Gynecomastia:

Combination of Breast Sonography, Physical Examination, and Mammography

Hollie Poe, Sonography Student

DMS 496 Clinical Practicum III

Summer 2016

CERTIFICATE OF AUTHORSHIP: I certify that I am the author of this research paper. I have cited all of the
sources from which I used data, ideas, or words (quoted or paraphrased). I also certify that this paper was
prepared by me specifically for this course.

Signature ___Hollie Poe__________________________ Date: ___07/02/2016_

 1

Gynecomastia:

Combination of Breast Sonography, Physical Examination, and Mammography

 2

Abstract

Gynecomastia is defined as a benign proliferation of glandular breast tissue in males. It primarily

results from an overabundance of estrogen or an underproduction of testosterone. Gynecomastia

may be affiliated with neonates, teenagers, adults, and the elderly. Depending on the age of the

individual the modality of choice used to evaluate gynecomastia can be ultrasound or a

mammogram. Another way gynecomastia can be evaluated is with a physical examination, which

is primarily done before the use of imaging tests. This is extremely important in confirming the

diagnosis of gynecomastia, pseudogynecomastia, and breast cancer. Sonographers that

participate in learning these clinical findings during a physical examination will add valuable

information to the patients study.

Keywords

Gynecomastia, Pseudogynecomastia, Breast Cancer, Mammography

The most common abnormal breast development in males is gynecomastia. Gynecomastia is

common in newborns, adolescents and older men, but may occur at any age.6 There are a variety

of causes that result in gynecomastia occurrence. These causes can be classified into

physiological, pharmaceutical, and pathological. Gynecomastia can be first discovered as a small

palpable lump located beneath the nipple. A change in hormone levels will cause that lump to

progress in size resulting in breast enlargement, whether it is bilateral or unilateral.3 Usually

gynecomastia will resolve on its own, but surgical intervention is an option if gynecomastia fails

to regress.2 It is important that gynecomastia is differentiated from pseudogynecomastia and

breast cancer, so that the individual can receive the proper treatment. A sonographer can learn
 3

how to differentiate between these three breast pathologies, which will assist the radiologist to

make a definite diagnosis.

Case Report

A male teenager presented as an outpatient with complaints of a firm right breast palpation felt

underneath the nipple for several weeks. The patient was also experiencing intermediate

tenderness of the palpable area with touch. The patients previous imaging tests and lab values

were unknown. However the patient did have a past history of drug abuse, which rose suspicion

that the patient may have gynecomastia. After this information was discovered the patient was

further questioned about the use of enhancing supplements and specific pharmaceuticals. The

patient denied the use of enhancing supplements, narcotics, and also denied any injury or trauma

to his breast.

A breast ultrasound with a 15MHz linear-array transducer was performed to evaluate the

right and left breasts. Both breasts were evaluated for the purpose of comparing one to the other.

The ultrasound demonstrated a heterogeneous; mainly hypoechoic mass with irregular borders

invading into the surrounding breast tissue on the right near the nipple and a less prominent

heterogeneous, hypoechoic mass with irregular borders found incidentally on the left breast near

the nipple (Figures 1 and 2). Each mass showed absent vascularity with the use of Color and

Power Doppler, therefore it was unnecessary to use spectral Doppler. The avascular mass seen in

the right breast near the nipple can be appreciated with the use of Color Doppler (Figure 3).

Measurements of each mass were taken in the radial and antiradial planes. The mass on the right

breast measured approximately four centimeters and the mass on the left breast measured about

two and a half centimeters (Figures 4 and 5). Based on the sonographic findings and clinical
 4

history, the patient was diagnosed with bilateral gynecomastia. The patient was suggested to

follow up with their primary care physician to discuss the ultrasound findings and to determine

the next step in his plan of care.

