• Type 1 diabetes (T1DM) is a condition in which the immune system attacks and destroys the insulin-producing ‘beta’ cells in the pancreas leading to insulin deficiency.

• This condition usually begins in childhood or adolescence (previously known as ‘juvenile’ diabetes) but may occur in adults as well.

• Insulin is needed to move blood sugar (glucose) from the bloodstream into the body’s cells. Without insulin, glucose cannot enter the cells and remains in the bloodstream causing high blood sugar levels.

• Symptoms may include increased thirst or hunger, frequent urination, weight loss or blurry vision, however, this may progress to a more severe clinical presentation known as diabetic ketoacidosis (see below).

• Insulin is needed to control blood sugar in T1DM, usually from the time of diagnosis.

• Insulin delivery systems include vials and syringes, pens and pump systems.

• There are various formulations of insulin from rapid-acting insulins, which are taken at mealtimes, to long-acting basal insulins which last for much longer periods.

• Insulin doses often need to be adjusted based on the blood sugar level and the amount of carbohydrates to be consumed in a meal.

• Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes that may be life-threatening if untreated.

• If the body is unable to use glucose for energy due to insufficient insulin, it breaks down fat to release chemical substances known as ketones. These may build up in the blood and cause the body to become too acidic.

• The imbalance between glucose-releasing (glucagon) and glucose-storing (insulin) hormones causes more glucose to be released from the liver, leading to very high blood sugar levels and severe dehydration.

• Patients may become drowsy or lethargic, have an upset stomach with vomiting and have heavy, labored breathing with a fruity (ketotic) odor. • Patients may be able to detect the presence of ketones in the urine using dipstick tests at home.

• DKA is a medical emergency and requires immediate treatment with intravenous fluids, correction of electrolyte abnormalities and IV insulin replacement.

• The most common cause is non-compliance with treatment or not taking one’s insulin as prescribed, but any severe illness including infections, trauma, drug intoxication, heart attacks or stroke could lead to DKA.

• Type 2 diabetes (T2DM) is the most common form of diabetes, and a condition associated with high blood sugar levels over long periods of time (chronic hyperglycaemia).

• The risk for developing T2DM is strongly influenced by genetics, as well as diet and lifestyle factors.

• Individuals over 40 years of age, those with a family history of T2DM in close relatives, those of South Asian descent and overweight or obese individuals are considered at higher risk.

• The initial problem is usually ‘insulin resistance’ which means it becomes harder for the hormone insulin, even at higher and higher levels, to move blood sugar into the body’s cells. Eventually, the body may not be able to produce enough insulin to keep blood sugar levels under control.

• This process results in high blood sugar levels, which over long periods of time, cause damage to the body’s tissue and increase the risk for diabetic complications (see below).

• Common symptoms include increased thirst, urinating more frequently including at night, fatigue, unintentional weight loss, vaginal thrush, recurrent sores or wounds that take longer than normal to heal.

• A diagnosis of T2DM may be made based on random blood sugar levels in a patient who has typical symptoms of diabetes, a high fasting blood sugar level, an oral glucose tolerance test and a blood test called glycated haemoglobin (HbA1c) that indicates longstanding high sugar levels.

• Prediabetes refers to a condition where the glucose levels are higher than normal but not high enough to diagnose diabetes yet.

• There is a high risk of progression to diabetes within a few years if there is no intervention such as changes in diet and lifestyle.

• The cornerstone of diabetes treatment is diet and lifestyle modification – this includes eliminating refined carbohydrates as far as possible, limiting highly processed foods, having a diet high in fiber and engaging in regular exercise.

• There are many medications used to treat T2DM but a drug known as metformin is usually the first option.

• If blood sugar levels are not controlled on metformin alone, other drugs may be added on over time.

• These include tablets that increase insulin secretion (sulfonylureas), that increase the effect of insulin after meals (‘gliptins’) or increase the amount of sugar excreted in the urine (‘gliflozins’).

• Injectable drugs include those that increase insulin release and lower weight by decreasing one’s appetite (‘glutides’) or different formulations of insulin.

• Several factors are considered when choosing a combination of glucose-lowering drugs including a patient’s age, the risk of weight gain and comorbid conditions such as coronary artery disease, heart failure and chronic kidney disease.

• T2DM is commonly thought of as a chronic and progressive disease and has no known cure, however, there is evidence that the course of diabetes may be ‘reversed’, or at least much improved, through significant dietary changes and weight loss.

