroepiandrosterone may besides be checked if there is tell of hormonal asymmetry on physical examination. If this evaluation does not reveal the campaign of gynecomastia, then it is considered to be idiopathic gynecomastia ( of unclear campaign ). [ 24 ]
differential diagnosis [edit ]
other causes of male front enlargement such as mastitis, [ 24 ] [ 47 ] breast cancer, pseudogynecomastia, lipoma, greasy vesicle, dermoid vesicle, hematoma, metastasis, ductal ectasia, fat necrosis, or a hamartoma are typically excluded before making the diagnosis. [ 24 ] Another condition that may be confused with gynecomastia is enlargement of the pectoral muscles. [ citation needed ]
Imaging [edit ]
mammography is the method of choice for radiologic examination of male breast weave in the diagnosis of gynecomastia when breast cancer is suspected on physical interrogation. [ 7 ] [ 9 ] however, since breast cancer is a rare induce of breast tissue expansion in men, mammography is rarely needed. [ 7 ] If mammography is performed and does not reveal findings suggestive of breast cancer, far visualize is not typically necessary. [ 9 ] If a tumor of the adrenal gland glands or the testes is thought to be creditworthy for the gynecomastia, sonography examination of these structures may be performed. [ 7 ]
histology [edit ]
early histological features expected to be seen on examination of gynecomastic weave attained by fine-needle aspiration biopsy include the comply : proliferation and lengthen of the ducts, an increase in connective tissue, an increase in inflammation, and swelling surrounding the ducts, and an increase in fibroblasts in the conjunction tissue. [ 23 ] Chronic gynecomastia may show different histological features such as increased connection tissue fibrosis, an increase in the numeral of ducts, less ignition than in the acute stagecoach of gynecomastia, increased subareolar adipose tissue, and hyalinization of the stroma. [ 22 ] [ 23 ] When surgery is performed, the gland is routinely sent to the lab to confirm the presence of gynecomastia and to check for tumors under a microscope. The utility of diseased examination of breast tissue removed from male adolescent gynecomastia patients has recently been questioned due to the rarity of breast cancer in this population. [ 48 ]
classification [edit ]
The spectrum of gynecomastia severity has been categorized into a grade system : [ 49 ]
- Grade I: Minor enlargement, no skin excess
- Grade II: Moderate enlargement, no skin excess
- Grade III: Moderate enlargement, skin excess
- Grade IV: Marked enlargement, skin excess
treatment [edit ]
Mild cases of gynecomastia in adolescence may be treated with advice on life style habits such as proper diet and use with reassurance. In more severe cases, medical discussion may be offered including medicine or surgical interposition. [ 23 ]
medicine [edit ]
Gynecomastia can respond well to aesculapian treatment although it is normally lone effective when done within the beginning two years after the start of male breast expansion. [ 7 ] Selective estrogen receptor modulators ( SERMs ) such as estrogen antagonist, raloxifene, and clomifene may be beneficial in the treatment of gynecomastia but are not approved by the Food and Drug Administration for use in gynecomastia. [ 7 ] [ 17 ] [ 50 ] Clomifene seems to be less effective than estrogen antagonist or raloxifene. [ 50 ] Tamoxifen may be used to treat gynecomastia in adults and of the medical treatments used, tamoxifen is the most effective. [ 51 ] [ 52 ] Recent studies have shown that treatment with estrogen antagonist may represent a safe and effective mode of treatment in cases of cosmetically disturbing or irritating gynecomastia. [ 17 ] [ 53 ] Aromatase inhibitors ( AIs ) such as anastrozole have been used off-label for cases of gynecomastia occurring during puberty but are less effective than SERMs. [ 16 ] [ 50 ] A few cases of gynecomastia caused by the rare disorders aromatase excess syndrome and Peutz–Jeghers syndrome have responded to treatment with AIs such as anastrozole. [ 16 ] Androgens / anabolic steroids may be effective for gynecomastia. [ 50 ] Testosterone itself may not be suitable to treat gynecomastia as it can be aromatized into estradiol, but nonaromatizable androgens like topical androstanolone ( dihydrotestosterone ) can be useful. [ 50 ]
surgery [edit ]
male with asymmetrical gynecomastia, before and after excommunication of the gland and liposuction of the shank If chronic gynecomastia does not respond to medical discussion, surgical removal of glandular breast tissue is normally required. [ 17 ] The American Board of Cosmetic Surgery reports operating room is the “ most effective known treatment for gynecomastia. ” [ 54 ] surgical approaches to the discussion of gynecomastia include hypodermic mastectomy, liposuction-assisted mastectomy, laser-assisted liposuction, and laser-lipolysis without liposuction. Complications of mastectomy may include hematoma, surgical scent infection, breast asymmetry, changes in sensation in the breast, necrosis of the areola or nipple, seroma, noticeable or afflictive scars, and contour deformities. [ 49 ] In 2019, 24,123 male patients undergo surgical treatment for gynecomastia in the United States, accounting for a 19 % addition since 2000. thirty-five percentage of those patients were between the ages of 20 and 29, and 60 % were younger than historic period 29 at the clock of the operation. At an average surgeon ‘s fee of $ 4,123, gynecomastia surgery was besides the 11th most dearly-won male cosmetic surgery of 2019. [ 55 ]
