What is the best approach to treat gynecomastia in an elderly man?

Treatment of Gynecomastia in Elderly Men

The best approach to treat gynecomastia in an elderly man is to first identify and address any underlying causes, followed by consideration of medical therapy with selective estrogen receptor modulators for recent-onset cases, or surgical intervention for long-standing cases (>12-24 months) that cause significant distress. 1

Diagnostic Evaluation

• Rule out malignancy: Male breast cancer is rare (<1% of all breast cancers) but should be considered, especially in older men (median age 63) 1
• Identify underlying causes:
  • Medication review: Check for medications known to cause gynecomastia including:
    • Spironolactone (well-documented cause) 1
    • 5-α reductase inhibitors (finasteride, dutasteride) 1
    • Phenytoin 1
    • Heart or hypertension medications 2
  • Evaluate for systemic conditions:
    • Hyperthyroidism
    • Chronic liver disease and cirrhosis
    • Hypogonadism
    • Renal insufficiency 3

Treatment Algorithm

Step 1: Address Underlying Causes

• Discontinue contributing medications when possible 3
  • For patients on spironolactone, consider switching to:
    • Eplerenone (25-50 mg daily initially, maintenance 50-100 mg daily) 1
    • Amiloride (10-40 mg/day) for cirrhosis-related ascites 1
• Treat underlying medical conditions 3
• Stop alcohol consumption in cases related to cirrhosis 1

Step 2: For Recent-Onset Gynecomastia (<12 months)

• Medical therapy with selective estrogen receptor modulators:
  • Tamoxifen may be considered at an early stage 2
  • Note: The European Association of Urology does not recommend routine use of SERMs for painful gynecomastia of recent onset 1
• For hypogonadism: Consider androgen replacement therapy 4

Step 3: For Long-Standing Gynecomastia (>12-24 months)

• Surgical intervention is the treatment of choice for:
  • Gynecomastia persisting over 12 months 2
  • Failure of medical therapy
  • Significant psychological distress
  • Suspected malignancy 1
• Surgical options based on severity:
  • Liposuction
  • Direct excision
  • Combined approaches 1

Special Considerations for Elderly Patients

• Higher risk of underlying pathology: More thorough evaluation for malignancy and systemic disease
• Medication interactions: Consider polypharmacy when introducing new treatments
• Surgical risk assessment: Evaluate comorbidities before recommending surgical intervention
• Psychological impact: Address body image concerns and psychological distress

Monitoring

• For patients on eplerenone:
  • Check serum potassium and creatinine before starting treatment
  • Monitor serum potassium approximately 1 week after initiation and monthly thereafter
  • Adjust dose based on potassium levels 1
• Regular follow-up to assess treatment efficacy and patient satisfaction

Common Pitfalls to Avoid

• Failing to distinguish true gynecomastia from pseudogynecomastia (fatty tissue deposition without glandular proliferation) 1
• Missing male breast cancer: Always consider this possibility, especially in elderly men
• Delaying treatment: Early intervention may prevent progression to fibrotic tissue that is less responsive to medical therapy 4
• Overlooking psychological impact: Gynecomastia can cause significant emotional distress even when benign 3