What is the workup for a middle-aged male patient with gynecomastia, normal testosterone and estrogen levels, and a mammogram showing symmetrical gynecomastia?

From the Guidelines

For a middle-aged male with symmetrical gynecomastia, normal testosterone and estrogen levels, and a benign mammogram, the workup should focus on identifying potential underlying causes, starting with a thorough medication review and laboratory testing, as gynecomastia is a common entity and breast cancer is rare in men 1. The initial step in the workup should include a thorough medication review to identify drugs associated with gynecomastia, such as spironolactone, finasteride, calcium channel blockers, and certain antipsychotics.

• Laboratory testing should include:
  • Liver function tests
  • Renal function tests
  • Thyroid function tests
  • Prolactin levels
  • Luteinizing hormone (LH)
  • Human chorionic gonadotropin (hCG) Additional testing for adrenal function may be warranted with a morning cortisol level, as suggested by the American College of Radiology 1. If the patient has any signs of hyperthyroidism, Graves' disease should be considered, and abdominal imaging may be appropriate to evaluate for adrenal or testicular tumors if laboratory findings suggest these possibilities, as recommended by the Journal of the American College of Radiology 1. Liver cirrhosis should be considered in patients with risk factors, and if all investigations are negative, idiopathic gynecomastia is the likely diagnosis, which may be observed or treated with tamoxifen 10-20 mg daily for 3-9 months if the condition is bothersome, as per the guidelines from the Journal of the National Comprehensive Cancer Network 1. Surgical correction with reduction mammoplasty may be considered for persistent cases causing significant psychological distress or physical discomfort, prioritizing the patient's quality of life and morbidity reduction 1.

From the Research

Workup for Gynecomastia

The workup for a middle-aged male patient with gynecomastia, normal testosterone and estrogen levels, and a mammogram showing symmetrical gynecomastia involves several steps:

• Ruling out pseudogynecomastia by careful history taking and physical examination 2
• A stepwise approach that includes imaging and laboratory testing to exclude neoplasms and endocrinopathies 2
• Evaluation of the patient's medical history to identify potential causes of gynecomastia, such as chronic conditions, medication use, or illicit drug use 3, 4
• Physical examination to assess the size and symmetry of the breast tissue, as well as to check for any signs of underlying disease 4

Laboratory Testing

Laboratory tests may include:

• Hormone level tests, such as testosterone and estrogen, to evaluate for any hormonal imbalances 5
• Liver function tests to evaluate for any underlying liver disease 3
• Renal function tests to evaluate for any underlying kidney disease 3

Imaging Studies

Imaging studies, such as mammography, may be used to:

• Confirm the diagnosis of gynecomastia 2
• Evaluate the size and symmetry of the breast tissue 2
• Rule out any underlying breast cancer 6

Treatment

Treatment for gynecomastia may include:

• Reassurance and monitoring for patients with idiopathic gynecomastia 6
• Medication, such as estrogen receptor modulators, to treat underlying hormonal imbalances 3
• Surgery to remove excess breast tissue 3, 6