To whom do we refer patients with gynecomastia?

From the Guidelines

Patients with gynecomastia should be referred to an endocrinologist or a breast specialist (breast surgeon) for comprehensive evaluation and management. Initial referral is typically to an endocrinologist to investigate underlying hormonal causes, particularly if the gynecomastia is painful, rapidly progressive, or associated with other endocrine symptoms, as suggested by the evaluation and management of testosterone deficiency guideline 1. The endocrinologist will conduct hormone testing, including testosterone, estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and thyroid function tests to identify potential hormonal imbalances. Some key points to consider when evaluating patients with gynecomastia include:

• The importance of measuring serum estradiol in testosterone deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy, as recommended by the evaluation and management of testosterone deficiency guideline 1
• The need for referral to an endocrinologist if patients have elevated baseline estradiol measurements, as suggested by the evaluation and management of testosterone deficiency guideline 1
• The role of imaging in the evaluation of symptomatic male breast, as outlined in the ACR Appropriateness Criteria for the evaluation of the symptomatic male breast 1 If medication-induced gynecomastia is suspected, the patient may need consultation with the prescribing physician to consider alternative medications. For cases where surgical intervention is being considered, especially for cosmetic concerns or long-standing gynecomastia that hasn't responded to medical management, referral to a breast surgeon or plastic surgeon is appropriate. These specialists can offer options ranging from liposuction to more extensive glandular tissue removal. Urgent referral is warranted if there are any suspicious features for male breast cancer, such as unilateral, hard, fixed masses, nipple discharge, or skin changes.

From the Research

Referral Options for Gynecomastia

Patients with gynecomastia can be referred to various specialists depending on the underlying cause and severity of the condition. The following options are available:

• Endocrinologists: For patients with hormonal imbalances or underlying endocrine disorders, referral to an endocrinologist may be necessary 2, 3.
• Surgeons: Surgical removal of breast tissue may be considered for patients with persistent gynecomastia or those who have not responded to medical therapy 4, 3.
• Primary Care Physicians: For patients with physiologic gynecomastia or those who require reassurance and monitoring, referral to a primary care physician may be sufficient 3.
• Oncologists: For patients with gynecomastia associated with antiandrogen therapy for prostate cancer, referral to an oncologist may be necessary 5.

Considerations for Referral

When referring patients with gynecomastia, the following factors should be considered:

• Underlying cause: Referral to a specialist who can address the underlying cause of gynecomastia, such as an endocrinologist or oncologist, may be necessary 2, 5.
• Severity of symptoms: Patients with severe breast pain or significant emotional distress may require referral to a surgeon or other specialist for further evaluation and treatment 4, 3.
• Patient preferences: Patient preferences and values should be taken into account when determining the best course of treatment and referral 3.