Gynecomastia

Gynecomastia - one- or two-sided enlargement of the mammary glands in men.

There is no precise data on the prevalence of gynecomastia, but it is found quite often and is not a rare condition.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Causes of the gynecomastia

Pathological gynecomastia develops due to the following pathological conditions:

• hormone-active tumors (testes, adrenal cortex, ectopic tumors of the lungs, liver, kidneys);
• Endocrine diseases, accompanied by a deficit of androgens;
• genetic diseases (Klinefelter's syndrome, XX-male);
• severe systemic diseases;
• taking certain medications (cimetidine, spironolactone, tricyclic antidepressants, koconazole, etc.).

The physiological gynecomastia develops as a result of an imbalance of sex hormones.

In 30% of cases, it is not possible to establish the cause of gynecomastia.

[10], [11], [12], [13], [14], [15]

Pathogenesis

Gynecomastia is caused by proliferation of previously inactive glandular tissue, as well as hyperplasia of adipose tissue.

[16], [17], [18], [19], [20], [21], [22], [23], [24]

Symptoms of the gynecomastia

Often, an increase in the mammary glands may be the only symptom of the disease. In some cases, in addition to enlarging the mammary glands, pain syndrome is also noted - palpation of the mammary glands is painful. In all cases, a thorough examination is necessary to identify the most characteristic symptoms and syndromes caused by an imbalance of sex hormones, such as:

• syndrome of impaired sexual function: decreased libido, impaired erection, decreased brightness of orgasm;
• syndrome of CNS damage: increased irritability, decreased ability to concentrate, sleep disturbance;
• depressive syndrome;
• catabolic syndrome: reduction of muscle mass and strength, osteoporosis;
• reduction of sexual hair;
• reduction in the size and density of the testicles.

[25], [26], [27], [28], [29]

Forms

Pathogenetically, gynecomastia is divided into the following types:

• physiological:
• gynecomastia of newborns;
• teenage gynecomastia (puberty and youth);
• age (gynecomastia of the elderly);
• pathological.

The localization of gynecomastia is divided into:

• one-sided (left-sided, right-sided);
• bilateral

By the nature of the development of tissue in the region of the breast gland, gynecomastia is divided into:

• true - there is a development of glandular tissue;
• false - the development of adipose tissue takes place.

In those cases where it is impossible to establish the causes of gynecomastia, they speak of idiopathic gynecomastia.

[30], [31], [32], [33], [34]

Complications and consequences

Rarely - changes in hepatic parameters.

[35], [36], [37], [38], [39], [40]

Diagnostics of the gynecomastia

Diagnosed gynecomastia without any difficulties: the diagnosis can be established on the basis of palpation of the mammary glands. A necessary part of the examination for gynecomastia is palpation of the testicles - to exclude an active testicular tumor, as well as Klinefelter's syndrome, which is characterized by hypoplastic and dense testicles.

The volume of laboratory tests is determined based on the clinical situation, they may include:

• determination of the level of LH, FSH, tostosterone, estradiol, TTT, prolactin in the blood;
• definition of karyotype (with increasing levels of LH, FSH) to exclude Klinefelter's syndrome;
• biochemical blood test (for evaluation of kidney and liver function).

[41], [42]

Differential diagnosis

When palpation, it is necessary to distinguish between gynecomastia and lipomastia - excessive deposition of adipose tissue in the area of the mammary glands. If there is difficulty in distinguishing fat from glandular tissue during palpation, ultrasound of the mammary glands or mammography can be performed.

Treatment of the gynecomastia

If gynecomastia develops as a result of endocrine diseases (hypothyroidism, hyperprolactinaemia, hypogonadism) or liver diseases, the main efforts should be directed to their cure.

With the imbalance of sex hormones, namely, a violation of the ratio between the level of androgens and estrogens in the body towards the predominance of estrogens, the goal of pharmacotherapy is to restore the balance between sex hormones.

Applied androgenic drugs, special attention among which merits placeolone, which is not subjected to aromatization in estrogens and, consequently, increases the ratio of androgens / estrogens towards androgens:

Mesterolon inside, regardless of food intake, 25 mg 1-3 r / day, 3 months.

Evaluation of treatment effectiveness

Evaluation of the effectiveness of treatment is conducted after 3 months from its onset on the basis of the clinical picture. In the absence of a reduction in the mammary glands, it is necessary to re-determine the levels of testosterone and estradiol in the blood to address the issue of increasing the dose of androgenic drugs

[43], [44], [45], [46], [47], [48], [49], [50], [51]

Errors and unreasonable appointments

The most common mistakes associated with the unreasonable appointment of a number of drugs, the effectiveness of which for this disease is not proven, such as:

• danazol;
• testolactone;
• clomiphene,
• tamoxifen.

Forecast

Physiological gynecomastia has a good prognosis, in most cases spontaneous reduction of the mammary glands occurs. The pubertal gynecomastia disappears within 2-after its appearance. In the case of pathological gynecomastia, the effectiveness of drug treatment is determined by the severity of the disease: with a significant increase in the mammary glands, medication is ineffective, with a moderate increase in treatment efficiency is 50-60%.

[52], [53], [54]