Discussion

Gynecomastia is a benign proliferation of the glandular tissue in the male breast beneath the

nipple or located in the subareolar region.1 It is considered the most common male breast

abnormality that clinically may present asymptomatic or symptomatic in a variety of ages.

Gynecomastia can affect one or both breasts and typically occurs when there is an imbalance in

the estrogen and testosterone hormone levels. Gynecomastia needs to be differentiated from a

pseudogynecomastia and breast cancer, so that the patient can receive the appropriate treatment

for their diagnosis. Gynecomastia may be discovered during a physical examination or through

imaging modalities like ultrasound, mammogram, computerized tomography scans (CT), x-ray,

and even magnetic resonance imaging scans (MRI).5

Gynecomastia typically affects males and can be associated with any age. It may affect

neonates, adolescents, adults, and the older generation. According to statistics, neonates have the

highest prevalence in developing gynecomastia and adolescents have the least, while the elderly

generation has the second prevalence in gynecomastia development. 6 Other associated factors

prone to gynecomastia development include: any type of steroid or enhancing supplements,

alcohol use, obesity, cosmetics, creams, lotions, certain health conditions, certain drugs, and

medications.2, 5,6

The general cause of gynecomastia results from a decrease in the amount of testosterone

levels and an overabundance of estrogen.5 The etiology of gynecomastia can be categorized into
 5

pharmaceutical, physiological, and pathological causes. The pharmaceutical causes refer to

medications or illicit drugs that result in the development of gynecomastia. Gynecomastia can

develop with medications such as anti-androgens, which are primarily used to treat prostate

enlargement and prostate cancer, anabolic steroids, androgens, HIV medications, anti-anxiety

medications, heartburn medications, ulcer medications, heart medications, antifungal

medications, antibiotics, tricyclic anti-depressants, and herbal remedies containing lavender and

tea tree oils.2,6 Any cosmetics, creams, and lotions containing lavender and tea tree oils have

been reported to cause gynecomastia. Substance abuse of amphetamines, heroin, marijuana,

methadone, and alcohol can also contribute to the development of gynecomastia.1, 2

The physiological causes refer to natural occurrences that cause the hormone imbalance

between estrogen and testosterone.2 Physiological gynecomastia has an increasing incidence in

newborns, adolescents, and men older than 50 years old.7 The main cause of physiological

gynecomastia in newborns is due to transplacental transfer of estrogen from the mother, which

results in these babies being born with enlarged breast called breast buds.2 Physiological

gynecomastia in adolescents is caused by hormonal changes due to puberty. Very tall or obese

boys are more likely to have gynecomastia.5 Physiological gynecomastia will increase with age,

because the testosterone levels will gradually decline the older the individual becomes. Therefore

physiological gynecomastia in men older than 50 years old will result from declining levels of

testosterone. Another physiological cause that can result in gynecomastia development is obesity.

Being overweight will increase the production of estrogen, which will result in enlargement of

the breast.5 Other physiological causes of gynecomastia development are malnutrition and

starvation. When the body is deprived of adequate nutrition, testosterone levels drop, but
 6

estrogen levels remain constant, causing hormone imbalance. Gynecomastia develops once

normal nutrition intake resumes.6

The pathological causes of gynecomastia can result from Klinefelter syndrome, tumors,

genetic defects and diseases related to the kidneys, liver, and thyroid. In some cases

gynecomastia can develop due to complications of cancer in the liver, kidneys, pituitary gland,

adrenal glands, and testicles. Older men that have chronic conditions such as cirrhosis of the liver

or an overactive thyroid are at a higher risk for gynecomastia to occur.5 There are a variety of

tumors that can cause the estrogen levels to rise, which will result in gynecomastia development.

