From the Guidelines
Gynecomastia is typically a benign condition that can often be diagnosed and managed without imaging, especially in cases where physical examination is consistent with gynecomastia or pseudogynecomastia. The majority of male breast problems are benign, with gynecomastia being the most common cause of a palpable mass, breast enlargement, or pain 1. Gynecomastia occurs physiologically in neonates and adolescents and with aging but can occur at any age as a side effect of many medications and recreational drugs, as a result of hormonal changes, and in the setting of chronic liver disease 1.
Key Considerations
- Gynecomastia is more likely to be painful than cancer, especially gynecomastia that has been present for <6 months 1.
- Breast cancer in men is rare, accounting for <1% of all breast cancers, and usually occurs in older men (median age of 63 years) 1.
- If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated 1.
Management Approach
- For mild cases, observation is often sufficient as many resolve spontaneously, especially in adolescents and newborns.
- For persistent or bothersome cases, addressing underlying causes is essential, such as discontinuing medications like spironolactone, ketoconazole, or certain antipsychotics if they're contributing factors.
- Medical treatment options include tamoxifen (10-20mg daily for 3-6 months), which blocks estrogen receptors, or anastrozole (1mg daily), which inhibits estrogen production.
- For established gynecomastia causing significant psychological distress or physical discomfort, surgical options include liposuction, excision of glandular tissue, or both.
- Laboratory evaluation including testosterone, estradiol, LH, FSH, and liver function tests may be warranted in adult men with unexplained gynecomastia to identify underlying causes.
From the Research
Definition and Prevalence of Gynecomastia
- Gynecomastia is a benign proliferation of the glandular tissue of the breast in men, with a reported prevalence of 32-65% depending on age and criteria used for definition 2.
- It is a common condition that can occur at different stages of life, including infancy, puberty, and adulthood 2, 3, 4, 5.
Causes and Risk Factors
- Gynecomastia can be caused by physiologic factors such as hypogonadism and altered estrogen-to-androgen ratio, as well as nonphysiologic factors like drugs and herbal products 4, 5, 6.
- Certain medications, including spironolactone, cimetidine, and ketoconazole, have been associated with the development of gynecomastia 6.
- The use of anabolic steroids, alcohol, and opioids may also contribute to the risk of developing gynecomastia 6.
Diagnosis and Evaluation
- The diagnosis of gynecomastia should be based on a thorough medical history and physical examination, including a breast examination and testicular ultrasound 2, 3, 4.
- Laboratory investigations, such as hormone level tests and liver and renal function tests, may be necessary to rule out underlying pathologies 2, 4.
- Breast imaging, such as ultrasound, may be used to confirm the diagnosis and rule out other breast conditions, such as breast cancer 2, 3, 4.
Treatment and Management
- Treatment of gynecomastia is often unnecessary, as most cases are benign and resolve spontaneously 2, 3, 4, 5.
- However, in some cases, medical treatment, such as testosterone replacement therapy, or surgical treatment may be necessary to address underlying conditions or alleviate symptoms 2, 4, 5.
- The use of selective estrogen receptor modulators, aromatase inhibitors, and non-aromatizable androgens is not recommended for the treatment of gynecomastia in general 2.