• ‘Diabetes remission’ implies that a patient has blood sugar levels that remain within the normal range without the need for medication, for an extended period of time.

• It is believed that excess fat stores in the liver and pancreas are responsible for insulin resistance and ineffective insulin secretion, respectively, therefore a significant amount of weight loss may help to reverse these changes.

• This is most often observed in the context of bariatric (weight loss) surgery, but it may also be achieved through dietary strategies such as intermittent fasting and a low carbohydrate diet as well.

• It is important that all such strategies are monitored by a physician, especially for patients on drug therapy.

• Gestational diabetes refers to high blood sugar that develops during pregnancy, in women who were not diabetic previously, and usually resolves after giving birth.

• Other less common forms of diabetes include monogenic diabetes (rare inherited defects); pancreatic diabetes (due to chronic pancreatitis or surgery); secondary diabetes from an excess of hormones that increase blood sugar such as cortisol (Cushing’s syndrome), growth hormone (acromegaly) or catecholamines (phaeochromocytoma); diabetes associated with drugs or chemicals, or genetic syndromes.

• If blood sugar levels remain high for long periods of time, they may damage various tissues and organs resulting in diabetes complications.

• Diabetes may damage small blood vessels leading to retinopathy (eye disease, that may lead to blindness), nephropathy (kidney damage that may lead to kidney failure) and neuropathy (damage to the nerves).

• It may also damage larger blood vessels through the process of atherosclerosis (narrowing of the arteries due to a build up of cholesterol plaques), which includes coronary artery disease (leading to angina and heart attack), stroke and peripheral vascular disease (leading to gangrene).

• As complications occur, various specialists may be involved in the further care of patients with diabetes – such as ophthalmologists (eye specialists), nephrologists (kidney specialists), neurologists and cardiologists.

• Blood sugar levels may be monitored using a glucometer, which measures blood sugar concentration in a small sample of blood placed on a disposable test strip.

• Continuous glucose monitoring (CGM) refers to a device with a sensor that remains beneath the skin and measures sugar concentrations every 5-15 minutes. The readings can be viewed on a mobile device and the data can be shared with your doctor.

• Blood sugar control over the long term can be monitored using a blood test known as glycated haemoglobin or HbA1c. This test gives an indication of average blood sugar levels over the previous 3 months.

• The targets for blood sugar control in patients with diabetes are individualized for each patient depending on their age and other medical conditions they may have.

• For most patients on insulin treatment, blood sugar targets range between 4.0-7.0 mmol/l before meals, and 5.0-10 mmol/l 2 hours after meals.

• The target HbA1c for most patients is less than 7.0%.

• Cholesterol disorders may be primary (due to an inherited condition) or secondary (due to another medical problem).

• Secondary causes are much more common and include obesity, diabetes, drugs such as steroids, hormonal conditions such as hypothyroidism.

• Lifestyle factors such as poor diet, smoking and physical inactivity are associated with higher cholesterol levels.

• High levels of cholesterol, especially in combination with other chronic diseases such as diabetes and high blood pressure, are associated with an increased risk for atherosclerosis (narrowing of the arteries).

• This may lead to diseases such as coronary artery disease (angina and heart attack) or stroke.

• A diet high in saturated fats (eg. red meat, butter, cheese), trans fats (eg. margarine, commercially baked and fried foods), refined carbohydrates and processed foods is associated with higher levels of ‘bad’ cholesterol (LDLc and triglycerides). Limiting these foods may help to reduce cholesterol levels.

• Foods such as oily fish, avocados and nuts help to raise ‘good’ cholesterol (HDL) levels.

• Most guidelines recommend lifestyle modification including diet and physical exercise as the first steps to lowering cholesterol.

• For patients unable to meet their cholesterol targets with lifestyle modification, medications may be needed.

• Statins are a class of cholesterol-lowering medications. These include drugs such as simvastatin, atorvastatin and rosuvastatin.

• They are used in patients with high levels of cholesterol and those at high risk of cardiovascular disease such as heart attack or stroke.

• Patients with a history of heart attack, stroke or vascular disease are usually treated with statins.

• In patients who are unable to tolerate statins due to negative side effects, or whose cholesterol levels remain too high despite being on the highest dose of statin may require other drugs to control their blood cholesterol.

• Obesity is a condition associated with excessive body fat that increases the risk of various health problems.

