From the Guidelines
The workup for male gynecomastia should begin with a thorough history and physical examination to identify potential causes, and most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging, as stated in the study by 1. The initial evaluation should focus on differentiating between gynecomastia and other breast conditions, such as pseudogynecomastia or malignancy.
- Key points to consider in the history include:
- Age of onset
- Duration of symptoms
- Presence of pain or tenderness
- Family history of breast cancer
- Medication use, including spironolactone, ketoconazole, cimetidine, finasteride, or certain antipsychotics
- Physical examination should assess for:
- Breast tenderness or masses
- Nipple discharge
- Testicular size and consistency Initial laboratory tests should include:
- Liver function tests
- Renal function tests
- Thyroid function tests
- Serum testosterone
- Estradiol
- Luteinizing hormone (LH)
- Follicle-stimulating hormone (FSH)
- Prolactin
- Human chorionic gonadotropin (hCG) Imaging studies, such as mammogram or breast ultrasound, may be considered to differentiate true gynecomastia from pseudogynecomastia or malignancy, particularly in unilateral or asymmetric cases, as recommended by 1 and 1. For men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended, as stated in the study by 1. However, if an indeterminate breast mass is identified, the initial recommended imaging study is ultrasound in men younger than age 25, and mammography or digital breast tomosynthesis in men age 25 and older, as recommended by 1. For persistent cases causing significant discomfort or psychological distress, medical therapy options include tamoxifen 10-20mg daily or raloxifene 60mg daily for 3-9 months, as these selective estrogen receptor modulators block estrogen effects in breast tissue. For cases resistant to medical therapy or present for more than 12 months (when fibrosis develops), surgical options including liposuction, subcutaneous mastectomy, or a combination may be necessary. The underlying pathophysiology involves an imbalance in the estrogen-to-androgen ratio at the breast tissue level, which stimulates ductal epithelial proliferation and stromal growth. Serum estradiol should be measured in testosterone deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy, as recommended by 1.
From the Research
Evaluation of Male Gynecomastia
The evaluation of male gynecomastia involves a thorough medical history and physical examination to detect underlying pathological conditions, reversible causes, and to discriminate from other breast lumps, particularly breast cancer 2.
- A medical history should include information on the onset and duration of gynecomastia, sexual development and function, and administration or abuse of substances associated with gynecomastia 2.
- Physical examination should detect signs of under-virilization or systemic disease and confirm the presence of palpable glandular tissue to discriminate gynecomastia from lipomastia and rule out suspicion of malignant breast tumor 2.
- The physical examination should also include examination of the genitalia to rule out the presence of a palpable testicular tumor and to detect testicular atrophy, aided by a testicular ultrasound 2.
Laboratory Investigations and Imaging
A set of laboratory investigations may integrate the evaluation, including:
- Testosterone (T)
- Estradiol (E2)
- Sex hormone-binding globulin (SHBG)
- Luteinizing hormone (LH)
- Follicular stimulating hormone (FSH)
- Thyroid stimulating hormone (TSH)
- Prolactin
- Human chorionic gonadotropin (hCG)
- Alpha-fetal protein (AFP)
- Liver and renal function tests 2.
- Breast imaging may offer assistance where the clinical examination is equivocal, and core needle biopsy should be performed if the clinical picture is suspicious for a malignant lesion 2, 3, 4, 5.
Treatment and Management
Treatment and management of gynecomastia depend on the underlying cause and may include:
- Watchful waiting after treatment of underlying pathology or discontinuation of substances associated with gynecomastia 2.
- Testosterone treatment should be offered only to men with proven testosterone deficiency 2.
- Surgical treatment is the therapy of choice for patients with long-lasting gynecomastia, which does not regress spontaneously or following medical therapy 2, 3, 4, 5.
- Drug therapy with tamoxifen may be considered at an early stage, and individual treatment requirements can range from simple reassurance to medical treatment or even surgery 3, 5.