Clinical presentations

Gynaecomastia (enlargement of the glandular tissue) should be differentiated from pseudogynaecomastia (excessive adipose tissue often seen in obese men) and breast cancer.

Ask the patient to lie on his back with his hands behind his head. Place your thumb and forefinger on each side of the breast and slowly bring them together toward the nipple. In gynaecomastia, a rubbery/firm disk of glandular tissue (at least 0.5 cm in diameter) will be felt extending concentrically from the nipple. In pseudogynaecomastia, the fingers will not meet any resistance until they reach the nipple.

Breast cancer tends to be eccentrically positioned (rather than symmetrical to the nipple), tends to be firm to hard in texture, and may be associated with skin dimpling, nipple retraction, discharge and axillary lymphadenopathy.

A careful history and physical examination are essential in detecting the symptoms and signs of the underlying cause of gynaecomastia (Box 20.1). Patients should be asked about any of the drugs that can cause gynaecomastia. Look for symptoms and signs of the possible underlying cause, i.e. hypogonadism, hyperthyroidism, chronic liver or chronic renal disease, thyrotoxicosis and testicular or other (human chorionic gonadotrophin [hCG]-or oestrogen-secreting) tumours.

Box 20.1 Causes of gynaecomastia

Physiological

Puberty, persistent pubertal (25% of cases), elderly

Drugs (10–25%)

Oestrogens, antiandrogens, spironolactone (antiandrogenic effects), cimetidine, nifedipine, herbal products/oils

Hypogonadism (primary 8%, secondary 2%)

Reduced serum testosterone production

Chronic liver disease (8%)

Enhanced aromatization (many patients are also on spironolactone)

Chronic renal failure (1%)

Reduced serum testosterone due to Leydig cell dysfunction

Thyrotoxicosis (1.5%)