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Gynecomastia refers to a female-appearing male breast Pubertal gynecomastia is common and the swelling usually subsides spontaneously within a year Gynecomastia is particularly common in teenagers who are very tall or overweight Gynecomastia develops in about 50% of athletes who abuse androgens and anabolic steroids It is seen in Klinefelter syndrome, which affects 1:500 men (See section on Klinefelter syndrome) Gynecomastia can develop in HIV-infected patients treated with highly active antiretroviral therapy (HAART), especially in men receiving efavirenz or didanosine; breast enlargement resolves spontaneously in 73% of patients within 9 months Gynecomastia is common among elderly men, particularly when there is associated weight gain However, it can be the first sign of a serious disorder Patients with Peutz Jeghers syndrome are prone to development of gynecomastia caused by testicular tumors The causes of gynecomastia are multiple and diverse (Table 26 15)

Pubertal gynecomastia often resolves spontaneously within 1 2 years Drug-induced gynecomastia resolves after the offending drug is removed Spironolactone can be stopped, with substitution of a selective aldosterone antagonist such as eplerenone Patients with painful or persistent (> 12 months) gynecomastia may be treated with a 3- to 9-month course of a SERM (eg, raloxifene or tamoxifen) SERM therapy is much more effective for glandular ( lumpy ) gynecomastia than for diffuse fatty gynecomastia There is some evidence that raloxifene, taken orally in a dose of 60 mg daily, may be the more effective drug Aromatase inhibitors (eg, letrozole, anastrozole, or exemestane) are marginally effective and should not ordinarily be used for adolescent boys, since long-term therapy may prevent epiphyseal fusion Surgical correction is reserved for patients with persistent or severe gynecomastia, since results are often disappointing Endoscopically assisted transaxillary liposuction and subcutaneous mastectomy may produce acceptable results Generally, it is prudent to treat patients for gynecomastia only when it becomes a troubling and continuing problem for them

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Lawrence SE et al Beneficial effects of raloxifene and tamoxifen in the treatment of pubertal gynecomastia J Pediatr 2004 Jul; 145(1):71 6 [PMID: 15238910] Mira JA et al; Grupo Andaluz para el Estudio de las Enfermedades Infecciosas Gynaecomastia in HIV-infected men on highly active antiretroviral therapy: association with efavirenz and didanosine treatment Antivir Ther 2004 Aug;9(4):511 7 [PMID: 15456082]

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Gynecomastia is graded according to severity: I, mild; II, moderate; III, severe Fatty gynecomastia is usually diffuse and nontender Glandular enlargement beneath the areola may be tender Pubertal gynecomastia is characterized by tender discoid enlargement of breast tissue 2 3 cm in diameter beneath the areola

Ramon Y et al Multimodality gynecomastia repair by crosschest power-assisted superficial liposuction combined with endoscopic-assisted pull-through excision Ann Plast Surg 2005 Dec;55(6):591 4 [PMID: 16327457] Rhoden EL et al Treatment of testosterone-induced gynecomastia with the aromatase inhibitor, anastrozole Int J Impot Res 2004 Feb;16(1):95 7 [PMID: 14963480]

primary hypogonadism without virilization: 3 -hydroxysteroid dehydrogenase deficiency (adrenal insufficiency with low serum 17-hydroxyprogesterone) and P450c17 deficiency (hypertension and hypokalemia with high serum 17-hydroxyprogesterone) A whole-body deficiency in P450 aromatose (P450arom) activity produces female hypogonadism associated with polycystic ovaries, tall stature, osteoporosis, and virilization

NeXT 24, 101, 182 NeXTSTEP 5, 24 NFS (network file system) 18 Nib file 79, 101 103, 219 nibtool 102 nice 45, 315 non-freed memory allocation detecting 165 non-interactive editor 112 noResponderFor 199 nroff 32 NSApp 225 NSApplication 192, 198 199 NSButton 229 NSDictionary 184, 186, 297 NSFileHandle 233 NSFileHandleReadCompletion Notification 238 NSMutableDictionary 186, 208, 221, 295, 297 NSMutableString 182, 222 NSNotificationCenter 238 NSObject 178 NSOffState 229 NSOnState 229 NSOpenPanel 230 NSPipe 233 NSSavePanel 230 NSString 182 183, 231 NSTask 231 launching subtask 231 NSTraceEvents 200 NSView 198 NSWindow 198 Number 255 nvi 116

Menarche ordinarily occurs between ages 11 and 15 years (average in the United States: 127 years) The failure of any menses to appear is termed primary amenorrhea, and evaluation is commenced (1) at age 14 years if neither menarche nor breast development has occurred or if height is in the lowest 3%, or (2) at age 16 years if menarche has not occurred

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An enzymatic defect in testosterone synthesis may present as a sexually immature phenotypic girl with primary amenorrhea Complete androgen resistance (testicular feminization) presents as a phenotypic young woman without sexual hair but with normal breast development and primary amenorrhea In both cases, the uterus is absent and testes are intraabdominal or cryptorchid Intra-abdominal testes are surgically resected Such patients are treated as normal but infertile, hypogonadal women

Cases to date in humans, mostly from Southeast Asia Clinically indistinguishable from influenza Epidemiologic factors assist in diagnosis Rapid antigen assays are the means of confirming diagnosis

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