Gynaecomastia - an Endocrinological or a Surgical problem?
Doing the right investigation at the right time is crucial in endocrinology. Nonetheless, an investigation led by a non-specialist is very tricky. We have an interesting case where breast surgeons investigated a patient for hypogonadism. As such, this is the second case in the literature.
Case presentation: A 66 year old gentleman was referred to the breast clinic for left sided gynaecomastia and ongoing fatigue. He had no complaints of erectile dysfunction. Interestingly, this gentleman had a right orchidectomy for chronic epididymitis 34 years ago. His background also includes a previous history of spinal fractures and osteopenia, COPD and hypercholesterolemia.
Breast surgeons arranged for serum hCG level to be measured, which revealed to be 5 IU/L using Roche assay systems (reference range of <3 IU/L). The biochemical picture was consistent with primary hypogonadism (FSH 110 IUL, LH 30.5 IUL and testosterone 2.5 nmol/L). He was referred to endocrinologists for the consideration of testosterone replacement therapy.
We understand that almost all patients referred with gynaecomastia to our surgical team had hCG, with estradiol, done as an initial biochemical assessment.
Discussion: Given the use of assays with highly specific monoclonal antibodies, cross reactivity is not a problem, thus, we can determine that in our patient hCG was found to be truly elevated. Even though it physiologically makes sense for hCG to be high, in practice, this is an unhelpful test in hypogonadism. In a small analysis at our local hospital, it was found that hCG level was requested 12 times in 2 months by breast surgeons alone for gynaecomastia cases. Taking into account that a single measurement of serum hCG runs at a cost of £5.97, we would like to challenge the use of hCG, especially in such scenarios, to avoid the high cost expenditure and potential patient discomfort, as well as unnecessary referrals. This brings the discussion as follows:
3. What is the gate keeping mechanism for running these tests?