What's the treatment for gynecomastia?

Treatment of Gynecomastia

The treatment for gynecomastia should begin with addressing underlying causes, followed by watchful waiting for physiologic cases, and progressing to medication adjustment or surgical intervention for persistent cases that cause significant distress. 1

Diagnostic Assessment

Before initiating treatment, proper assessment is essential:

• Clinical Examination:

  • Confirm presence of actual glandular tissue (vs. pseudogynecomastia/lipomastia)
  • Examine genitalia and include testicular ultrasound (low sensitivity of palpation alone) 2
  • Rule out suspicious breast lesions

• Laboratory Evaluation when indicated:

  • Testosterone, estradiol, SHBG, LH, FSH
  • TSH, prolactin
  • hCG, AFP (if testicular tumor suspected)
  • Liver and renal function tests 2

Treatment Algorithm

1. Address Underlying Causes

• Discontinue contributing medications if possible 1:

  • Antipsychotics (especially those causing hyperprolactinemia)
  • 5-α reductase inhibitors (finasteride, dutasteride)
  • Spironolactone
  • Phenytoin

• Treat underlying medical conditions that may cause gynecomastia:

  • Hypogonadism
  • Hyperthyroidism
  • Liver disease
  • Renal insufficiency

2. Watchful Waiting

• Recommended for:
  • Physiologic gynecomastia (newborns, adolescents)
  • After addressing underlying causes 1, 2
  • Pubertal gynecomastia (resolves spontaneously in >90% of cases within 24 months) 2

3. Pharmacological Interventions

• Testosterone replacement:

  • Only for men with proven testosterone deficiency 2
  • Not recommended for gynecomastia without hypogonadism

• For antipsychotic-induced gynecomastia:

  • Switch to prolactin-sparing antipsychotics (aripiprazole, clozapine, quetiapine)
  • Consider adding aripiprazole to current regimen to reduce prolactin levels 1

• For spironolactone-induced gynecomastia:

  • Switch to eplerenone (25-50 mg daily initially, maintenance 50-100 mg daily)
  • Alternative: amiloride (10-40 mg/day) for patients with cirrhosis-related ascites 1

• Not generally recommended:

  • Selective estrogen receptor modulators (SERMs)
  • Aromatase inhibitors
  • Non-aromatizable androgens 2

4. Surgical Management

• Indications for surgery:

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

• Surgical options:

  • Liposuction (for predominant fatty component)
  • Direct excision (for predominant glandular tissue)
  • Combined approaches 1

Important Considerations

• Gynecomastia is not considered a premalignant condition, but male breast cancer should be ruled out, especially in older men 1

• Untreated hyperprolactinemia may lead to long-term effects including bone mineral density loss 1

• Early treatment should be pursued for better outcomes, particularly when significant psychological distress is present 3

• The extent and type of surgery depend on the size of breast enlargement and amount of adipose tissue 2

Pitfalls to Avoid

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

• Don't delay treatment for persistent cases causing psychological distress

• Don't overlook medication causes - many common medications can induce gynecomastia

• Don't miss testicular tumors - include testicular examination and ultrasound in evaluation 2

• Don't use hormone therapy for chronic established cases - it's only effective in the acute proliferative phase with approximately 30% response rate 4