From the Guidelines
Gynecomastia in a young male with elevated testosterone and LH levels is most likely caused by an imbalance between estrogen and testosterone activity, and management should prioritize addressing underlying causes such as androgen resistance syndromes, testicular tumors, or liver disease. The condition may also be due to hyperthyroidism or exogenous testosterone use that converts to estrogen through aromatization 1. Key considerations in management include:
- Identifying and treating any underlying medical conditions that may be contributing to the gynecomastia
- Discontinuing any exogenous androgens or medications that might be exacerbating the condition
- Considering symptomatic treatment with selective estrogen receptor modulators like tamoxifen (10-20mg daily for 3-6 months) or aromatase inhibitors such as anastrozole (1mg daily) to reduce the conversion of testosterone to estrogen 1
- Referral to an endocrinologist for further evaluation and management, particularly in cases of suspected androgen insensitivity or other complex hormonal imbalances
- Surgical options, including liposuction or mastectomy, may be considered for persistent gynecomastia lasting over 12 months that causes significant psychological distress
- Regular monitoring of hormone levels is crucial to assess treatment efficacy and adjust management strategies as needed 1.
From the Research
Potential Causes of Gynecomastia
- Gynecomastia is a benign proliferation of glandular breast tissue in men, which can be caused by various factors, including physiological and non-physiological conditions 2, 3.
- Physiological gynecomastia is common in newborns, adolescents, and older men, and is usually self-limited 3.
- Non-physiological gynecomastia may be caused by chronic conditions, such as cirrhosis, hypogonadism, and renal insufficiency, as well as the use of medications, supplements, or illicit drugs 3.
- In cases of high testosterone and LH levels, partial androgen insensitivity syndrome (PAIS) may be a potential cause of gynecomastia, characterized by a novel mutation in the androgen receptor gene 4.
Diagnostic Approach
- A thorough medical history and physical examination, including breast and genitalia examination, are essential for the diagnosis of gynecomastia 2, 5.
- Laboratory investigations, such as testosterone, estradiol, LH, FSH, and thyroid-stimulating hormone (TSH) levels, may be helpful in identifying underlying pathological conditions 2, 5.
- Breast imaging and core needle biopsy may be necessary in cases where the clinical examination is equivocal or suspicious for a malignant lesion 2, 5.
Management Options
- Discontinuing the use of contributing medications and treating underlying diseases are the mainstay of treatment for gynecomastia 3, 5.
- Medications, such as estrogen receptor modulators, and surgery may have a role in treating gynecomastia in select patients 3, 5.
- In cases of PAIS, surgery for breast reduction may be recommended due to the persistent nature of the condition 4.
- Watchful waiting may be recommended after treatment of underlying pathology or discontinuation of substances associated with gynecomastia 2.