This patient had galactorrhea and gynecomastia on the L. He reported gynecomastia since age 13, only on the L breast.
Drugs and liver disease are the most common causes of gynecomastia in adults.
Medications which cause gynecomastia includemethadone, spironolactone, verapamil, amlodipine, nifedipine, risperidone, alcohol, piods, omeprazole. Herbal products such as lavender or tea tree oil and dong quai can cause gynecomastia
Physiologic : Gynecomastia is common with benign pubertal changes in adolescent boys with 75% of cases resolving within two years without treatment. Gynecomastia can also result from malnutrition as in ulcerative colitis or cystic fibrosis wheretestosterone levels drop while the adrenal glands continue to produce estrogencausing a hormone imbalance. It can also occur with normal prolactin levels in people with increased sensitivity to prolactin.
Chronic disease: Renal failure patients may have gynecomastia because testosterone production is suppressed by high levels of urea causing hypogonadism. Cirrhotics may develop gynecomastia because they have increased secretion of androstenedione from the adrenals which is converted to estrogen leading to decreased testosterone by increasing sex hormone binding globulin. In Graves disease increased aromataseactivity causes increased conversion of testosterone to estrogen which causes gynecomastia in 10-40% of patients.
Tumors causing gynecomastia. Leydig cell tumors or Sertoli cell tumors, HCG secreting choriocarcinomaor pituitary tumors , or bronchogenic carcinoma . Patients with prostate ca treated with antiandrogens may develop gynecomastia.
Primary hypogonadism as is seen in Klinefeltersor central hypogonadism with decreased luteinizing hormone can cause decreased testosterone and gynecomastia. Central hypogonadism is also caused by high prolactin.
Our patient was screened for testicular tumors, hyperprolactinemia and hyperthyroidism. All tests were negative and it was determined that the most likely source of galactorrhea was stimulation of the breast by his girlfriend.
Shulman D, Francis GL, Palmert RM , et al. 2008, Use of aromatase inhibitors in children and adolescents with disorders of growth and adolescent development. Pediatrics 121 (4) e975-983.
Dickson G. 2012. Gynecomastia. American Family Physician 85(7) 716-722.
Cuhaci N, Polat SB, Evranos B, et al 2014. Gynecomastia: Clinical evaluation and management. Indian J Endocrinol Metab. 18(2) 150-158.