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Recurrent gynecomastia


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20's YOM, overall in excellent health with hx extracurricular anabolic steroid use a couple of years ago who denies any recent use, c/o recurrent painful unilateral gynecomastia. I'd previously run labs to r/o hormonal weirdness and given him a 3 month course of Tamoxifen ending in December, and now six months later it's back and hurting again.

I'm rerunning hormone/thyroid labs, but in the absence of metabolic weirdness, which I do not suspect, I'm wondering if there's any support for another course of Tamoxifen rather than surgical intervention. He did tolerate the first one well, and there has been no imaging or biopsy to confirm it's progressed to a fibrotic stage. I can't seem to find anything in UpToDate or general literature applicable to recurrent gynecomastia years after cessation of offending steroids.

Should we try tamoxifen again, refer to surgery, or do something else entirely? What might I be missing?

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Another course likely won't do much. At this point refer to surgery. May or may not be covered by insurance. No reason to think it's anything more than steroids? No signs of pituitary adenoma?

So much steroid use these days among young men with little thought of androgen blocking. Even most TRT clinics negate this crucial component. 

I work in EM but had a friend go through the same thing 

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Prior/current military service? Recreational gun use?

As an FYI, unilateral gynecomastia also seen in rifle/MG shooters because of chronic percussion against the chest. Maybe not in your pt's case, but something to keep in mind.

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1 hour ago, UGoLong said:

I'd definitely do an ultrasound next. Fast, least invasive, and the results might be helpful for the surgeon.

UpToDate wasn't real hot on the utility of ultrasound, otherwise I'd have already ordered one. POCUS isn't going to be helpful in this case, because I wouldn't know what I'm looking at, absent clear signs of infection or a fluid collection.

2 hours ago, Apollo1 said:

Prior/current military service? Recreational gun use?

As an FYI, unilateral gynecomastia also seen in rifle/MG shooters because of chronic percussion against the chest. Maybe not in your pt's case, but something to keep in mind.

There's some occupational firearms use, but this recurred in the other breast, and I'm not sure the extent/routine of his long gun training.

4 hours ago, ventana said:

Do you have mammo and tissue ??

zebra is breast ca.    I would want tissue dx the decide.  More common is cannabis abuse. 

also you did not mention exam findings and how noticeable.  

THC metabolites not detected on UDS done last fall for an unrelated reason, and I have reason to believe his employer prohibits MJ use and tests randomly. No biopsy yet, will likely order mammogram/breast U/S as described above and let surgery get a biopsy if they think it appropriate.

It's diffuse, painful to palpation, central but not limited to a small subareolar disc as would be typical of pubertal gynecomastia. Visibly asymmetrical L vs R, but not profoundly so such that it would be easy to overlook if he hadn't brought it up, no dimpling or other skin signs, without nipple discharge. In other words, nothing to suggest breast cancer--which we agree is a zebra worth looking out for. Painful with pectoral muscle use or palpation, which suggests cancer less likely.

Excellent thoughts and questions, folks.

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5 hours ago, rev ronin said:

Painful with pectoral muscle use or palpation

Interesting. It doesn't sound like there are any masses, nodules, or lymph nodes to be worried about but if there's some adherence/scarring or involvement of the muscle, that would be a little more concerning. 

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22 hours ago, rev ronin said:

No biopsy yet, will likely order mammogram/breast U/S as described above and let surgery get a biopsy if they think it appropriate.

 

That is the winning (And least risky) proposition..... 

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6 hours ago, UGoLong said:

I wasn't suggesting POC ultrasound; I would let an expert read it. Looking for fluid or masses.

No, but I DO have POCUS here, for when I can learn something from a quick look and don't NEED the full deal. This... I'm not going to do. The older I get, the more I get that it's not about me and what all I can do, and so play "stay in my own lane" for the patient's benefit, rather than "what new cool thing can I do?" for mine.

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