What are the recommended treatments for gynaecomastia?

Gynecomastia: Understanding and Treatment Options

Gynecomastia is a benign proliferation of glandular breast tissue in men that can be effectively treated with a combination of addressing underlying causes, medication therapy, and surgery in select cases. The approach to treatment should prioritize addressing any underlying medical conditions first, followed by medical therapy for persistent cases, with surgery reserved for cases resistant to other interventions.

Definition and Prevalence

Gynecomastia is defined as the benign enlargement of male breast tissue and is extremely common, affecting approximately 30-50% of healthy men at some point in their lives 1. It occurs due to an imbalance between estrogen and androgen action at the breast tissue level, with either increased estrogen activity or decreased androgen effects 2.

Types and Causes

Physiologic Gynecomastia

• Neonatal: Due to maternal estrogens
• Pubertal: Occurs in 50-60% of adolescents, typically resolves within 1-2 years
• Aging-related: Common in men over 50 years due to decreasing testosterone levels

Pathologic Gynecomastia

• Medication-induced: Common culprits include:

  • Antiandrogens (bicalutamide, flutamide)
  • Spironolactone
  • Estrogens and estrogen-like compounds
  • Some antipsychotics and antidepressants

• Medical conditions:

  • Hypogonadism
  • Liver cirrhosis
  • Renal insufficiency
  • Hyperthyroidism
  • Tumors (rare): testicular, adrenal, or ectopic sources of estrogen

Diagnostic Approach

When evaluating gynecomastia, it's important to distinguish it from pseudogynecomastia (fatty tissue deposition) and male breast cancer:

1. Clinical examination: True gynecomastia presents as firm, rubbery tissue directly beneath the nipple, often bilateral, and may be tender especially if recent onset (<6 months) 3

2. Laboratory testing: For cases with concerning features or recent onset:

   • Serum testosterone, estradiol, LH levels
   • Liver and kidney function tests
   • Thyroid function tests
   • Serum prolactin if indicated

3. Imaging: Not routinely required for typical cases but may include:

   • Ultrasound: First-line imaging in younger men (<25 years) with indeterminate masses 3
   • Mammography: More useful in men >25 years with suspicious findings

Treatment Algorithm

Step 1: Address Underlying Causes

• Discontinue contributing medications when possible
• Treat underlying medical conditions (liver disease, hypogonadism, etc.)
• Observe pubertal gynecomastia as it often resolves spontaneously

Step 2: Medical Therapy for Persistent Cases

For persistent, painful, or cosmetically distressing gynecomastia:

1. Selective Estrogen Receptor Modulators (SERMs):

   • Tamoxifen: 10-20 mg twice daily has shown significant reduction in breast size in clinical trials 4
   • Consider for painful gynecomastia or cases <12 months duration
   • Most effective for recent-onset cases

2. Aromatase Inhibitors:

   • May be considered for cases with elevated estrogen levels
   • Less evidence for effectiveness than tamoxifen

3. Androgens:

   • For confirmed hypogonadism
   • Testosterone replacement therapy when appropriate

Step 3: Surgical Management

For cases resistant to medical therapy or present >12 months:

• Liposuction: Effective for fatty gynecomastia
• Subcutaneous mastectomy: For glandular tissue removal
• Combined approaches: For mixed glandular/fatty gynecomastia

Special Considerations

Prophylactic Management

For patients starting medications with high risk of gynecomastia:

• Breast bud irradiation (8-10 Gy in one fraction) can prevent painful gynecomastia in patients receiving long-term bicalutamide therapy 3

Monitoring

• Follow-up within 3-6 months of initiating medical therapy
• Reassess need for surgical intervention if inadequate response after 3-6 months of medical treatment

Potential Pitfalls and Caveats

1. Failure to rule out breast cancer: Though rare in men (<1% of all breast cancers), it's essential to evaluate suspicious findings (hard, fixed masses, skin changes, nipple discharge)

2. Delayed treatment: Fibrotic changes can occur in long-standing gynecomastia (>12 months), making medical therapy less effective

3. Incomplete evaluation: Missing an underlying serious condition (e.g., testicular tumor) can have significant consequences

4. Psychological impact: The emotional distress of gynecomastia is often underestimated and should be considered when determining treatment approach

By following this structured approach to evaluation and treatment, most cases of gynecomastia can be effectively managed with good outcomes for both physical symptoms and psychological well-being.