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E48 Endocrinology
Female Reproductive Endocrinology Toronto Notes 2019
Pathophysiology
• hormonalimbalancedueto:
■ increased estrogen activity
◆ increased production, or increased availability of estrogen precursors for peripheral conversion to estrogen
■ decreased androgen activity
◆ decreased androgen production, binding of androgen to sex hormone binding globulin (SHBG),
or androgen receptor blockage
History
• recentchangeinbreastcharacteristics • pain?
■ trauma to testicles
■ mumps
■ alcohol and/or drug use ■ FHx
■ sexual dysfunction
Physical Exam
• signsoffeminization • breast
■ rule out red flags suggesting breast cancer: unilateral, eccentric, hard or fixed mass, skin dimpling or retraction, and nipple discharge or crusting
■ gynecomastia occurs concentrically around nipple, is not fixed to underlying tissue • genito-urinaryexam
• stigmataofliverorthyroiddisease
Investigations
• laboratory:serumTSH,PRL,LH,FSH,testosterone,estradiol,LFTs,creatinine,hCG(ifhCGis elevated, need to locate the primary tumour); however not all investigations are required for every case of gynecomastia
• CXRandCTofchest/abdomen/pelvis(tolocateneoplasm)
• testicularU/S(ifprimaryhypogonadismsuspectedormassonphysicalexamination)
• MRIofhypothalamic-pituitaryregionifsecondaryhypogonadismorpituitaryadenomasuspected
Treatment
• initialobservationformostmenwithgynecomastia(afterstoppingoffendingmedicationsandtreating underlying cause)
• medical
■ correct the underlying disorder, discontinue responsible drug
■ androgens for hypogonadism
■ anti-estrogens: tamoxifen has most evidence for benefit
■ aromatase inhibitors: less evidence of benefit as compared to anti-estrogens
• surgical
■ usually required for macromastia, gynecomastia present for >1 yr (fibrosis is unresponsive to
medication), or failed medical treatment; also for cosmetic purposes
Female Reproductive Endocrinology
• seeGynecology,GY22
Occurrence of Gynecomastia
3 Peaks
Infancy Puberty Ages 50-80
% Affected
60-90 4-69 24-65