What is gynecomastia?

Gynecomastia: Definition and Management

Gynecomastia is defined as the benign proliferation of glandular breast tissue in men, most commonly presenting as a soft, rubbery, or firm mobile mass directly under the nipple that is often tender, especially if present for less than 6 months. 1

Clinical Characteristics

• Physical Examination Findings:

  • Presents as a disc-like area of breast tissue under the nipple
  • Bilateral in approximately 50% of cases
  • Often tender, particularly when present for less than 6 months
  • Typically soft, rubbery, or firm and mobile 2, 1

• Important Distinctions:

  • True gynecomastia: Actual glandular breast tissue enlargement
  • Pseudogynecomastia: Fatty tissue deposition without glandular proliferation, common in patients with elevated BMI 2, 1

Causes and Pathophysiology

Gynecomastia results from an imbalance between estrogen and androgen action at the breast tissue level, causing:

• Increased estrogen action
• Decreased androgen action
• Or both 3, 4

Common Causes:

1. Physiologic:

   • Neonatal period (maternal hormones)
   • Puberty (hormonal fluctuations)
   • Aging/senescence 5, 6

2. Pathologic:

   • Medications: Spironolactone is a common cause 7
   • Chronic conditions: Cirrhosis, hypogonadism, renal insufficiency
   • Substance use: Various medications, supplements, or illicit drugs
   • Rare causes: Tumors (testicular, adrenal, etc.) 5

Diagnosis

Most cases of gynecomastia can be diagnosed based on clinical findings without imaging 2, 1. The American College of Radiology emphasizes that:

• Imaging is not routinely indicated for typical presentations
• Ultrasound and mammography should be reserved for cases with indeterminate physical findings 1
• Unnecessary imaging may lead to additional procedures without clinical benefit 2

Management Approach

1. Physiologic Gynecomastia

• First-line: Observation and reassurance, especially for pubertal gynecomastia which typically resolves spontaneously 1, 6
• Follow-up: Regular assessment to monitor progression or regression 1

2. Medication-Induced Gynecomastia

• Primary approach: Discontinue contributing medications when possible 5
  • For example, replace spironolactone with amiloride (10-40 mg/day) in cirrhosis-related gynecomastia 1

3. Medical Therapy

• Selective Estrogen Receptor Modulators (SERMs): May be considered for painful gynecomastia of recent onset, though not routinely recommended 1
• Androgen therapy: May help in cases of hypogonadism 3

4. Surgical Intervention

Indicated for:

• Long-standing gynecomastia (>12-24 months)
• Failure of medical therapy
• Significant psychological distress
• Suspected malignancy 1

Surgical options include:

• Liposuction
• Direct excision
• Combined approaches
• Choice depends on composition (fatty, glandular, or mixed) 1, 6

Important Clinical Considerations

• Breast cancer risk: Male breast cancer is rare (<1% of all breast cancers) but should be considered, especially in older men (median age 63) 2
• Psychological impact: Gynecomastia can cause significant anxiety and psychosocial discomfort, warranting prompt evaluation 4
• Reversibility: Drug-induced gynecomastia is often reversible upon discontinuation of the offending agent 7

Pitfalls to Avoid

1. Unnecessary imaging: Clinical assessment alone is sufficient for diagnosis in most cases 2, 1
2. Delayed treatment: Early intervention may prevent permanent fibrotic changes in long-standing cases 4
3. Missing underlying pathology: Always consider and rule out serious underlying conditions 5
4. Overlooking medication effects: Many commonly prescribed medications can cause gynecomastia, with spironolactone being a notable example 7