From the Guidelines
For a 46-year-old male patient with bilateral minimal benign gynecomastia, the recommended management is reassurance and observation, as the condition is likely to be asymptomatic and not causing significant psychological distress, with clinical follow-up as recommended by the BI-RADS Category 2 findings. The patient's recent bilateral digital diagnostic mammography with tomosynthesis and computer-aided detection showed minimal benign gynecomastia bilaterally, with no suspicious mass, suspicious calcifications, or unexpected architectural distortion in either breast. According to the American College of Radiology Appropriateness Criteria 1, in men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended, but since imaging has already been performed, the focus should shift to managing the gynecomastia.
Some key points to consider in the management of this patient include:
- A thorough evaluation to rule out underlying causes such as medications (spironolactone, finasteride, certain antipsychotics), hormonal disorders, liver disease, or substance use 1
- Watchful waiting is appropriate for idiopathic and minimal gynecomastia, as many cases resolve spontaneously within 1-2 years
- Medical therapy, including tamoxifen 10-20 mg daily or raloxifene 60 mg daily for 3-9 months, can be considered for patients experiencing pain or psychological distress
- Weight loss should be encouraged if the patient is overweight, as adipose tissue can contribute to estrogen production
- Surgical options like liposuction or mastectomy are typically reserved for cases that are persistent beyond two years, cause significant discomfort, or create substantial psychological impact, as supported by the guidelines for the evaluation of the symptomatic male breast 1.
From the Research
Recommended Management for Bilateral Minimal Benign Gynecomastia
The patient's condition, bilateral minimal benign gynecomastia, is a common condition in males, particularly during puberty and in older age 2. The recommended management for this condition is primarily focused on relieving symptoms and addressing any underlying causes.
Evaluation and Diagnosis
The evaluation of gynecomastia should include a detailed medical history, clinical examination, and specific blood tests to rule out underlying pathologies 2. The physical examination should confirm the presence of palpable glandular tissue to discriminate gynecomastia from lipomastia (pseudo-gynecomastia) and rule out the suspicion of malignant breast tumor 2.
Treatment Options
Treatment options for gynecomastia are varied and depend on the underlying cause and severity of the condition. 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.
Pharmacological Treatment
Pharmacological treatment, such as selective estrogen receptor modulators (SERMs), may be considered in select patients [(3,4)]. Tamoxifen, a SERM, has been found to be a safe and effective alternative treatment for male pubertal gynecomastia 4.
Surgical Treatment
Surgical treatment is reserved for patients with long-lasting gynecomastia that does not regress spontaneously or following medical therapy 2. The extent and type of surgery depend on the size of breast enlargement and the amount of adipose tissue 2.
Patient-Specific Recommendations
For the 46-year-old male patient with bilateral minimal benign gynecomastia, clinical follow-up is recommended 2. The patient's condition should be monitored, and any changes or worsening of symptoms should be evaluated and addressed accordingly.