These tumors associated with gynecomastia are testicular tumors, adrenal tumors, Leydig cell

tumors, Sertoli cell tumors, germ cell tumors, and hepatic tumors.6,7 Although testicular tumors

are rare, approximately 10 percent of people with testicular tumors will present with

gynecomastia alone. Leydig and Sertoli cell tumors will produce androgen and estrogen, which

will result in an overproduction of estrogen leading to breast enlargement. The germ cell tumors

will produce a intratesticular human chorionic gonadotrophin, which can cause dysfunction of

the Leydig cells. The primary function of those Leydig cells is to secrete testosterone, therefore

when this is affected; there is an underproduction of testosterone.7 Adrenal tumors may secrete

estrogen and estrogen precursors, causing a similar disruption in the estrogen-to-testosterone

ratio.6 Finally gynecomastia may result from various chemotherapy treatments or a radiation

treatment affecting the testicles.2

Gynecomastia may develop unilaterally or bilaterally. It is more common for

gynecomastia to develop in both breasts. If it is discovered unilaterally, further evaluation is done

to make sure that the palpable area is located underneath the nipple, instead of being located

outside the areola region. The reason for this is because male breast cancer has a higher
 7

incidence of being associated with one breast versus both breasts.3 In the beginning stages of

gynecomastia, it usually presents as a small palpable lump that can be felt underneath the nipple

of the breast. The lump may progress in size due to an imbalance of sex hormones, making it a

concern for the individual.2, 5 As a final result gynecomastia in the majority of cases will resolve,

whether it is sporadically or by discontinuation of the underlying cause.7

The common signs and symptoms of gynecomastia include: breast enlargement, the

presence of a firm or rubbery mass extending concentrically from the nipple, pain, and

tenderness.3,5 If there is nipple discharge; skin changes; rapidly enlarging breast, hard fixed

palpable breast masses; coincident testicular masses; or systemic symptoms such as weight loss

then this should raise concern and the patient needs to be further evaluated for possible breast

carcinoma until proven otherwise.7 In some cases individuals with gynecomastia will present

without symptoms. Individuals who present with asymptomatic gynecomastia can have blood

drawn to determine the cause.3 Laboratory tests can also be done to evaluate the hormone levels

in the blood to confirm hormone imbalance.

The sonographic features of gynecomastia on sonography can be described in four

patterns. One pattern consists of a focal nodular round or oval hypoechoic mass in the

retroareolar region. The second pattern can be characterized by a poorly defined, but vague

hypoechoic mass in the retroareolar region. The third pattern can be described as a flame shaped,

irregular hypoechoic mass extending into the surrounding tissues. Finally the fourth pattern can

be seen with an increased anterior-posterior (AP) depth at the nipple. The mass in the fourth

pattern may be seen isoechoic, hypoechoic, or hyperechoic extending into the surrounding breast

tissues. The sonographic appearance in asymptomatic and symptomatic gynecomastia differs.

According to an article in the journal of ultrasound in medicine on sonographic features of

 8

gynecomastia, symptomatic breast masses had an increase in the AP depth at the nipple

compared to asymptomatic gynecomastia.4 Symptomatic masses were also found to be nodular

and flame-shaped in appearance, while the majority of asymptomatic masses varied in

sonographic appearance. Sonographically, the presence of masses that are taller than wide, have

microlobulations, or an eccentric mass located away from the retroareolar region should raise the

suspicion for breast cancer.

Gynecomastia, pseudogynecomastia, and breast cancer can be closely related in clinical

presentation, but can be differentiated from each other through patient history, imaging test such

as ultrasound and mammogram, and specific findings during a physical examination. A true

gynecomastia is typically a rubbery or firm mound of tissue located in the retroarelar region.1

Pseudogynecomastia is described as an increase in adipose tissue without enlargement of the

breast glandular tissue.3,7 The differentiation between gynecomastia and pseudogynecomastia is

made on a physical examination. In patients with true gynecomastia, a rubbery or firm mound of

tissue that is concentric with the nipple areolar complex is felt, whereas in patients with

pseudogynecomastia there is an absence of this finding. Breast carcinoma has the same mass

characteristics as gynecomastia, but it can be differentiated from gynecomastia by its location.

