What is the treatment for gynecomastia?

Treatment of Gynecomastia

The treatment of gynecomastia should begin with identifying and addressing underlying causes, followed by watchful waiting in most cases, with medication or surgery reserved for persistent cases that cause significant physical or psychological distress. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Differentiate true gynecomastia (glandular breast tissue enlargement) from pseudogynecomastia (fatty tissue deposition) 2

• Evaluate for underlying causes:

  • Medications (especially spironolactone, 5-α reductase inhibitors) 2
  • Chronic conditions (cirrhosis, hypogonadism, renal insufficiency) 3
  • Hormonal imbalances
  • Substance use/abuse

• Key diagnostic tests 1:

  • Testosterone, estradiol, SHBG, LH, FSH
  • TSH, prolactin
  • hCG, AFP (to rule out testicular tumors)
  • Liver and renal function tests
  • Testicular ultrasound (recommended due to low sensitivity of palpation) 1

Treatment Algorithm

1. Address Underlying Causes

• Discontinue contributing medications when possible 1, 3
• Treat underlying medical conditions 3
• Stop alcohol consumption in cases related to cirrhosis 4

2. Initial Management

• Watchful waiting is first-line approach after addressing underlying causes 1
  • Most cases of pubertal gynecomastia resolve spontaneously within 24 months 1
  • Adult cases may resolve with treatment of underlying conditions 3

3. Medical Treatment

• Testosterone replacement only for men with proven testosterone deficiency 1

• Alternative medications for patients with spironolactone-induced gynecomastia:

  • Eplerenone (25-50 mg daily initially, maintenance 50-100 mg daily) - a selective mineralocorticoid receptor antagonist with significantly lower risk of gynecomastia 2
  • Amiloride (10-40 mg/day) for patients with cirrhosis-related ascites who develop gynecomastia 2

• Not generally recommended due to limited evidence 1:

  • Selective Estrogen Receptor Modulators (SERMs)
  • Aromatase inhibitors
  • Non-aromatizable androgens

4. Surgical Treatment

• Surgery is the treatment of choice for patients with 1, 5:

  • Long-standing gynecomastia (>12-24 months)
  • Failure of medical therapy
  • Significant psychological distress
  • Suspicious lesions requiring tissue diagnosis

• Surgical options 6:

  • Liposuction for predominantly fatty gynecomastia
  • Direct excision for predominantly glandular tissue
  • Combined approaches for mixed cases

Special Considerations

Physiologic Gynecomastia

• Newborns: Usually self-resolving, rarely requires intervention 3
• Adolescents: Affects approximately 50% of mid-pubertal boys; >90% resolve spontaneously within 24 months 1
• Elderly men: More common due to age-related hormonal changes 1

Medication-Induced Gynecomastia

• Spironolactone is well-documented to cause gynecomastia 2
• Eplerenone has a significantly better side effect profile regarding gynecomastia 2
• Anastrozole has been studied for pubertal gynecomastia but efficacy was not demonstrated 7

Pitfalls and Caveats

• Do not assume all breast enlargement in men is benign; male breast cancer is rare but should be considered, especially in older men 2
• Identifying a medication cause should not preclude further investigation, as multiple factors may contribute 1
• Early treatment is recommended to minimize emotional distress and physical discomfort 3
• Surgical treatment should be considered only after adequate trial of medical management or when gynecomastia is long-standing 1, 5