INVESTIGATING GYNECOMASTIA IN ELDERLY MEN
"How should unilateral gynecomastia in an elderly man be investigated?" inquires ROBERT BOYKO, MD, of Mississauga, ON. He adds, "When and to whom would you refer such a patient?"
Gynecomastia frequently shows up in elderly men and is almost always benign. It's due to an imbalance in the estrogen:testosterone ratio, either in the circulating hormones or at the level of the breast tissue. From the history, you may discover that it's been a long-standing problem, or that there's an associated illness which may contribute, such as liver disease or an orchidectomy for prostate cancer. Medications often cause gynecomastia, and the list of offenders is huge, including many commonly used drugs. On physical examination, you'll need to distinguish true gynecomastia -- the presence of real breast tissue -- from adipose tissue. This is usually quite obvious with palpation. Gynecomastia is often unilateral, so that finding in itself isn't ominous. Finding a very hard mass or mobile lump should raise suspicions and be followed with mammogram and possibly biopsy. If you can't find an obvious medical cause, then I'd suggest checking liver and renal function, thyroid function, prolactin levels and measuring free testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and estradiol. You can also measure beta-HCG (human chorionic gonadotropin), a tumour marker which could stimulate the production of estrogen. If you suspect that this could be breast cancer, I'd refer to a breast surgeon; if the patient wants cosmetic surgery, that's usually in the domain of a plastic surgeon. HL