Others [edit ]
Radiation therapy and estrogen antagonist have been shown to help prevent gynecomastia and front pain from developing in prostate gland cancer patients who will be receiving androgen privation therapy. The efficacy of these treatments is specify once gynecomastia has occurred and are therefore most effective when used prophylactically. [ 56 ] In the United States, many policy companies deny coverage for operating room for gynecomastia treatment or male breast decrease on the footing that it is a cosmetic procedure. [ 57 ] [ 58 ] [ 59 ] [ 60 ]
prognosis [edit ]
Gynecomastia is not physically harmful, but in some cases it may be an indicator of early more unplayful underlie conditions, such as testicular cancer. [ 7 ] The glandular tissue typically grows under the influence of hormonal foreplay and is often affectionate or painful. furthermore, gynecomastia frequently presents social and psychological difficulties such as low self-esteem or shame for the martyr. [ 48 ] [ 49 ]
epidemiology [edit ]
Gynecomastia is the most common benign disorder of the male breast tissue and affects 35 percentage of men, being most prevailing between the ages of 50 and 69. [ 5 ] [ 9 ] New cases of gynecomastia are common in three long time populations : newborns, adolescents, and men older than 50 years. [ 49 ] Newborn gynecomastia occurs in about 60–90 percentage of male babies and most cases resolve on their own. [ 23 ] [ 24 ] During adolescence, about 50 to 70 percentage of males are estimated to exhibit signs of gynecomastia. [ 7 ] Gynecomastia in older men is estimated to be deliver in 24–65 percentage of men between the ages of fifty and eighty. Estimates on asymptomatic gynecomastia is about up to 70 % in men aged 50 to 69 years. [ 23 ] [ 61 ] The prevalence of gynecomastia in men may have increased in holocene years, but the epidemiology of the disorder is not fully understood. [ 29 ] The use of anabolic steroids and vulnerability to chemicals that mimic estrogen in cosmetic products, organochlorine pesticides, and industrial chemicals have been suggested as possible factors driving this addition. [ 29 ] [ 60 ] According to the american Society of Plastic Surgeons, breast decrease surgeries to correct gynecomastia are becoming increasingly common. In 2006, there were 14,000 procedures of this type performed in the United States alone. [ 60 ]
club and acculturation [edit ]
Gynecomastia can result in psychological distress for those with the condition. Common slang or derogative terms for gynecomastia include man tits, man boobs or moobs. [ 62 ] Support groups exist to help improve the self-esteem of affect people. [ 60 ] In 2019, a 12-person Philadelphia jury awarded $ 8 billion in punitive damages to plaintiffs tied to the manipulation of risperidone. Risperidone is an atypical major tranquilizer that was in the first place approved to treat psychosis, but its use in children, including those with autism, ADHD, and schizophrenia diagnoses, has grown over the final two decades. [ 63 ] In Murray v. Janssen Pharmaceuticals, Murray was a Risperidone user who was prescribed the medicine at age nine and developed male breasts. A jury decided in Murray ‘s favor in November 2015 and awarded him $ 1.75 million. The $ 1.75 million jury verdict represented damages for “ disfigurement and mental anguish, ” though it was late reduced to $ 680,000. [ 64 ] In the second helping of the bifurcated trial, the plaintiffs sought to prove that the companies knew and measuredly disregarded testify that Risperidone could lead to gynecomastia in young males, and however promoted the medication off-label and released the medication into the open market for prescription and use by patients without disclosing the side effects. [ 64 ] The jury found for the plaintiffs in the second share of the test and awarded $ 8 billion in punitive damages. The sum was late reduced to $ 6.8 million by Judge Kenneth Powell Jr. [ 65 ]
etymology [edit ]
The term comes from greek γυνή gyné ( stem turn gynaik- ) ‘female ‘ and μαστός mastós ‘breast ‘. [ 3 ]
See besides [edit ]
References [edit ]
- Explanatory notes
- ^
γυνή
gyné (stem gynaik-) meaning “female” and
μαστός
mastós meaning “breast”.[3] The condition comes from the Greek ( shank ) meaning “ female ” andmeaning “ breast ” .
- Citations
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