• It is defined by ‘body mass index’ (BMI) or the ratio of weight to height (kg/m2 ).

• Normal BMI is between 18-24.9 kg/m2

• Overweight is defined as BMI between 25-29.9 kg/m2

• Obesity is defined as BMI above 30 kg/m2

• There are lower cutoffs for South Asians as they tend to have higher amounts of visceral fat (around the internal organs) and higher cardiovascular risk at a lower BMI than other population groups.

• Another important measure is waist circumference which gives an indication of higher amounts of visceral fat.

• The most common cause of obesity is poor diet with excess caloric intake for the body’s needs, combined with physical inactivity.

• In particular, diets high in refined carbohydrates and processed food are associated with increased obesity risk.

• There are genetic, behavioral, hormonal and metabolic factors that impact on body weight.

• Less common causes of obesity include rare genetic syndromes and endocrine conditions such as hypothyroidism and Cushing’s syndrome. A Specialist would be able to investigate and exclude these less common causes.

• Obesity may be linked to a variety of medical problems including prediabetes or diabetes, high blood pressure, high cholesterol, cardiovascular disease, fatty liver disease, chronic kidney disease, sleep apnoea, osteoarthritis and gout.

• It is also linked to a higher risk for a number of cancers.

• In order to lose weight, a patient needs to eat at a calorie deficit – that is, they take in less energy than they burn through their basal metabolic rate (the energy cost of the body’s normal functions) and physical activity.

• This can be achieved through a low calorie diet, limiting refined carbohydrates and processed foods, and methods such as time-restricted eating or intermittent fasting. This is best done with the guidance of a trained dietitian or nutritionist.

• ‘Crash diets’ or ‘fad diets’ that require extreme changes to one’s diet and lifestyle are usually not sustainable in the long-term, and it is important that a diet is suitable for an individual’s culture and lifestyle.

• Patients who are unable to achieve weight loss with diet strategies may require medical therapy.

• These include drugs that work by decreasing the absorption of fat in the gut, or reducing appetite by increasing the feeling of satiety (fullness).

• Over-the-counter weight loss drugs or supplements often do not have sufficient evidence for their benefit, and in some cases, may contain ingredients that have negative health consequences or interact with other medications.

• Bariatric (weight loss) surgery is considered for patients with severe obesity and related medical problems who are unable to achieve sufficient weight loss with diet or medication.

• This is usually when the BMI is over 40 kg/m2, or over 35 kg/m2 with two or more associated medical conditions.

• It is important that a full medical and psychological evaluation is conducted prior to bariatric surgery, and patients are followed up for complications or nutrient deficiencies.

• The main forms of bariatric surgery are those reduce the size of the stomach (eg. sleeve gastrectomy, gastric banding) and those that also decrease the absorption of food (eg. Roux-en-Y gastric bypass).

• The decision on which type of surgery would be best suited for a patient is individualized and decided on in discussion with the bariatric surgeon.

• The thyroid gland is a butterfly-shaped gland situated at the front of the neck, under the Adam’s apple.

• It produces and releases thyroid hormones in response to the body’s needs.

• Thyroid hormones play a vital role in metabolism, growth and development of the human body.

• Normal thyroid function is necessary for the cardiovascular, neurological and gastrointestinal systems to function properly.

• Hypothyroidism is a condition in which the thyroid gland is unable to produce enough thyroid hormones for the body’s needs.

• It is most often due to autoimmune destruction of normal thyroid tissue by antibodies (Hashimoto’s thyroiditis), but it may also be due to surgery, iodine deficiency, viral infection or drugs.

• Common symptoms include weight gain, cold intolerance (feeling cold most of the time), dry skin, brittle hair, constipation, fatigue, muscle stiffness, low mood and poor memory.

• It is diagnosed using a blood thyroid function test.

• Hypothyroidism is treated with thyroid hormone replacement in the form of levothyroxine tablets (SA trade names: Euthyrox or Eltroxin).

• This needs to be taken on a daily basis and treatment is generally lifelong.

• The dose of thyroxine is adjusted based on thyroid function tests done every 3 to 6 months.

• This refers to an early mild form of hypothyroidism, where the thyroid hormones may be in the normal range but the levels of thyroid stimulating hormone (TSH) from the pituitary gland are increased.

• In most cases, treatment is not required, but there are specific clinical situations in which thyroid hormone replacement may be needed.

• ‘Hyperthyroidism’ refers to overproduction of thyroid hormone by the thyroid gland.

