Overview
Definition:
Gynecomastia is benign enlargement of male breast glandular tissue
Galactorrhea is inappropriate lactation, typically milky discharge from the nipple in males or females
While distinct, both can stem from endocrine dysregulation.
Epidemiology:
Gynecomastia is common in newborns (maternal estrogen), puberty (hormonal fluctuations), and older men (aging, hypogonadism)
Idiopathic gynecomastia is frequent
Galactorrhea incidence is lower, often associated with hyperprolactinemia or certain medications.
Clinical Significance:
Distinguishing true gynecomastia from pseudogynecomastia (adipose tissue) and identifying the underlying cause of galactorrhea is vital for appropriate management, preventing unnecessary investigations, and addressing potential serious pathology like pituitary tumors or endocrine disorders.
Clinical Presentation
Symptoms:
Gynecomastia: Palpable breast tissue, often bilateral but can be unilateral
Tenderness or discomfort in the breast
Galactorrhea: Milky nipple discharge, spontaneous or expressible
May be associated with menstrual irregularities (females) or hypogonadism symptoms (males).
Signs:
Gynecomastia: Firm, rubbery subareolar mass >2 cm diameter
Palpable glandular tissue
Pseudogynecomastia: Diffuse adipose tissue without a discrete glandular component
Galactorrhea: Milky discharge observed on nipple expression
Evaluate for signs of hypogonadism (e.g., small testes) or pituitary mass (e.g., visual field deficits).
Diagnostic Criteria:
Gynecomastia: Clinical diagnosis based on physical examination showing glandular proliferation
Histological confirmation is rarely needed
Galactorrhea: Confirmed by observing milky discharge upon gentle expression of the nipple
Rule out milk from residual breastfeeding or infant feeding.
Diagnostic Approach
History Taking:
Detailed menstrual history (females), sexual history and pubertal development (males)
Inquire about medication use (e.g., antipsychotics, antihypertensives, opioids, cimetidine, spironolactone)
Ask about illicit drug use (e.g., marijuana, heroin)
Family history of endocrine disorders or breast cancer
Symptoms of hypogonadism (fatigue, decreased libido) or hyperthyroidism/hypothyroidism
Recent weight changes or nutritional status.
Physical Examination:
Palpate breast tissue carefully to distinguish glandular from adipose tissue
Measure breast tissue diameter
Examine testes for size and consistency
Assess secondary sexual characteristics
Check for signs of liver disease (jaundice, ascites) or thyroid dysfunction
Perform a focused neurological exam if pituitary pathology is suspected.
Investigations:
Initial labs: Beta-hCG (if pregnancy suspected)
Consider prolactin levels (elevated in galactorrhea)
Thyroid-stimulating hormone (TSH) and free T4
Luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone levels, especially if hypogonadism suspected or gynecomastia persists beyond puberty
Liver function tests
Karyotype if XXY syndrome is suspected
Imaging: Mammography or ultrasound may differentiate gynecomastia from pseudogynecomastia or malignancy (rare)
Pituitary MRI if hyperprolactinemia is significant or neurological signs are present.
Differential Diagnosis:
Gynecomastia: Pseudogynecomastia (obesity)
Breast cancer (rare in males, especially young)
Adipomastia
Lipoma
Abscess
Galactorrhea: Pathologic galactorrhea (hyperprolactinemia from pituitary adenoma, medications, hypothyroidism)
Physiological galactorrhea (pregnancy, lactation)
Spurious galactorrhea (mastitis, nipple irritation).
Management
Initial Management:
For physiological gynecomastia of puberty, reassurance and watchful waiting are often sufficient
Discontinue offending medications if feasible and they are the likely cause
Review and address lifestyle factors such as obesity.
Medical Management:
For symptomatic or persistent gynecomastia: Tamoxifen (SERM) or aromatase inhibitors (e.g., anastrozole) may be used in selected cases, though evidence in adolescents is limited and off-label
For galactorrhea due to hyperprolactinemia: Dopamine agonists (bromocriptine, cabergoline) are the mainstay of treatment
Dosage and duration depend on the cause (e.g., prolactinoma size)
Treat hypothyroidism if present.
Surgical Management:
Surgical options (mastectomy, liposuction) are reserved for cases of severe, persistent, or psychologically distressing gynecomastia unresponsive to medical management or when pseudogynecomastia is prominent.
Supportive Care:
Psychological support for patients with significant cosmetic concerns
Regular monitoring of hormone levels and tumor size (if applicable)
Patient education regarding potential causes and management options.
Complications
Early Complications:
For gynecomastia: Postoperative pain, hematoma, infection, or contour deformities after surgery
For galactorrhea treatment: Nausea, dizziness, and gastrointestinal upset from dopamine agonists.
Late Complications:
For gynecomastia: Persistent cosmetic disfigurement
For galactorrhea: Infertility if untreated hypogonadism
Visual impairment if large pituitary adenomas are left untreated.
Prevention Strategies:
Careful medication review to identify and avoid drugs causing gynecomastia or hyperprolactinemia
Prompt evaluation of persistent breast enlargement or nipple discharge
Early diagnosis and treatment of underlying endocrine disorders.
Key Points
Exam Focus:
Differentiate true gynecomastia (glandular) from pseudogynecomastia (fat)
Recognize common causes of galactorrhea: hyperprolactinemia (pituitary adenoma, medications), hypothyroidism
Understand the hormonal basis: estrogen excess, androgen deficiency, or increased estrogen/androgen ratio.
Clinical Pearls:
In pubertal boys, gynecomastia often resolves spontaneously within 1-3 years
Always inquire about medications and illicit drug use
A palpable mass >2cm in diameter under the areola is highly suggestive of gynecomastia
Prolactin levels are crucial for galactorrhea evaluation.
Common Mistakes:
Attributing all male breast enlargement to gynecomastia without considering pseudogynecomastia
Over-investigating benign pubertal gynecomastia
Failing to consider medication side effects as a cause for both conditions
Not adequately evaluating for pituitary tumors in cases of significant galactorrhea.