Describe Gynaecomastia in detail.

The Concept

Gynaecomastia is the benign enlargement of the male breast due to proliferation of glandular (ductal) tissue. The unifying mechanism is an imbalance between oestrogen and androgen activity — either too much oestrogen effect or too little androgen effect — because the breast tissue is the same in both sexes and responds to oestrogen. This is distinct from pseudogynaecomastia, which is simply fatty enlargement (in obesity) without true glandular tissue, and is distinguished by palpating a firm disc of tissue behind the nipple in true gynaecomastia.

Causes

It is helpful to group the causes by mechanism. Physiological gynaecomastia is common and benign at three ages — the newborn (maternal oestrogens), puberty (a transient hormonal surge), and old age (falling testosterone). Pathological causes include liver disease (reduced oestrogen breakdown), drugs (spironolactone, digoxin, cimetidine, anti-androgens, cannabis, anabolic steroids), hypogonadism and Klinefelter's syndrome, hyperthyroidism, and oestrogen-secreting tumours (testicular, adrenal).

Assessment & Management

Assessment aims to exclude male breast cancer (which is typically a hard, eccentric, fixed lump — unlike the soft, central, concentric disc of gynaecomastia) and to identify a treatable cause: history (drugs, symptoms), examination (including testes), and investigations (liver, thyroid, and hormone profile) as indicated. Management is to treat the cause — stop the offending drug, manage the underlying disease — since much gynaecomastia then resolves. Persistent, longstanding (fibrotic) or cosmetically distressing cases may need surgical excision (subcutaneous mastectomy) or liposuction.

Assessment in Practice

A practical assessment starts by distinguishing true gynaecomastia (a firm, mobile, concentric disc of tissue felt behind the areola) from pseudogynaecomastia (soft fat, no disc) and from male breast cancer (a hard, painless, eccentric, often fixed lump, perhaps with skin or nipple change). Any features suggesting cancer, or a unilateral firm eccentric mass, prompt triple assessment. Otherwise, targeted tests — drug history, liver and thyroid function, and a hormone profile (testosterone, LH, oestrogen, prolactin, hCG) — look for a treatable cause, especially in new, tender or progressive cases.

Exam Pointer

For the viva, anchor the answer on the single defining idea and its safe rule: state the mechanism, the classic clinical picture, the mandatory role of triple assessment where a lump or discharge is involved, and the specific management — and be ready to contrast the condition with the malignancy it can mimic, since that contrast is what examiners most often probe.

Male Breast Cancer — the Key Exclusion

The single most important task in assessing gynaecomastia is to exclude male breast cancer, which, though rare, presents as a hard, painless, eccentric (off-centre) fixed lump, sometimes with skin dimpling or nipple change or discharge — quite unlike the soft, central, concentric, often tender disc of true gynaecomastia. Any such suspicious features trigger triple assessment. Reassuringly, most gynaecomastia is benign and physiological or drug-related, and resolves when the cause is removed; surgery is reserved for persistent, fibrotic or cosmetically distressing cases.

A concentric disc distinguishes it from fatty pseudogynaecomastia.

• Gynaecomastia = benign enlargement of male breast glandular tissue from an oestrogen:androgen imbalance (vs pseudogynaecomastia = fat only).
• Physiological (benign): newborn, puberty, old age.
• Pathological: liver disease, drugs (spironolactone, digoxin, cimetidine, anti-androgens), hypogonadism/Klinefelter's, hyperthyroidism, oestrogen-secreting tumours.
• Exclude male breast cancer (hard, eccentric, fixed) and find a treatable cause.
• Treat the cause; excision/liposuction for persistent or distressing cases.