#1
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Ãèíåêîìàñòèÿ
Äîáðûé âå÷åð,ïàöèåíò 59 ëåò ,îæèðåíèå 1ñò. îáðàòèëñÿ ñ äèñêîìôîðòîì â îáëàñòè ëåâîé ãðóäíîé æåëåçû.íàëè÷èå õð.çàáîëåâàíèé îòðèöàåò, ïðèåì êàêèõ ëèáî ïðåïàðàòîâ îòðèöàåò.ñî ñëîâ îêîëî 5 ëåò íàçàä áûëè áîëè â ïðàâîé ãðóäíîé æåëåçå â òå÷åíèå äâóõ ìåñÿöåâ ïîëó÷àë àíäðîãåëü, äîñòèíåêñ.çàòåì, ââèäó ðåãðåññà ñèìïòîìîâ ïðåïàðàò ñàìîñòîÿòåëüíî îòìåíèë (óðîâåíü ïðîëàêòèíà áûë îêîëî 600).â ñâÿçè ñ æàëîáàìè â òå÷åíèå ïîñëåäíèõ òðåõ ìåñÿöåâ îáðàòèëñÿ ê ýíäîêðèíîëîãó .ïî äàííûì îáñëåäîâàíèÿ â á/õ áåç îñîáåííîñòåé ñêô,ïå÷åíî÷íûå òðàíñàìèíàçû â ðåôåðåíñå.â êëèíè÷åñêîì àíàëèçå êðîâè ÑÎÝ 33 Ñðá-27 .ãîðìîíû òòã -1.2 ëã-15.94(äî7.7.) ôñã-41.07(äî 12.4) îáùèé òåñòîñòåðîí -10íìîëü/ë ýñòðàäèîë 77.9(äî 115.65)ïðîëàêòèí-812.27 (äî 350), ìàêðî ïðîëàêòèí -129 ïðîöåíò-15 îò îáùåãî.äýà-ñ 1.53(äî3.0) â - ÕÃ× ìåíåå 0.5 (äî 2.2)ïñà -1.202(ìåíåå 4-õ)àëüôàôåòîïðîîòåèí íå ñäàë .ÓÇÈ ãðóäíûõ æåëåç ,îðãàíîâ ìîøîíêè ïîêà íå ïðîøåë.íà âîïðîñ åñòü ëè ó ïàöèåíòà äåòè -îòâåòèë íåîõîòíî è êîðîòêî -íåò.ïî÷åìó?-íó ,íå ñëîæèëîñü .íå î÷åíü êîíòàêòåí.áîëüøå íå óäàëîñü óçíàòü èíôîðìàöèè.âîïðîñ òàêîé:÷òî òåïåðü ñ ýòèì âñå äåëàòü?êàêàÿ äàëüíåéøàÿ òàêòèêà ?ñïàñèáî çà îòâåò.îïûòà âåäåíèÿ òàêèõ ïàöèåíòîâ íåò ,áóäó î÷åíü áëàãîäàðíà çà âàøó ïîìîùü.
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#2
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Íà÷íèòå ñ ÓÇÈ ìîëî÷íûõ æåëåç - ãèíåêîìàñòèÿ èëè ëèïîìàñòèÿ ó íåãî. "Äèñêîìôîðò" - íå êëèíè÷åñêèé ñèìïòîì.
Ïîâûøåííûå ÔÑÃ è ËÃ õàðàêòåðíû äëÿ ãèïîãîíàäèçìà. |
#3
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Ïåðâè÷íûé ãèïîãîíàäèçì ñàì ïî ñåáå âûçûâàåò ãèíåêîìàñòèþ, òóò åùå ñâîáîäíîãî Ò íå çíàåì, ïëþñ âîçðàñò è íåáîëüøîå îæèðåíèå. Íè÷åãî óäèâèòåëüíîãî íåò. Ó íåãî ýòî óæå áûëî è óëó÷øèëîñü íà àíäðîãåëå. Òàê ÷òî ÿ áû íå ñîìíåâàëñÿ â äèàãíîçå. Áîëåë ëè ñâèíêîé â äåòñòâå? Êàðèîòèï? ßè÷êè ïðîùóïàëè?
Ãèíåêîìàñòèÿ èëè ëèïîìàñòèÿ íèêîãî åùå íå óáèâàëè, à âîò îñòåîïîðîç âïîëíå ìîæåò. Åñëè ñ ïðîñòàòîé ïðîáëåì íåò è PSA íîðìàëåí, íå âèæó ïðè÷èí íå äàòü òåñòîñòåðîí.
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#4
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À ïðîëàêòèí?
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#5
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Ïî÷åìó òàêîé âûñîêèé Ñ-ðåàêòèâíûé áåëîê - 27?