• ‘Thyrotoxicosis’ refers to excess circulating levels of thyroid hormone, regardless of the source.

• This is most often caused by an autoimmune condition called Grave’s disease, that stimulates the thyroid gland to produce excessive amounts of thyroid hormone.

• Less common causes include toxic nodules and toxic multinodular goitre.

• Common symptoms include unintentional weight loss, rapid or irregular heart beat, heat intolerance (feeling hot all the time), increased sweating, irritability, agitation, difficulty sleeping, muscle weakness and irregular or absent periods.

• Proptosis or ‘bulging’ of the eyes may be seen in Grave’s disease.

• The evaluation of hyperthyroidism includes blood thyroid function tests and other special investigations including thyroid antibodies and nuclear imaging scans.

• Treatment may include medications that lower thyroid hormone levels (carbimazole), a form of radiotherapy directed against thyroid tissue (radio-iodine) and in some cases, surgery (thyroidectomy).

• Drugs known as beta-blockers may be used in the short-term to control symptoms of thyrotoxicosis such as palpitations.

• The most appropriate form of long-term treatment is decided based on discussion with the patient, and the cause of hyperthyroidism.

• Thyroid nodules are solid or fluid-filled lumps that may form within the thyroid gland.

• Most are benign and do not cause symptoms, however some may be pre-cancerous and require a biopsy.

• The decision to biopsy a nodule is usually based on the characteristics of a nodule on ultrasound.

• The adrenal glands are small endocrine glands located above each kidney.

• Each gland is comprised of an inner part called the ‘medulla’ and an outer part called the ‘cortex’.

• The adrenal medulla produces hormones involved in the ‘fight-or-flight’ response known as catecholamines. These include adrenaline, noradrenaline and dopamine.

• The adrenal cortex has 3 layers and produces hormones involved in control of blood pressure (aldosterone), regulation of the stress response (cortisol) and sex hormones (androgens).

• Many endocrine conditions may result in high blood pressure. This is known as ‘secondary’ hypertension.

• Adrenal causes include excessive production of aldosterone (Conn’s syndrome), cortisol (Cushing’s syndrome) and catecholamines (phaeochromocytoma).

• Other conditions associated with high blood pressure include acromegaly (excess growth hormone), hyperthyroidism, hypothyroidism and hyperparathyroidism.

• Symptoms of chronic excess cortisol release or exposure include weight gain (especially around the mid-section, rounded ‘moon’ face and ‘buffalo hump’ behind the neck), thinning of the skin resulting in wide stretch marks (striae) and easy bruising, weakness of the muscles in the arms and thighs, mood swings, depression, irritability, slow healing of wounds and skin infections.

• Women may also experience irregular or absent periods and increased hair growth over the face and body (hirsutism).

• Chronic high cortisol levels may also result in diabetes or hypertension.

• Special tests are needed to determine whether cortisol levels are in excess, and whether this is due to the pituitary gland, adrenal glands or other causes (eg. drugs).

• Symptoms include palpitations, headache, excessive sweating, anxiety or a feeling of impending doom.

• Patients may have a rapid heart rate (tachycardia) and high blood pressure.

• If unrecognized, events such as trauma or surgery, anaesthesia or certain drugs may provoke a crisis.

• Certain genetic syndromes are associated with a higher risk of these tumors, and close family members may need to be screened as well.

• The pituitary gland is a small, pea-sized gland located beneath the brain in a special chamber called the sella turcica (‘Turkish saddle’).

• It is often called the ‘master gland’ as it secretes multiple hormones and regulates a number of different endocrine systems.

• The pituitary gland contains two distinct lobes which are connected to a part of the brain called the hypothalamus by a stalk.

• The anterior (front) lobe of the pituitary produces hormones that control growth, the reproductive organs, lactation, thyroid function and cortisol production from the adrenal glands.

• The posterior (back) lobe produces hormones that control the water balance in the body and contraction of the uterus during labor.

• Conditions that result in compression or damage of normal pituitary tissue may result in low levels of pituitary hormones.

• These include tumors in and around the pituitary gland, genetic conditions, trauma, surgery and radiation.

• One or more hormones may be deficient resulting in symptoms related to the respective endocrine glands.

• Symptoms may include fatigue, decreased sense of well-being, loss of libido and infertility in both sexes and absent periods in females.

• If low pituitary function occurs at an early age, there may be a delay in, or absence of, normal growth and puberty.

