Wednesday, January 6, 2016
Differentiating gynecomastia from fatty tissue with atypical antipsychotic use
A recent discussion board conversation between SDBP members highlighted one of the challenges of managing children on antipsychotics: distinguishing gynecomastia in boys who have steady weight gain. Dr. Ami Bax asked members whether they found specific approaches such as breast exam, prolactin, ultrasound etc. to be helpful, and how they generally counsel their families.
Members seem to agree that physical exam and palpation of the breasts should be a basic part of assessment; as much can be inferred from what is felt and the pattern of development (e.g. unilateral vs. bilateral).
Dr. Dan Coury went on to poll several coleagues in other disciplines (Endocrine, Adolescent Medicine, Pediatric Surgery) about their view of the issue:
- All of the specialists agreed that palpation was the best way to distinguish between "firmer, more fibrous feeling" breast tissue and surrounding adipose tissue; typically with a distinct margin between the two. Pediatric surgery did note that the margin is actually less distinct when it comes to attempting an excision.
- None of the specialists recommended use of imaging, e.g. ultrasound, when palpation was unclear. Adolescent Medicine pointed out that there may be little benefit if the findings were so subtle as to be non-palpable. Pediatric Surgery pointed out that patients who request intervention tend to do so because of pain/discomfort (and not cosmetic reasons) thus making imaging moot.
- Finally, Endocrine suggested that it is helpful to have baseline Prolactin, Free T4, and TSH level drawn prior to start of antipsychotic medications in order to facilitate addressing abnormal labs if and when they later appear.
Thanks to all members who contributed to this discussion!