With breast carcinoma the mass is usually hard or firm and fixed somewhere outside the nipple

areolar complex. Breast carcinoma can also be differentiated from gynecomastia by its

association with the breast unilaterally. Clinically gynecomastia will present bilaterally in

approximately 50% of patients. In addition, skin dimpling and nipple retraction are not present

with gynecomastia, but they may be seen in patients with breast carcinoma.3 If the differentiation

between gynecomastia and breast carcinoma cannot be made on the basis of clinical findings

alone, then it is suggested that the patient receives a mammogram. Mammography has 90%
 9

sensitivity and specificity for distinguishing malignant from benign breast diseases. If the patient

is younger than 30 years old a breast ultrasound will be ordered instead of a mammogram for

further evaluation.4 Patient history can also be helpful in differentiated gynecomastia,

pseudogynecomastia, and breast cancer. Typically patient history associated with breast cancer

includes: a family history of breast cancer, exposure to ionizing radiation, or a personal history of

breast cancer that has received therapeutic chest radiation.6 Gynecomastia may be associated with

malnutrition, obesity, certain medications, substance use, certain health conditions including

diseases of the thyroid, liver, and kidney, tumor affiliations, physiological causes that occur in

puberty and increasing age. Finally pseudogynecomastia may result from obesity or from an

unknown etiology.7

The treatment options for gynecomastia vary. If the individual has an asymptomatic

gynecomastia, surgical intervention is usually unnecessary, because overtime it will regress.1

However, if gynecomastia fails to resolve on its own, then hormonal treatments may be

necessary to lower the estrogen levels, raise the testosterone levels, or both.5 If the underlying

cause of gynecomastia is medication or substance use, then withdrawal from the medication or

substance is recommended to improve the condition. If certain health conditions are causing

gynecomastia development, then those disorders need medical attention and treatment, so that

the individuals gynecomastia can be resolved.2 Surgery is optional for the individual if the breast

enlargement persists. The two most common surgeries used to correct gynecomastia are

liposuction and mastectomy. Liposuction is a surgery that primarily removes the unwanted breast

fat without removal of the glandular breast tissue. A mastectomy is a type of surgery that

removes the breast gland tissue. In most cases, gynecomastia is not life threatening or physically

harmful, but it can be an early indicator of a serious medication.5 The prognosis is excellent for
 10

gynecomastia, whether it is associated with physiological or pharmaceutical causes, because it

normally will resolve on its own. As stated before gynecomastia associated with pharmaceutical

causes will only resolve when there is discontinuation of medications or substance use resulting

in the breast enlargement. If gynecomastia is corrected using surgery, the prognosis is often

great, when performed by a surgeon experienced in gynecomastia.2

The sonographic appearance of gynecomastia alone is unreliable, when confirming

gynecomastia, because there are a variety of pathologies that may display the same sonographic

appearance. When gynecomastia is suspected it is essential that the sonographer gathers

information from the patient prior to beginning the exam. This information may include: the

patients past medical history, current medications, and symptoms the patient is experiencing. A

very important part of the breast ultrasound is the physical examination of the palpable area. This

is very vital for sonographers to understand, because this can contribute to the diagnosis of

gynecomastia versus its differential diagnosis. By learning the clinical presentation of

pseudogynecomastia, gynecomastia, and breast cancer, the sonographer can provide useful

information to the radiologist to make a more accurate diagnosis.

