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which comes first? endo or surgeon

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which comes first? endo or surgeon
« on: June 07, 2011, 07:16:07 AM »
hi guys, I've been lurking in the forums for some time. my question is i have booked an appointment with a local surgeon for an initial consultation of my G, ( this will be my second consultation with a surgeon, last time was years ago in my home country, but i was a student then so i didn't have the means for surgery so i never followed up).  but read in these forum that its a good measure to check with an endo too to rule out any hormonal issues that might still influence G, FYI I'm 27. anyone checked with an endo first before going to your surgeon?  should i just  cancel my appointment with my surgeon and set a new one for an endo? thanks.  :)

Linkback: https://www.gynecomastia.org/smf/index.php?topic=23418.0

Re: which comes first? endo or surgeon
« Reply #1 on: June 07, 2011, 01:33:11 PM »
Im not bothering with an endo. My moobs have not grown randomly, and I feel any solution to a hormonal imbalance would largely be prescription medication for the rest of my life. I think I'll stick with just the surgery ;)

Re: which comes first? endo or surgeon
« Reply #2 on: June 07, 2011, 05:54:32 PM »
Keep your appointment with your surgeon. If your gyne has been around for more than a year or two an endo can't do anything to reverse it. (not even sure if they could reverse it early on, but perhaps stop the growth)
Definitely make an appointment with an endo before surgery. Just to have an understanding of your hormone levels and any other factors that can relate to caused of gynecomastia.

It can't hurt to cover all of your bases and make sure, as a whole, your body is in tip top shape before going under the knife. Making sure everything is in place will mean you have better success long term at keeping it away forever.


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Offline jojo82

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Re: which comes first? endo or surgeon
« Reply #3 on: June 07, 2011, 06:52:45 PM »
What SHOULD come first is your primary care physician. He should be able to take care of some preliminary tests in-house, like a testicle exam. He should then refer you to an endocrinologist if he feels that it's necessary. That is why it's so important to first start with your PCP- instead of deciding if you need an endo, your PCP makes that decision for you. From there, you can pick the right plastic surgeon.

Don't skip steps here.

Re: which comes first? endo or surgeon
« Reply #4 on: June 07, 2011, 07:57:26 PM »
In my case- my doctor disregarded my gyne as "just fat" and said losing weight should help.
Problem is even when I was very under weight, I remember being self conscious to some degree about my chest.

My doctor also told me I didn't have psoriasis and to put some lotion on and it should help, and blamed the cold weather. A year later it's 10x worse and it most definitely is psoriasis.

My point? GP's aren't specialists and don't always know everything about every specific disease/discorder/condition. That's why they are called general physician.

That's just my 2 cents. I'm seeing an endo whether my GP says to or not. I've got nothing to lose. 

Re: which comes first? endo or surgeon
« Reply #5 on: June 07, 2011, 10:48:45 PM »
thanks for the all the advice, booked an endo appt. next week.  :)

Re: which comes first? endo or surgeon
« Reply #6 on: June 08, 2011, 09:48:45 AM »
Go see an endo. I had mines make sure my hormones were in check so that if I did get surgery, my G wouldn't grow back. Once my endo cleared me on that, I went and got the surgery.

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Offline jojo82

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Re: which comes first? endo or surgeon
« Reply #7 on: June 08, 2011, 04:56:19 PM »
In my case- my doctor disregarded my gyne as "just fat" and said losing weight should help.
Problem is even when I was very under weight, I remember being self conscious to some degree about my chest.

My doctor also told me I didn't have psoriasis and to put some lotion on and it should help, and blamed the cold weather. A year later it's 10x worse and it most definitely is psoriasis.

My point? GP's aren't specialists and don't always know everything about every specific disease/discorder/condition. That's why they are called general physician.

That's just my 2 cents. I'm seeing an endo whether my GP says to or not. I've got nothing to lose.  

