What are the latest guidelines for treating gynecomastia?

Guidelines for Treating Gynecomastia

The treatment of gynecomastia should begin with identifying and addressing underlying causes, followed by watchful waiting for physiologic cases, with medical therapy reserved for persistent cases and surgery as the definitive treatment for long-standing gynecomastia that doesn't respond to other interventions. 1, 2

Diagnosis and Evaluation

Initial Assessment

• Differentiate true gynecomastia (glandular breast tissue enlargement) from pseudogynecomastia (fatty tissue deposition) 1
• Rule out breast cancer, especially in older men 1
• Identify underlying causes:
  • Physiologic: newborn, pubertal, aging-related
  • Pathologic: medications, systemic diseases, hormonal disorders 2

Required Evaluations

• Medical history: onset/duration, sexual development, medication use 2
• Physical examination: breast tissue assessment, signs of undervirilization, systemic disease 2
• Genital examination: testicular assessment (including ultrasound) 2
• Laboratory tests (when indicated):
  • Hormonal panel: testosterone, estradiol, SHBG, LH, FSH
  • Other tests: TSH, prolactin, hCG, AFP, liver/renal function 2
• Imaging: only when clinical examination is equivocal 2
• Biopsy: only when malignancy is suspected 2

Treatment Algorithm

Step 1: Address Underlying Causes

• Discontinue contributing medications when possible 1, 2
  • Common culprits: spironolactone, 5-α reductase inhibitors, phenytoin
• Treat underlying medical conditions 2
  • Cirrhosis, hypogonadism, renal insufficiency, hyperthyroidism

Step 2: Observation (First-Line Approach)

• Watchful waiting is recommended after addressing underlying causes 2
• Pubertal gynecomastia: resolves spontaneously in >90% of cases within 24 months 2
• Duration: observation period of 12-24 months for non-physiologic cases 1, 2

Step 3: Medical Therapy (For Persistent Cases)

• Testosterone replacement: ONLY for men with proven testosterone deficiency 2
• Alternative medications when specific drugs must be continued:
  • Replace spironolactone with eplerenone (25-50 mg daily initially, 50-100 mg maintenance) 1
  • Replace spironolactone with amiloride (10-40 mg/day) for cirrhosis-related ascites 1
• Not routinely recommended (limited evidence):
  • Selective Estrogen Receptor Modulators (SERMs) 1, 2
  • Aromatase inhibitors 2
  • Non-aromatizable androgens 2

Step 4: Surgical Treatment (For Refractory Cases)

• Indications:
  • Long-standing gynecomastia (>12-24 months)
  • Failure of medical therapy
  • Significant psychological distress
  • Suspected malignancy 1, 2
• Surgical options:
  • Liposuction
  • Direct excision
  • Combined approaches 1

Special Considerations

Medication-Induced Gynecomastia

• Spironolactone: well-documented to cause gynecomastia 1
• 5-α reductase inhibitors (finasteride, dutasteride): strong association with gynecomastia 1
• Phenytoin: can contribute through effects on hormone metabolism 1
• Other medications: antibiotics, antiulcer drugs, growth hormones, chemotherapy 3
• Substances of abuse: alcohol, marijuana, heroin, amphetamines, anabolic steroids 3

Age-Specific Considerations

• Infants: typically resolves spontaneously within first year of life 2
• Adolescents: affects ~50% of mid-pubertal boys; >90% resolve within 24 months 2
• Adults: prevalence increases with age; ~45-50% have underlying pathology 2

Pitfalls and Caveats

1. Don't assume all cases are physiologic - proper investigation may reveal underlying pathology in 45-50% of adult cases 2

2. Don't miss breast cancer - though rare in men (<1% of all breast cancers), it should be considered, especially in older men 1

3. Don't delay treatment - early intervention is recommended to minimize emotional distress and physical discomfort 4

4. Don't overlook substance abuse - alcohol, marijuana, heroin, amphetamines, and anabolic steroids can cause gynecomastia 3

5. Don't routinely use SERMs or aromatase inhibitors - these are not recommended for general treatment of gynecomastia due to limited evidence 2