What is the initial approach to a male patient presenting with gynecomastia?

Initial Approach to Male Gynecomastia Workup

The initial approach to a male patient presenting with gynecomastia should include a detailed history focusing on medication use, physical examination to distinguish true gynecomastia from pseudogynecomastia, and targeted laboratory testing to identify underlying causes. 1

Diagnostic Evaluation

History Taking - Key Elements

• Age of onset and duration (physiologic vs. pathologic)
• Medication review (focus on known causative agents):
  • Spironolactone (high association) 1
  • Phenytoin (affects hormone metabolism) 1
  • 5-α reductase inhibitors (finasteride, dutasteride) 1
  • Cimetidine (can cause gynecomastia, especially with prolonged use) 2
• Alcohol consumption (relevant for cirrhosis-related cases) 1
• Symptoms of underlying conditions:
  • Liver disease
  • Hypogonadism
  • Renal insufficiency
  • Hyperthyroidism

Physical Examination

• Distinguish true gynecomastia (glandular tissue) from pseudogynecomastia (fatty tissue):
  • True gynecomastia: firm, rubbery, disc-like tissue centered under the nipple
  • Pseudogynecomastia: soft, diffuse fatty tissue without discrete mass 1
• Assess for:
  • Tenderness (may indicate recent onset)
  • Symmetry vs. asymmetry
  • Signs of malignancy (hard, fixed mass, skin changes, nipple discharge, axillary lymphadenopathy)
  • Signs of underlying conditions (e.g., testicular abnormalities, liver disease stigmata)

Laboratory Testing

• Initial laboratory panel:
  • Liver function tests
  • Renal function tests
  • Thyroid function tests
  • Hormonal evaluation:
    • Total and free testosterone
    • Estradiol
    • Luteinizing hormone (LH)
    • Follicle-stimulating hormone (FSH)
    • Human chorionic gonadotropin (hCG) - to rule out testicular tumors

Imaging

• Mammography or breast ultrasound indicated if:
  • Unilateral or asymmetric breast enlargement
  • Hard or suspicious mass
  • Age >50 years (higher risk of male breast cancer)
  • Nipple discharge or skin changes 1

Important Considerations

Age-Related Patterns

• Neonatal: Usually physiologic, resolves within weeks
• Pubertal: Common (affects up to 65% of adolescents), typically resolves within 1-2 years
• Adult: More likely to have underlying pathology requiring investigation

Red Flags Requiring Urgent Evaluation

• Recent rapid growth
• Unilateral enlargement
• Hard or fixed mass
• Nipple discharge (especially bloody)
• Axillary lymphadenopathy
• Skin changes (dimpling, retraction, ulceration)

Common Pitfalls

1. Failure to distinguish true gynecomastia from pseudogynecomastia

   • True gynecomastia requires glandular tissue evaluation
   • Pseudogynecomastia may only need weight management

2. Missing medication-induced causes

   • Always perform thorough medication review
   • Consider both prescription and over-the-counter medications
   • Cimetidine can cause gynecomastia with prolonged use (>1 month) 2

3. Overlooking serious underlying conditions

   • Male breast cancer is rare (<1% of all breast cancers) but should be considered, especially in older men 1
   • Testicular tumors can present with gynecomastia due to hCG production

4. Unnecessary testing

   • Most cases of gynecomastia can be diagnosed based on clinical findings without extensive imaging 1
   • Target testing based on history and physical examination findings

Management Considerations

The management approach depends on the underlying cause:

1. Physiologic gynecomastia: Reassurance and observation
2. Medication-induced: Consider discontinuation or alternative medications
   • For spironolactone: Consider eplerenone (25-50 mg daily) 1
   • For cimetidine: Consider discontinuation or alternative H2 blocker 2
3. Underlying medical condition: Treat the primary condition
4. Persistent cases (>12-24 months): Consider medical therapy or surgical options 1

Remember that gynecomastia causes significant psychological distress in many patients, and addressing these concerns is an important part of management.