• A large pituitary tumor may also cause headaches and decreased vision by compressing the optic nerves.

• Prolactin levels normally rise during pregnancy, lactation and breastfeeding.

• A number of other factors may cause a rise in prolactin levels including medications such as antipsychotics and antidepressants, nipple stimulation, chest trauma, intercourse, exercise, seizures, chronic liver and kidney disease, among others.

• A pituitary tumor that produces excessive amounts of prolactin is known as a prolactinoma.

• High prolactin levels may cause irregular or absent periods in females, impotence in males, milky discharge from the nipples (galactorrhoea), loss of sex drive and infertility.

• Cushing’s syndrome refers to excessive levels of the stress hormone, cortisol, over a long period of time, that causes damage to various tissues.

• Cushing’s disease refers to Cushing’s syndrome caused by a pituitary tumor.

• Signs include weight gain especially around the belly and the back of the neck (‘buffalo hump’), a round ‘moon face’, redness or plethora, thin skin with wide stretch marks and easy bruising, poor wound healing and low bone mass with an increased risk of fractures.

• It may also cause irregular or absent periods, increased hair growth over the face and body in women, mood swings, irritability and depression.

• The diagnosis and management of this condition is often challenging and best managed by a subspecialist in hormonal disorders (Endocrinologist).

• Excess growth hormone levels is most often caused by a pituitary tumor (adenoma).

• When this occurs in childhood, it results in a condition called pituitary gigantism, where the entire body increases in size and stature.

• When it occurs in adulthood, it causes certain parts of the body, such as the jaw, lips, nose, tongue, hands and feet, to enlarge.

• These changes occur gradually over many years and may not be noticed by the patient or their family members.

• Some patients may report having to change rings or shoe sizes as an adult.

• Other symptoms include headaches, excessive sweating, joint pain, muscle weakness, sleep apnoea and carpal tunnel syndrome.

• The diagnosis and management of this condition may be challenging and is best managed by a subspecialist in hormonal disorders (Endocrinologist).

• Parathyroid hormone (PTH) is produced by the parathyroid glands in the neck.

• PTH is responsible for controlling calcium levels in the blood and keeping them within normal range.

• It regulates calcium metabolism through its effects on vitamin D, and effects on the bones, kidneys and intestines.

• The most common cause is excess production of PTH from a parathyroid tumor (adenoma).

• Hyperparathyroidism may result in low bone mass (osteoporosis) with a high risk of fracture, kidney stones, gastrointestinal (eg. heartburn, constipation) and neuropsychiatric (eg. depression, anxiety) symptoms.

• Other causes of high calcium levels include cancer, some medications, and taking too much calcium or vitamin D supplements.

• Low calcium levels may be due to damage to the parathyroid glands, genetic conditions, low levels of magnesium or vitamin D, chronic kidney disease and drugs that prevent absorption of calcium from the bones.

• Calcium is necessary for normal function of nerves and muscles, including the heart.

• Very low levels of calcium may cause numbness and tingling of the fingers and toes, cramps, spasms of the hands and feet and seizures.

• Vitamin D is needed to maintain normal levels of calcium and phosphate.

• The hormone is produced in the skin through exposure to sunlight, and also obtained through food sources and supplements, and later activated in the kidneys.

• It’s primary action is on calcium absorption from the intestines, but it also stimulates calcium mobilization from bone and resorption of calcium in the kidneys.

• In children, low levels of vitamin may result in a condition known as ‘rickets’ which causes misshapen bones and abnormal growth.

• In adults, it may cause weakened and demineralized bones (osteomalacia). Patients may also experience bone or muscle pain, fatigue and muscle weakness.

• Very often, vitamin D deficiency may not produce symptoms and is diagnosed on a blood test.

• Osteoporosis is a condition associated with a loss of bone mass, causing the bones to become fragile and brittle.

• This is often due to hormonal causes, most commonly after menopause.

• Patients are at increased risk of fractures, even after mild trauma such as falling from a bed or chair.

• ‘Osteopenia’ refers to low bone mass that is not as severe as osteoporosis.

• The diagnosis is based on a bone densitometry (DXA) scan and a scoring system called the FRAX model.

• All women over the age of 65 should have a bone density test, and earlier for women with risk factors such as early menopause.

• Men over the age of 70, or younger men with risk factors such as low testosterone, should also have a bone density test.

