Y.K. TAN*, C.R. BIRCH# and D. VALERIO*
*Department of Surgery and #Department of Medicine, Grantham and District Hospital, Grantham NG31 8DG, UK

Association of gynaecomastia with hyperthyroidism is uncommon but has been well documented in the past. Gynaecomastia in a patient with hyperthyroidism rarely presents as a primary complaint. When this occurs, it may present a diagnostic challenge to the clinician. We present the case of a patient who was referred initially to the breast clinic with bilateral gynaecomastia. Hyperthyroidism was subsequently confirmed and treated; gynaecomastia regressed with return to the euthyroid state.

A 49-year-old Caucasian man was seen in the breast clinic with a 3-month history of bilateral painful breast enlargement. He was generally fit and healthy with normal libido. He was not on any medications and only consumed 1-2 units of alcohol weekly. On further questioning, he revealed that he had lost 12 kg of weight unintentionally despite having an increased appetite over a period of about 10 months. He also admitted having an abundance of energy with restlessness, and a disturbed sleeping pattern. He denied any history of palpitations or change in bowel habit.

Physical examination confirmed bilateral gynaecomastia. There was no axillary lymphadenopathy. He had a pulse rate of 100 beats per minute and a blood pressure of 110/70 mmHg. There was evidence of palmar erythema and a fine tremor. His thyroid gland was not enlarged clinically and ophthalmopathy was absent. There was no evidence of chronic liver failure or hypogonadism clinically.

Thyroid function tests confirmed thyrotoxicosis with an elevated free thyroxine (T4) of 47.6 pmol/l (normal range 10-24 pmol/l) and a sub-normal TSH level of < 0.1 mU/l (normal range 0.4-5 mU/l). Full blood count, urea and electrolytes, liver function tests, testosterone and prolactin levels were all within normal limits. Chest radiography, ultra-sound scans of the abdomen and testes were also normal.

The patient was treated with carbimazole 20mg daily for his thyrotoxicosis. He became euthyroid clinically and his gynaecomastia resolved completely about two months following successful treatment. Repeat thyroid function tests showed normal free T4 of 11.9 pmol/l and a TSH level of 0.1 mU/l.

Gynaecomastia, as a clinical feature of hyperthyroidism, is uncommon but well documented. Its incidence has been quoted to be between 2% and 44%.¹ It is, however, rather rare for gynaecomastia to present as the primary complaint in a patient who is hyperthyroid.^1,2 This may be due to the patient’s anxiety about the enlarged breasts and, hence, overlooking the less obvious symptoms of hyperthyroidism. The number of patients presenting to the breast clinic with such a clinical picture will be predictably few and far between.

Grave’s disease is the most common type of hyperthyroidism seen in association with gynaecomastia.3 It is mostly bilateral but may also be unilateral on presentation, and the breast(s) is (are) usually tender.^1-4 Although uncommon, the coexistence of gynaecomastia and hyperthyroidism may be more prevalent subclinically. Becker et al (1974) performed bilateral breast biopsies on 18 patients with hyperthyroidism; 15 of the cases (83%) were found to have histologic evidence of gynaecomastia in both breasts.⁵ In addition, they did not observe any correlation between the severity or duration of hyperthyroidism and the histological or clinical presence of gynaecomastia

The pathogenesis of gynaecomastia in association with hyperthyroidism is still obscure. It has been postulated that increased activity of oestrogen is implicated. However, Chopra et al (1972) found that some patients had no detectable gynaecomastia clinically despite elevated serum total and free oestradiol (E).⁶ In a subsequent study, Chopra et al (1974) discovered that the ratio of serum free E and testosterone (T ) (E/T) was significantly higher in patients with gynaecomastia than those without gynaecomastia.⁷ This, however, represented only a small number of patients. They concluded that the balance between circulating oestrogen and androgen may play a significant role in the genesis of gynaecomastia in hyperthyroidism.

Clinical disappearance of gynaecomastia associated with hyperthyroidism normally takes place with reversal of hyperthyroidism to the euthyroid state following treatment, as was observed in this case.³ It is possible that a patient who is hyperthyroid and has gynaecomastia may be referred to the breast clinic initially. Recognition of this association, therefore, is important as treatment of the problem is simple and unnecessary surgery, investigations and delay of appropriate treatment can be avoided.

Correspondence: Mr D Valerio, Department of Surgery, Grantham and District Hospital, Grantham, Lincolnshire NG31 8DG, UK

“Adopt a Book”

This is one of the latest initiatives designed to involve Fellows more closely in their own splendid College collections. Always of interest, heritage awareness is heightened as we approach our Quincentennial year in 2005.

The Library of the Royal College of Surgeons of Edinburgh dates back to 1696, when the “new” Hall of the Incorporation of Barbers and Surgeons was being built in High School Yards, provision being made for the “books and certain other rarities”. The present collection of books is a notable one, containing titles from the fifteenth, sixteenth, seventeenth and of course later centuries.

These interesting books have, in the main, been donated by Fellows. We are hopeful that Fellows may now consider “adoption” - supporting the cost of restoring one (or more) of the antiquarian books in the collection. We can identify titles requiring conservation work, in several ways - by author, age, subject, or indeed by the extent of work necessary. We would have the specialist work carried out and on the slip case of each book thus “adopted” would be inscribed in gold, an acknowledgement of the named benefactor’s generosity or the name of the person in whose memory the gift was being made, for example:

“This book has been carefully restored through the generosity of Mr AH Chirurgeon FRCSEd July 2001”

Each individual or group who ‘adopts’ a College Library Book will receive a Scroll and their names will feature in the Newsletter and on the Website pages at http://www.rcsed.ac.uk/heritage

We plan to host “Heritage Evenings” featuring, amongst antiquarian books and other College Heritage items of interest, any books and archive papers ‘adopted’ at that point.

If you are considering supporting this initiative, please complete and return the form below, and the Librarian will contact you with further information.

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Bilateral gynaecomastia as the primary complaint in hyperthyroidism

“Adopt a Book”