From the Guidelines
The workup for male gynecomastia should begin with a thorough history and physical examination to identify potential causes, as most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging 1. The initial evaluation should include a comprehensive medical history, physical examination, and laboratory tests to identify underlying causes of gynecomastia. Key points to consider in the workup include:
- Initial laboratory tests should include liver function tests, renal function tests, thyroid function tests, serum testosterone, estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and human chorionic gonadotropin (hCG) 1.
- If the patient has a testicular mass or asymmetry, a testicular ultrasound should be performed to rule out testicular tumors.
- For patients with suspicious breast findings, a mammogram or breast ultrasound may be necessary to differentiate true gynecomastia from pseudogynecomastia or breast cancer, with ultrasound recommended for men younger than 25 and mammography or digital breast tomosynthesis for men 25 and older 1. Management depends on the underlying cause; if medication-induced, discontinuing the offending agent may resolve the condition. For idiopathic or persistent gynecomastia, medical therapy options include tamoxifen or anastrozole, and surgical options like liposuction or mastectomy may be considered for cosmetic concerns or cases resistant to medical therapy. The workup is important because gynecomastia can result from various conditions including hormonal imbalances, liver disease, kidney disease, medications, or rarely, tumors that need to be identified and addressed.
From the Research
Male Gynecomastia Workup
The workup for male gynecomastia involves a thorough medical history and physical examination to detect underlying pathological conditions, reversible causes, and to discriminate from other breast lumps, particularly breast cancer 2.
- The medical history should include information on the onset and duration of gynecomastia, sexual development and function, and administration or abuse of substances associated with gynecomastia 2.
- The physical examination should detect signs of under-virilization or systemic disease and confirm the presence of palpable glandular tissue to discriminate gynecomastia from lipomastia and rule out suspicion of malignant breast tumor 2.
- A set of laboratory investigations may be included in the evaluation, such as:
- Breast imaging may be used when the clinical examination is equivocal, and core needle biopsy should be performed if the clinical picture is suspicious for a malignant lesion 2, 4.
Diagnostic Approach
The diagnostic approach to gynecomastia should be individualized, based on the patient's presentation and related factors, and guided by thorough history taking and physical examination 4, 5.
- Unless the patient has associated symptoms or suspicion for an underlying clinical disorder causing the gynecomastia, further investigation may not be necessary 4.
- Gynecomastia is not considered a premalignant condition, and routine screening is not cost-effective; imaging studies should be pursued only if physical examination findings suggest malignancy 4, 6.
Treatment
Treatment of gynecomastia may include reassurance, medication, or surgery, and should be tailored to the individual patient's circumstances 2, 6.
- Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with gynecomastia 2.
- Testosterone treatment should be offered only to men with proven testosterone deficiency 2.
- Surgical treatment is the therapy of choice for patients with long-lasting gynecomastia that does not regress spontaneously or following medical therapy 2.