Adult-onset bilateral enlargement on spironolactone — cause hunt, drug review and selective imaging

Model answer

(A) Workup with cause-hunt numbers (5 marks)

• Frame the purpose: detection of underlying pathological conditions, reversible causes, and discrimination from other lumps particularly cancer — adult disease is a symptom until proven otherwise.^[1]
• Take the history: onset and duration, sexual development and function, administration or abuse of substances associated with GM — his 8-month painful course with spironolactone, omeprazole and alcohol sits inside this screen.^[1]
• Examine breast for palpable glandular tissue to separate GM from lipomastia and rule out malignant tumour, detect under-virilization or systemic disease, and include genitalia to rule out palpable testicular tumour and detect atrophy.^[1]
• Add testicular ultrasound to the genital examination and send the panel: testosterone, estradiol, SHBG, LH, FSH, TSH, prolactin, hCG, AFP, liver and renal function tests.^[1]
• Quote the yield that justifies this: 43% of adult-onset cases have a detectable, often treatable cause versus 7.7% with young onset in 786 examined men — his age group is the high-yield group.^[7]

(B) Drug review (2 marks)

• Quote the share: drugs cause about 10-25% of gynaecomastia, with most reported associations on poor-quality evidence — review, do not reflex-stop everything.^[8]
• Place spironolactone on the definite list with cimetidine, ketoconazole, hGH, estrogens, hCG, anti-androgens, GnRH analogs and 5-α reductase inhibitors — spironolactone is a stop-or-swap candidate with watchful waiting after discontinuation.^[8][1]
• Place omeprazole and alcohol on the probable list with risperidone, verapamil, nifedipine, alkylators, efavirenz, anabolic steroids and opioids — contributors to review alongside the definite drug.^[8]

(C) Imaging versus biopsy (3 marks)

• Apply the boundary: image when examination is equivocal; seek core needle biopsy directly for suspicious lesions.^[1]
• Support selectivity: most lesions diagnose clinically with imaging only when examination is inconclusive; the purpose is confirming gland versus pseudo, excluding cancer, and finding cause.^[10]
• Quote the overuse brake: 557 imaged men gave 519 BI-RADS 1-2, 38 BI-RADS 3+, 160 sampled and 5 cancers (0.89%), with sensitivity 80% and specificity 99% — imaging is not warranted without suspicious abnormalities and routine imaging is discouraged.^[11]
• Decide for him: bilateral painful enlargement with palpable gland and no suspicious lump gets no routine mammogram; any dominant hard eccentric mass, nipple inversion, skin change or inconclusive examination gets imaging, and a suspicious picture goes straight to core biopsy.^[1][10]