A case reported to the American Institute of Ultrasound in Medicine (AIUM) had many

similarities and dissimilarities to the case presented in this paper. They reported that an 81 year

old man with gynecomastia of the left breast was admitted to the breast imaging unit of their

hospital to rule out underlying disease. The patient was healthy and managed to abstain the use

of medications.8 This is similar to the case reported in this research paper, because both patients

abstained from use of medications. Both cases are different, because the case reported in this

paper is a teenager, while the patient in the case reported by the AIUM is an elderly patient. In

both cases the patient presented with a palpable mass located in the retroareolar region. Another
 11

similarity in both cases is the use of high frequency probes and Gray-scale ultrasound was used

to evaluate the mass. The sonographic appearance reported in both cases was also similar. The

sonographic features included a solid hypoechoic mass with irregular borders that displayed

avascularity with the use of Color Doppler. This case reported by the AIUM differs from the case

reported in this paper in a variety of ways. One of the ways this case differs is the mass

measurement. The mass measurement reported in the AIUM case was smaller than the case

reported in this paper. Another difference between the cases is the performance of breast

ultrasound on contralateral breast. The case reported in this paper was performed on the right,

while the breast ultrasound reported by the AIUM was performed on the left. Comparison of the

right and left breast was done in both cases. The case reported by the AIUM had a normal

ultrasound of the right breast, whereas the case reported in this paper discovered bilateral

gynecomastia. Another difference between the two cases is the performance of a mammogram

and an ultrasound guided core needle biopsy was reported in the AIUM case, which confirmed

the diagnosis of gynecomastia.8

Conclusion

The diagnosis of gynecomastia relies on a combination of information. This information includes

patient history, symptoms the individual is experiencing, current medications the individual is

taking, the sonographic appearance of the pathology, and physical evaluation of the palpable

area. If inadequate information is obtained further imaging tests, such as mammography can be

used.4 This was presented in the AIUM case, where the patient presented with an insufficient

amount of patient history and was unable to suggest that the ultrasound findings were in the

category 3 of the BI-RADS assessment chart. Because of the sonographic appearance of the

mass being hypoechoic and diffuse, it was categorized as 4 being suspicious in the BI-RADS
 12

assessment chart, which resulted in the patient having a mammogram due to the uncertainty of

the mass being benign or malignant.8 The case reported in this paper differs, because the patient

is younger than 30 years old, therefore a mammogram would provide insufficient findings due to

the excessive amount of dense breast tissue. Although the patient reported in this paper had

inadequate patient history, the clinical presentation of the patient, sonographic findings, and age

of the patient was enough information to make a confident diagnosis of bilateral gynecomastia.

Overall gynecomastia can occur in all age groups, can result from a variety of causes, can vary in

sonographic appearance, may require treatment, but usually recedes on its own, may present

asymptomatic or symptomatic, and can be discovered from a physical examination or through

imaging modalities.2, 3,4,5,7

 13

References

1. Johnson RE, Kermott CA, Murad MH. Gynecomastia Evaluation and Current Treatment

Options. Dove Press Journal. 2011:7 145-148.

2. Hurd R, Ogilvie I, Zieve D. Breast Enlargement in Males. MedlinePlus.

https://www.nlm.nih.gov/medlineplus/ency/article/003165.htm Updated March 2, 2016.

Accessed March 17, 2016.

3. Braunstein GD. Gynecomastia. The New England Journal of Medicine. 2007;357:1229-37.

4. Baum J, Dialani V, Mehta TS. Sonographic features of Gynecomastia. Journal of Ultrasound

in Medicine. 2010;29(4):539-47.

5. Ferrara MH. Human Diseases and Conditions. 2nd ed. New York, NY: Charles Scribners Sons,

2010.

6. Niewoehner CB, Schorer AE. Gynaecomastia and Breast Cancer in Men. BMJ. 2008; 336:709-

13.

7. Dickerson G. Gynecomastia. American Family Physician. 2012; 85(7):716-722.

8. Arensman L, Bosch VD, Hillegerberg RV, Kemps B, Kwee RM, Maurice MA, Mourad E,

Ouamari E, Willem P. Contrast-Enhanced Breast Ultrasonography Reveals an Unusual Breast

Tumor in a Male Patient With Gynecomastia. Journal of Ultrasound in Medicine. 2006;25(10):

1347-51.