Evaluation of Gynecomastia
For further information on gynecomastia surgery reference can be made to the following pages:
Gynecomastia Surgery
Gynecomastia Causes
Gynecomastia Treatment
History and Physical Examination for Gynecomastia
The patient will be queried as to the duration and timing of the breast enlargement. A thorough family history should be obtained. A review of symptoms focusing on signs and symptoms associated with hypogonadism should be obtained, including erectile dysfunction or decreased libido. Signs and symptoms of systemic diseases associated with gynecomastia should also be reviewed. Finally, an extremely thorough medication history and social history should be obtained.
On physical examination, the breast tissue can be elevated up off of the chest wall by pinching, allowing for accurate measurement. Tenderness should be noted and an attempt should be made to elicit nipple discharge. Bilateral breast examination should be performed to compare symmetry, and a thorough examination for adenopathy should be performed. In addition, percussion and palpation of the liver should be performed, as should be a testicular examination.
Unintentional Exposure to Oestrogen
Oestrogen can be absorbed into the body unintentionally through a variety of mechanisms:
Medications
Skin creams
Antibalding lotions
Vaginal estrogen cream (through intercourse)
Occupations
Barbers (who apply oestrogen-containing creams into the scalp)
Morticians (who apply oestrogen-containing creams onto corpses)
Factory workers involved in manufacturing oestrogens
Diet
Milk or meat from oestrogen-treated cows
Phytoestrogens in plants or animals
Mammography
Mammography is extremely useful in imaging gynecomastia. Gynecomastia appears as a flame-shaped opacity extending into the surrounding fat. Mammography can effectively distinguish between malignant and benign breast disease. If the history, physical and mammography all suggest simple gynecomastia, biopsy may be avoided.
Biopsy
If at this point in the evaluation there is any concern that an underlying malignancy might be present, then a biopsy is indicated.
Biopsy not necessary in every patient with gynecomastia, but patients with worrisome features such as an asymmetric or hard mass, fixed mass, skin ulceration, bloody nipple discharge, or an abnormality on imaging should have a biopsy performed.
Core-needle biopsy has been the biopsy method of choice in this situation, although now that the cytologic features of gynecomastia have been well described, fine-needle aspiration biopsy is an option if an experienced cytopathologist is available.
Laboratory Evaluation
If the history does not suggest a drug as the inciting agent, then several laboratory tests may help find the cause. Biochemical assessment of the liver (liver function
tests), kidney (BUN/Cr), and thyroid (T3, T4, thyroid-stimulating hormone) should be performed because gynecomastia may be the result of underlying liver disease, chronic renal failure, or thyroid disease.
A chest x-ray study, if one has not been done recently, should be obtained. This is particularly true in older individuals. In addition to these tests, measurements
of serum concentrations of several hormones may be obtained. These include serum estradiol (or estrone), testosterone, LH, SHBG, hCG, and prolactin. These tests do not need to be obtained routinely in every patient with gynecomastia, but their use should be guided by the clinical situation. If any abnormalities are discovered, further workup and treatment should proceed accordingly. However, the majority of cases will have a normal laboratory evaluation and will be labeled as idiopathic gynecomastia.
