From the Guidelines
The initial workup for a 38-year-old male presenting with painful gynecomastia should include a thorough history, physical examination, and targeted laboratory tests, prioritizing the identification of underlying causes such as hypogonadism, hyperprolactinemia, or liver dysfunction, as recommended by the most recent guidelines 1. The workup should begin with a detailed history focusing on medication use, including prescription drugs like spironolactone, finasteride, and antipsychotics; illicit drugs like marijuana; and anabolic steroids, as well as alcohol consumption, and symptoms of underlying conditions like liver disease, hypogonadism, or hyperthyroidism.
- The physical exam should assess breast tissue development, check for testicular abnormalities, and look for signs of systemic disease.
- Laboratory evaluation should include liver function tests, renal function tests, thyroid function tests (TSH, free T4), and hormonal studies including total and free testosterone, estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin levels, as suggested by the evaluation and management of testosterone deficiency guidelines 1.
- If the patient has unilateral gynecomastia or any concerning features like rapid growth, skin changes, or nipple discharge, mammography or breast ultrasound should be considered to rule out breast cancer, in line with the recommendations for the symptomatic male breast 1. This comprehensive initial approach allows for identification of the underlying cause, which is essential for appropriate management of painful gynecomastia, and is supported by the guidelines for the diagnosis and treatment of conditions that may be associated with gynecomastia, such as heart failure 1.
From the Research
Initial Workup for Gynecomastia
The initial workup for a 38-year-old male presenting with painful gynecomastia should include:
- A thorough history taking to identify any underlying causes or associated symptoms 2, 3, 4, 5
- A physical examination to assess the breast tissue and check for any signs of malignancy or other underlying conditions 2, 3, 4, 5
- Limited laboratory investigations to exclude breast malignancy and serious underlying endocrine or systemic disease 3, 4
- Consideration of thyroid function tests, as gynecomastia can be a presenting symptom of Graves' disease or other thyroid disorders 6
Laboratory Investigations
Laboratory investigations may include:
- Thyroid function tests to rule out hyperthyroidism or other thyroid disorders 6
- Hormone level tests to assess the balance of androgenic and estrogenic effects on the breast 3
- Other tests as indicated by the patient's history and physical examination findings 2, 3, 4, 5
Imaging Studies
Imaging studies, such as breast ultrasound, are not routinely recommended unless physical examination findings suggest malignancy 2.
Treatment
Treatment depends on the cause of the gynecomastia and may include observation, withdrawal of an offending drug, therapy of an underlying disease, giving androgen or antiestrogen drugs, or plastic surgery 3, 4.