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#6
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Dr.B |
#7
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Dr.B |
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#8
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Äà,êàê ãîâîðèòñÿ áóäåì ïîñìîòðèì ÷òî ïî ÓÇÈ íàì ñêàæóò.êàðèîòèï íå çíàåì.ÿè÷êè íå ïàëüïèðîâàëà
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#9
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òàêîé âûñîêèé ÑÐÁ áûâàåò è ïðè òîëüêî îæèðåíèè, áåç âñÿêèõ ñîïîòñòâ. âîñïàë. ïðîöåññîâ, ñâÿçàíî ëè åòî ñ ãèïåðåñòðîãåíåìèåé? ó æåíøèí ÷àñòîòà ïîâûøåíèÿ ñðá áîëåå 10 ñ îæèðåíèåì èìò áîëåå 30 = 20%, ó ìóæ÷èí âñåãî 5%;
ñðåäè êàíäèäàòîâ íà áàðèàòðèþ ÖÐÁ≥20 ìã/Ë, 52/674 = 7.7%
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
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èíòåðåñíîå íàáëþäåíèå îò áîëãàðñêèõ âðà÷åé ïî ïîâîäó ãèíåêîìàñòèè - îíè ïèøóò, ÷òî ïðèìåíåíèå ðàçíûõ âåùåñòâ ìîæåò áûòü àññîöèèðîâàíî ñ ãèíåêîìàñòèåé ïîñëå 40 ëåò
Medication-induced GM was a rare reason for GM in patients younger than 40 years (2.8%) but turned out to be the most frequent cause for the complaints after the same age (55.6%). îíè ïðåäïîëàãàþò, ÷òî ïàöèåíòû ìîãóò ñêðûâàòü îò âðà÷åé èõ óïîòðåáëåíèå â ïîëîâèíå ñëó÷àåâ è ãèíåêîìàñòèÿ èäåò êàê èäèîïàòè÷åñêàÿ: Interestingly, only 5.5% of our patients recognized anabolic steroid use, whereas no one admitted use of marihuana. The reported prevalence of anabolic steroids use in other adult GM groups was significantly higher (12.9%–13.9%) [11, 20]. Thus, the unexplained hyperestrogenemia in some of our patients might be related to unreported anabolic or drug abuse. Other studies have shown that more than a half of anabolic steroid users would not disclose their substance abuse to any physician, which coincides with our impression [21]. Other possible explanations for the unexplained hyperestrogenemia might be an idiopathic increase of aromatase activity in some patients, obesity and an intake of unknown endocrine disruptors. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#11
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Ìîãóò,ìîãóò.êàê ãîâîðèò Ôàäååâ :"âñå âðóò"íî,ìû ðàáîòàåì ñ ÷åì åñòü.ñàõàðíîãî äèàáåòà ó ïàöèåíòà íåò.
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#12
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Öèòàòà:
À âîò ýòî ïëîõî: áîëüíîãî íàäî îáñëåäîâàòü ôèçèêàëüíî. Óæ ñðàçó è ÓÇÈ. A îðõèäîìåòð è ïàëü÷èêè íà ÷òî äàäåíû? ßè÷êè ìàëåíüêèå, êðóãëûå, òâåðäûå- Êëÿéíôåëüòåð. È êàðèîòèï ïîäòâåðäèò.:-). Âñå îñòàëüíîå,- àíàáîëèêè, îðõèò, ãèïîãîíàäîòðîïíûé ãèïîãîíàäèçì è ïð. Ñðàçó äàåòñÿ íàïðâëåíèå êóäà èäòè.
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Dr.B |
#13
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ìåòàáîëè÷åñêèé ñèíäðîì è îæèðåíèå æå åñòü?
åãî ñîîòíîøåíèå îáùèé òåñòîñòåðîí -10íìîëü/ë / ýñòðàäèîë 77.9 = 7.8 èëè ìèí. öèôðà êàê ïðè ãèíåêîìàñòèè è ìåòàáîëè÷. ñèíäðîìå: Estradiol (pmol/l) to testosterone (nmol/l) ratio 56.0 [7.2–691.8] (n = 18) [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ìåòàáîëè÷åñêèé áûë ó 84.2% ñ "Medication and AAS-induced GM" [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#14
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Ñòàðûé àíåêäîò
Èèñóñ ðåøèë âåðíóòüñÿ íà çåìëþ è ïîìî÷ü áîëüíûì â îáðàçå âðà÷à. Ïîÿâèëñÿ â ïîëèêëèíèêå, ïåðâûé áîëüíîé- ïàðàëèòèê ñ ðîæäåíèÿ. Èèñóñ íà íåãî íàëîæèë ðóêè è ïðîèçíåñ:” âñòàíü è èäè!” Òîò ìãíîâåííî èçëå÷èëñÿ, âñòàë è ïîøåë. Ñíàðóæè âñå åãî îêðóæèëè, êàê, ìîë, íîâûé äîêòîð ? ‘’Äà òàê ñåáå, äàæå ÓÇÈ ùèòîâèäêè íå íàçíà÷èë”
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Dr.B |
#15
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îêàçûâàåòñÿ, â ñâîáîäíîé âåðñèè åñòü åâðî-ðåêîìåíäàöèè íà ýòó òåìó:
EAA clinical practice guidelines—gynecomastia evaluation and management 2019 R7. We recommend that the physical examination should include the examination of the genitalia to rule out the presence of a palpable testicular tumor and to detect testicular atrophy (1 ⊕⊕⊕⊕). R8. We recommend that genitalia examination is aided by a testicular ultrasound, as the detection of a testicular tumor by palpation has low sensitivity (1 ⊕⊕○○). R9. We suggest that a set of evaluations may include T, E2, SHBG, LH, FSH, TSH, prolactin, hCG, AFP, and liver and renal function tests (2 ⊕⊕○○). R10. We suggest that breast imaging may offer assistance, where the clinical examination is equivocal (2 ⊕⊕○○). R11. We suggest that, if the clinical picture is suspicious for a malignant lesion, core needle biopsy should be performed (2 ⊕⊕○○). R12. We recommend watchful waiting after treatment of underlying pathology or discontinuation of the administration/abuse of substances associated with GM (1 ⊕⊕○○). R13. We recommend that T treatment should be offered only to men with proven testosterone deficiency (1 ⊕⊕⊕○). R14. We do not recommend the use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), or non-aromatizable androgens in the treatment of GM in general (1 ⊕⊕○○). [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |