[Scielo] Gynecomastia: Physiopathology, evaluation and treatment
Gynecomastia: physiopathology, evaluation and treatment
Ginecomastia: fisiopatologia, avaliação e tratamento
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Mastology Department, Hospital Sírio-Libanês, São Paulo, Brazil
Alfredo Carlos Simões Dornellas de Barros, Marcelo de Castro Moura Sampaio
ABSTRACT
Gynecomastia (GM) is characterized by enlargement of the male breast, caused by glandular proliferation and fat deposition. GM is common and occurs in adolescents, adults and in old age. The aim of this review is to discuss the pathophysiology, etiology, evaluation and therapy of GM. A hormonal imbalance between estrogens and androgens is the key hallmark of GM generation. The etiology of GM is attributable to physiological factors, endocrine tumors or dysfunctions, non-endocrine diseases, drug use or idiopathic causes. Clinical evaluation must address diagnostic confirmation, search for an etiological factor and classify GM into severity grades to guide the treatment. A proposal for tailored therapy is presented. Weight loss, reassurance, pharmacotherapy with tamoxifen and surgical correction are the therapeutic options. For long-standing GM, the best results are generally achieved through surgery, combining liposuction and mammary adenectomy.
RESUMO
A ginecomastia (GM) é caracterizada pelo aumento do volume mamário em homens, provocada por proliferação glandular e depósito de gordura. É comum e pode ocorrer em adolescentes, adultos e idosos. O objetivo desta revisão é discutir a fisiopatologia, etiologia, avaliação clínica e terapia da GM. Um desequilíbrio entre estrogênios e androgênios é reconhecido como a condição fundamental para a determinação do quadro, podendo ser atribuído a fatores fisiológicos, tumores ou distúrbios endócrinos, doenças não-endócrinas, uso de drogas ou ser de causa idiopática. A avaliação clínica deve enfocar a confirmação diagnóstica, a procura de uma causa específica e a classificação em graus de gravidade para orientar o tratamento. Um roteiro de conduta individualizada é apresentado, variando entre perda de peso e explicações verbais, tratamento com tamoxifeno e correção cirúrgica. Para casos de GM persistente, os melhores resultados são obtidos em geral mediante abordagem cirúrgica, combinando lipoaspiração e adenectomia mamária.
INTRODUCTION
Gynecomastia (GM) is a benign condition characterized by enlargement of the male breast, which is attributable to proliferation of the glandular tissue and local fat deposition. It can be physically uncomfortable, psychologically distressing and may have a negative impact on selfconfidence and body image. Pseudogynecomastia is common in obese men, and consists of lipomastia alone, without glandular proliferation. This condition, together with neonatal transient breast hypertrophy caused by the high estrogenic milieu of pregnancy, should not be considered to be true GM, and these are beyond the scope of this paper. Male breast tissue proliferation can occur at all ages and may be unilateral or bilateral. It has been estimated that 30% to 60% of boys exhibit GM during adolescence and that at least one third of the adult male population may be affected. The differences between samples can be accounted for by the criteria used to define them and the diversity of the samples studied.1-3 The highest prevalence of GM is found in old age, when it is detected in up to 65% of men.4,5 GM is common and clinically important. Nevertheless, major gaps in knowledge regarding its modern epidemiology exist, and it has not been proven whether the apparent rise in its incidence is true. Nonetheless, over recent decades, there have been substantial increases in the use of anabolic steroids and in environmental contamination with xenoestrogens or estrogen-like substances that, at least theoretically, can stimulate glandular proliferation of the male breast.6,7 This review addresses the pathophysiology, etiology and clinical evaluation of GM and discusses the selection of patients for tailored therapy, which remains a challenge for physicians. We performed a search for published scientific papers in PubMed, SciELO and the Cochrane Database of Systematic Reviews (Table 1), covering 2000 to 2011.