From the Guidelines
Adolescent gynecomastia typically requires a focused workup to determine if intervention is needed, starting with a thorough history and physical examination, and laboratory testing including liver function tests, thyroid function tests, and hormonal studies, with imaging reserved for cases with suspicion of a mass, as recommended by the American College of Radiology 1. The workup should include:
- A thorough history and physical examination to identify potential underlying causes such as medication use, substance abuse, signs of liver disease, hypogonadism, or hyperthyroidism
- Laboratory testing including: + Liver function tests + Thyroid function tests + Hormonal studies (testosterone, estradiol, luteinizing hormone, follicle-stimulating hormone, and prolactin) as recommended by the American Urological Association 2
- Imaging is not routinely needed unless there's suspicion of a mass, in which case ultrasound is preferred for men younger than 25 years old, as recommended by the American College of Radiology 1 Most cases of adolescent gynecomastia are physiologic and resolve spontaneously within 1-2 years. Observation is appropriate for mild cases with breast diameter less than 4 cm, while persistent cases causing significant psychological distress may require medical therapy with tamoxifen 10-20 mg daily for 3-9 months, or surgical intervention for severe cases that persist beyond 2 years or cause significant psychological distress 2. Reassurance about the benign and often self-limiting nature of the condition is essential, as is addressing any underlying causes such as obesity through lifestyle modifications. Key points to consider in the workup and management of adolescent gynecomastia include:
- Measuring serum prolactin levels in patients with low total testosterone and low or low/normal LH levels to screen for hyperprolactinemia 2
- Referring patients with elevated prolactin levels or non-secreting adenomas to an endocrinologist for further evaluation 2
- Measuring serum estradiol levels in testosterone deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy 2
From the Research
Evaluation of Adolescent Gynecomastia
The evaluation of adolescent gynecomastia involves a thorough history and clinical examination to formulate targeted investigations and management 3. The following factors should be evaluated:
- Examination of breasts and testes
- Systemic examination to identify any underlying conditions
Causes of Gynecomastia
Gynecomastia can be caused by various factors, including:
- Pubertal gynecomastia
- Obesity
- Drugs
- Hypogonadism
- Liver or renal failure
- Thyrotoxicosis
- Klinefelter syndrome
- Tumors
- Environmental pollutants 3
Management of Adolescent Gynecomastia
The management of adolescent gynecomastia depends on the severity and duration of the condition. The following approaches can be considered:
- Observation and reassurance for mild cases 4
- Medical therapy, such as tamoxifen, for cases with emotional distress or psychological limitation [(3, 5)]
- Surgical procedures for severe and persistent cases that do not respond to medical therapy [(4, 5, 6)]
Treatment Options
Treatment options for adolescent gynecomastia include:
- Testosterone therapy for hypogonadism 3
- Anti-estrogen drugs, such as tamoxifen, to reduce breast size [(3, 5)]
- Surgical removal of breast tissue for severe and persistent cases [(4, 5, 6)]