I never said they were specialists. You may end up saving money going through your primary care physician, since some necessary tests can be done in his office. There are also other conditions that can cause gynecomastia that are NOT directly related to your endocrine system (many cancers and organ problems). Many surgeons worth their salt won't even operate on you until you've had tests that clear you from certain conditions.

Re: which comes first? endo or surgeon
« Reply #8 on: June 10, 2011, 02:42:55 AM »
I believe I've read from most of the doctors here that if your gynecomastia is stable, and has been for some time, then there's really no reason to consult an endocrinologist.  

An endo is typically advised for someone whose gyne is NOT stable....when you suspect (or simply want to rule out) whether there could be some medical reason for your gyne.  Most of the time, no significant medical reason or problem can be found.  Thus, if your gyne is stable now and has been for awhile, there's really not anything to be gained from going to the endocrinologist.    

I also agree that the primary care physician should be the first one consulted.  A lot of them don't really know that much about gyne, but they can still order the hormonal blood tests that ANY knowledgeable doctor should order, and order other tests if something looks suspicious (i.e., mammogram/ultrasound).  After these tests, if there's an indication for an endocrinologist, the PCP will hopefully make the referral. 


Re: which comes first? endo or surgeon
« Reply #9 on: June 10, 2011, 03:34:26 AM »
in my case, since i'm working abroad, i don't have my "doctor" per se, when i'm sick, i go to a clinic and whoever is the attending physician during that time would be ok. That us why i decided to meet with the specialist on my own. i booked the surgery on aug 2 just this morning, didn't realize how fast the entire consultation happened. first, i was sitting in the waiting area second i'm already being fitted with the vest. i'm still meeting the endo in two weeks just to check my hormones and all should be set.  :)

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DrBermant

Re: which comes first? endo or surgeon
« Reply #10 on: June 10, 2011, 03:55:20 AM »
In my case- my doctor disregarded my gyne as "just fat" and said losing weight should help.
Problem is even when I was very under weight, I remember being self conscious to some degree about my chest.

My doctor also told me I didn't have psoriasis and to put some lotion on and it should help, and blamed the cold weather. A year later it's 10x worse and it most definitely is psoriasis.

My point? GP's aren't specialists and don't always know everything about every specific disease/discorder/condition. That's why they are called general physician.

That's just my 2 cents. I'm seeing an endo whether my GP says to or not. I've got nothing to lose.  

Unfortunately, that is a very common problem that I have been analyzing with other Endocrinologists over the years. In evolving my Red Flag system of trying to optimize who should be evaluated by an Endocrinologist and who should not, the goal was a cost savings for the patient, not wasting the time of Endocrinologists seeing patients they had nothing to offer other than time and expense, and minimizing the many problem cases I was seeing from other surgeons and recurrence after surgery.

The breast is a gland part of the endocrine system for both male and females. An Endocrinologist is a specialist of the endocrine system and the diseases, diagnosis, and treatment of these organs. They are the most trained in the medical evaluation and medical management of these structures. The problem is a world shortage of these specialists and the complexity of diagnosis of the issues behind gynecomastia. It really takes a passion to work through all of the possibilities and many of the existing Endocrinologists seem to rather work on other aspects like diabetes or thyroid or other elements.

In the years of this dialogue, I would go over evaluations done by less trained individuals with these specialists trying to understand if further testing was needed or if patients should start out with their family docs, internists, or general practitioners. Such discussions ended up in me being invited to lecture several times to various groups of Endocrinologists about this Red Flag System and my Dynamic Technique of surgical intervention. The system evolved was well received at the National Meetings of their society when I was asked to speak as "Ask the Expert." So at least in their eyes, and the title of the lecture, that is what they considered I was.

The findings are that in certain cases no surgery should be done when an unstable condition was present. The Endo evaluation was the best place to start, stabilize the patient, and once the problem was under control, then consider surgery. If patients exhibited no Red Flags, the endo eval became optional but would be one of low yield, most likely an unnecessary expense, and delay before the emotional concerns could be addressed with corrective surgery.

