Gynaecomastia
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Direct answer
Reassurance cures the majority of teenage breast lumps in boys: pubertal gynaecomastia — a tender, palpable disc of glandular tissue beneath the areola — appears in up to half of adolescent boys and resolves within months to two years without treatment. True pathological gynaecomastia in adult men is usually drug-induced or reflects an oestrogen-androgen imbalance from liver disease, renal failure, hyperthyroidism or hypogonadism; a hard, asymmetric, fixed mass is not gynaecomastia at all but possible male breast cancer, proportionately commonest in Klinefelter syndrome. Evaluation examines the testes and checks liver, renal and thyroid function with testosterone, prolactin and beta-hCG; treatment removes the offending drug or treats the cause, with tamoxifen for painful persistent tissue and subcutaneous mastectomy for long-standing enlargement.
What you must remember
- Physiological windows: neonatal (maternal oestrogen), pubertal (up to half of adolescent boys, resolving within 6-24 months), and ageing (obesity and falling testosterone); pseudogynaecomastia is diffuse fat without a disc — pinched, it feels soft and shapeless.
- Drug list to memorise: spironolactone, cimetidine, digoxin, oestrogens, anti-androgens (flutamide, bicalutamide), ketoconazole, marijuana, heroin, methadone and some antiretrovirals — stopping the culprit is the treatment.
- Endocrine causes: Klinefelter syndrome (47,XXY — small firm testes, infertility, eunuchoid habitus), testicular tumours (germ-cell via beta-hCG, Leydig cell via oestrogen), hyperprolactinaemia and hyperthyroidism.
- Systemic causes: cirrhosis with impaired oestrogen clearance (spider naevi, palmar erythema travel with it), chronic kidney disease, and refeeding after starvation.
- Workup beyond physiological: clinical examination including testes, LFTs, creatinine, TSH, testosterone with LH and FSH, prolactin, beta-hCG; testicular ultrasound when markers or examination are abnormal.
- Cancer red flags: unilateral hard fixed mass, nipple retraction or discharge, axillary nodes — core biopsy; male breast cancer is under 1% of breast cancers, but Klinefelter syndrome raises the risk many-fold.
- Treatment ladder: observation for physiological disease; withdraw the causative drug; tamoxifen 10-20 mg daily for painful persistent tissue; subcutaneous mastectomy — with liposuction, plus skin excision for grade III skin excess — for persistence beyond about two years or genuine psychological burden.
A pubertal boy with a tender breast
A 14-year-old is brought with a 2 cm tender disc under the left areola, noticed three months ago; he plays sport and dreads the changing room. The history excludes anabolic steroid use — an urban Indian gym reality worth asking about directly — and examination finds normal testes and a soft, mobile, tender retroareolar disc rather than fat. No bloods are needed at this point: pubertal gynaecomastia is the diagnosis, and the treatment is explanation with a timeline — most resolve within six months to two years as the hormonal seesaw settles. A review at six to twelve months is scheduled only if the tissue persists, enlarges, or the boy's distress grows.
Contrast the 58-year-old with a new, progressively tender enlargement, on spironolactone for ascites, with palmar erythema: here the pathway is drugs and liver, bloods for LFT, testosterone and prolactin, and coordination with hepatology. And contrast again the 65-year-old with a hard, eccentric, fixed mass and nipple retraction — that is a biopsy, not a hormone panel; the diagnosis until proven otherwise is male breast cancer.
How NBE asks drug causes
The question is nearly always a list: four drugs, one answer, and spironolactone or cimetidine is keyed. The second standard stem pairs gynaecomastia with small testes and infertility — Klinefelter, with its markedly elevated male breast cancer risk as the quotable fact. The third is the bedside sorting: a firm disc of tissue is gynaecomastia, diffuse soft fullness is pseudogynaecomastia of obesity, and a hard eccentric mass is cancer. Surgery appears as a single line — subcutaneous mastectomy for persistent disease — and tamoxifen as the medical option for pain.
Frequently asked questions
What is the commonest cause of gynaecomastia overall?
Physiological pubertal gynaecomastia, which resolves within months to two years and needs only reassurance.
Name the classic drug causes.
Spironolactone, cimetidine, digoxin, oestrogens, anti-androgens, ketoconazole, marijuana and heroin — withdrawal of the drug is the first treatment.
When is surgery offered?
For enlargement persisting beyond about two years, pain unresponsive to tamoxifen, or significant psychological distress — by subcutaneous mastectomy, with skin excision in advanced grades.
Why does Klinefelter syndrome matter in this topic?
Its 47,XXY hypogonadism causes gynaecomastia and carries a many-fold increased risk of male breast cancer, making any new mass in these men a biopsy question.
How is gynaecomastia distinguished from male breast cancer?
Gynaecomastia is a symmetrical, tender, retroareolar disc of glandular tissue; cancer is a hard, often eccentric mass, possibly fixed, with nipple changes or nodes — and it is confirmed by core biopsy.