• A diet high in calcium, and exercise (especially resistance training) are helpful in preserving bone mass.

• Patients with osteoporosis are at high risk of fracture and medications are often required.

• These include drugs that prevent the resorption of bone tissue (bisphosphonates), drugs that block receptors involved in bone breakdown (denosumab) and drugs that promote new bone formation as well (romosozumab, teriparatide).

• Some patients with symptoms related to menopause (women) or low testosterone (men) may also benefit from hormonal replacement therapy.

• Hirsutism refers to excessive male-pattern hair growth, particularly coarse, pigmented hair, in a female eg. over the face, chest, back and limbs.

• This may be due to genetic or ethnic factors, but in some cases is due to excessive levels of androgens (male hormones).

• Androgens may be produced in the ovaries and adrenal glands in females, and several conditions may cause excess secretion.

• PCOS is a hormonal disorder associated with enlarged ovaries containing multiple cysts (fluid filled sacs or follicles) on the outer edges.

• The cause is not well understood, but is likely due to a combination of genetic and environmental factors.

• The main features include irregular periods and excessive levels of male hormones (androgens) which may cause excess hair growth over the face and body.

• Other features include weight gain, hair loss, acne, and irregular or absent ovulation during the menstrual cycle leading to problems with fertility.

• Patients often have insulin resistance which increases the risk for type 2 diabetes.

• CAH is a group of genetic conditions that affect hormone production in the adrenal glands.

• The most common mutation is in an enzyme needed to produce cortisol and/or aldosterone.

• Androgen (male hormone) levels are increased which may affect sexual development in females.

• More severe forms (complete loss of the enzyme) that occur in infancy can be life-threatening.

• Milder forms may present in adulthood with irregular or absent periods, acne, unwanted hair growth and infertility.

• Primary amenorrhoea refers to periods not having started at the expected age (generally by 16 years).

• Causes include genetic (chromosomal) abnormalities such as Turner syndrome, low levels of sex hormones due to damage to the ovaries or pituitary gland, and abnormalities of the uterus, cervix or vagina.

• Secondary amenorrhoea refers to periods having stopped for over 3 months in women who had regular periods previously.

• Causes include ovarian disorders such as PCOS, premature or early menopause, severe stress, excessive weight loss or exercise, diseases involving the pituitary gland or hypothalamus, thyroid conditions, high levels of androgens (male hormones), drugs and damage to the reproductive organs.

• Couples who fail to conceive after at least 1 year of regular unprotected intercourse should be evaluated for fertility problems.

• Investigation may be offered sooner in women over the age of 35 years, or if there is a known medical condition that affects fertility.

• Infertility may be due to female factors (45%), male factors (30%) or a combination of the two (30-40%).

• Female factors include failure to ovulate due to ovarian, pituitary or thyroid problems, high prolactin levels, and damage to the uterus or Fallopian tubes.

• Male factors include genetic disorders, damage to the testes from infection, trauma, drugs or toxins, hypothalamic or pituitary disease and abnormalities of the sperm.

• Obesity, chronic illness and smoking (including vaping) reduce fertility in both sexes.

• Male hypogonadism or low testosterone levels occurs when the testicles fail to produce enough testosterone.

• There are multiple possible causes such as genetic conditions, damage to the testes by infection, injury, radiation or drugs, hypothalamic or pituitary disorders, or chronic systemic illness including obesity, diabetes, cirrhosis and HIV.

• There is also a natural drop in testosterone levels as men age.

• Testosterone helps to develop and maintain the sex organs and reproductive function, muscle mass, bone density and sense of well-being.

• Low testosterone levels may result in low libido or sex drive, problems getting or maintaining an erection, loss of armpit or pubic hair and problems with fertility.

• Low testosterone levels in male children may result in delayed or absent puberty.

• Gynaecomastia (‘man boobs’) refers to enlargement of glandular breast tissue in a male.

• This is generally due to hormonal imbalances – reduced male hormones (testosterone) and increased female hormones (estrogen).

• This may occur during puberty, ageing, with the use of certain prescription medications, drugs such as cannabis and anabolic steroids, conditions that damage the pituitary gland or testes, thyroid dysfunction and chronic liver disease.

• There may be pain, swelling and sensitivity of the breasts, and some patients may have a discharge from the nipples. One or both breasts may be affected.

• Pseudo gynaecomastia or lipomastia refers to an increase in fatty tissue in the breasts due to obesity.