So the consensus from these many years of discussions was that starting with a less specialized physician was not effective. I have too many examples of patients "evaluated" by these generalists that so missed the boat. I presented a selection of these failure cases during these lectures. When I have a Red Flag patient, I will only accept the evaluation by an experienced Endocrinologist who is willing to provide me with a note indicating factors critical to give me green light for surgery.

Part of my clinical exam for all of my gynecomastia patients include an assessment of genitalia, body hair distribution, body fat distribution, and thyroid. Unfortunately, some of the failures I was seeing were patients having no testicles (patients never examined), Klinefelter tiny testicles, female body fat, female body hair distribution. Sorry, this is something better left for those with a passion for diagnosis and what tests to order. I remember being ridiculed on this forum years ago that I was performing a testicle exam on each of my gynecomastia patients. Well, such exams were what uncovered many underlying undiagnosed endocrine conditions that they became part of my exam documentation for what any patient needed before I would operate on them. The consensus was that this should be part of any surgeon's exam for gynecomastia and are factors of the Red Flag system. if your doctor is bypassing these steps, then they could be letting those with Red Flags get operated. That is the only explanation I can conceive other than sheer negligence in having some of the missed diagnoses that have had recurrences that then came to me for help some of which I have published on my site.

I believe I've read from most of the doctors here that if your gynecomastia is stable, and has been for some time, then there's really no reason to consult an endocrinologist.  

An endo is typically advised for someone whose gyne is NOT stable....when you suspect (or simply want to rule out) whether there could be some medical reason for your gyne.  Most of the time, no significant medical reason or problem can be found.  Thus, if your gyne is stable now and has been for awhile, there's really not anything to be gained from going to the endocrinologist.    

I also agree that the primary care physician should be the first one consulted.  A lot of them don't really know that much about gyne, but they can still order the hormonal blood tests that ANY knowledgeable doctor should order, and order other tests if something looks suspicious (i.e., mammogram/ultrasound).  After these tests, if there's an indication for an endocrinologist, the PCP will hopefully make the referral.  

Sorry, this was a major factor. Ordering testing is not that simple. For one, what tests are ordered are not always the same. It takes the specialist to know where to start with the myriad of interlocking hormonal systems that can be involved. That a global assessment was needed. Not all laboratories have the same skills nor standards. Some, it turns out, are actually terrible in some hormonal tests that I was told by these specialists that they did not trust the lab values and the tests were a waste of money needing to be repeated. The same goes for time of day when the tests are drawn, and other factors critical for the assessment. The mammogram, ultrasound is something I nor the many Endocrinologists I have worked with even order unless there is something on our clinical exams. I find it fun and interesting to see what a mammogram shows and can fine tune my surgical sculpture when such a test was ordered, but otherwise consider it to be wasted radiation and unnecessary expense for most gynecomastia patients.

In addition it took years of discussions on this forum and elsewhere that operating on stable patients was a bad idea. If you use the search function on this forum and look for recurrence (use the oldest posts first), it was the opinion of many that such recurrences were "rare," and so uncommon that surgery is a cure. Yet, I was seeing case after case after case of unstable patients done elsewhere coming to me for regrowth. It is nice to see that campaign of mine now echoed by others. By the way, recurrences in my practice have been exceptionally rare. But the fact is that surgery does not prevent recurrence and working on a stable problem is much better than one that is not.

So the answer can be a knowledgeable surgeon first as long as that doctor is going to look at the patient at least with enough thoroughness to not operate without critical evaluation for Red Flags as I have outlined here and elsewhere. If the surgeon looks at the chest only and says let's operate, my suggestion is consider getting another opinion and better evaluation before risking a preventable recurrence.

Hope this helps,

Michael Bermant, M.D.


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