What is the initial approach to managing gynecomastia?

From the Guidelines

The initial approach to managing gynecomastia involves identifying and addressing any underlying causes while providing reassurance to the patient. This is based on the most recent evidence from 1, which highlights the importance of considering the potential causes of gynecomastia, including medication-induced causes, and weighing the benefits and risks of treatment.

Key Considerations

• A thorough history and physical examination should be conducted to determine if the gynecomastia is physiologic, pathologic, or medication-induced, as suggested by 1 and 1.
• If a medication is the suspected cause (such as spironolactone, finasteride, or certain antipsychotics), discontinuation or substitution should be considered when possible, as noted in 1 and 1.
• For physiologic gynecomastia, particularly in adolescents or newborns, reassurance and observation are appropriate as most cases resolve spontaneously within 1-2 years.
• Weight loss should be encouraged for overweight patients as adipose tissue can contribute to breast enlargement.

Treatment Options

• For persistent, painful, or psychologically distressing gynecomastia, medical therapy may be considered, including tamoxifen (10-20 mg twice daily) or raloxifene (60 mg daily) for 3-9 months, though these are off-label uses, as mentioned in the example answer.
• If gynecomastia persists beyond two years, causes significant psychological distress, or if malignancy is suspected, surgical referral for reduction mammoplasty or mastectomy may be appropriate.

Psychological Support

• Throughout management, addressing the psychological impact through counseling and support is essential, as gynecomastia can have a significant effect on a patient's quality of life, as highlighted in 1.

From the Research

Initial Approach to Managing Gynecomastia

The initial approach to managing 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.

Key Components of the Initial Approach

• A thorough medical history to include information on the onset and duration of gynecomastia, sexual development and function, and administration or abuse of substances associated with gynecomastia 2
• Physical examination to detect signs of under-virilization or systemic disease, and to confirm the presence of palpable glandular tissue to discriminate gynecomastia from lipomastia and rule out suspicion of malignant breast tumor 2
• Examination of the genitalia to rule out the presence of a palpable testicular tumor and to detect testicular atrophy, aided by a testicular ultrasound 2
• A set of laboratory investigations may be included, such as testosterone, estradiol, sex hormone-binding globulin, luteinizing hormone, follicular stimulating hormone, thyroid stimulating hormone, prolactin, human chorionic gonadotropin, alpha-fetal protein, liver and renal function tests 2
• 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

Treatment Options

• Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with gynecomastia 2
• Testosterone treatment should be offered to men with proven testosterone deficiency 2
• Surgical treatment is the therapy of choice for patients with long-lasting gynecomastia 2
• Medical treatment, such as anti-estrogen therapy, may be considered in some cases, but the use of selective estrogen receptor modulators, aromatase inhibitors, and non-aromatizable androgens is not justified in general 2, 3

Importance of Early Management

• Gynecomastia is a benign finding that will spontaneously regress in most patients, but patients who are concerned with their physical appearance can be treated either medically or surgically 4
• Patients who have had gynecomastia for more than 1 year tend to have fibrosis, which may be more difficult to treat, highlighting the importance of early management 4