Can gynecomastia be painful?

Gynecomastia Can Be Painful

Yes, gynecomastia can be painful, particularly when caused by medications like spironolactone, which can cause or exacerbate painful gynecomastia requiring medication changes or specific pain management. 1, 2

Understanding Painful Gynecomastia

Gynecomastia is defined as benign proliferation of glandular breast tissue in men, distinct from pseudogynecomastia which is fatty tissue deposition without glandular involvement 2. While many cases are asymptomatic, painful gynecomastia (also called mastodynia) is a recognized clinical presentation that can significantly impact quality of life.

Key Causes of Painful Gynecomastia

1. Medication-induced:

   • Spironolactone is most strongly associated with painful gynecomastia, affecting approximately 10% of male patients 2
   • Other medications that can cause painful gynecomastia include:
     • Hormone replacement therapies
     • Antipsychotics
     • 5-α reductase inhibitors 2

2. Risk factors that increase likelihood of painful gynecomastia:

   • Advanced age
   • Liver disease
   • Renal insufficiency
   • Obesity
   • Concurrent use of multiple medications that can cause gynecomastia
   • Pre-existing hormonal imbalances 2

Management of Painful Gynecomastia

For Medication-Induced Cases:

1. Medication adjustment:

   • For spironolactone-induced painful gynecomastia, switching to eplerenone is recommended 1, 2
   • Recommended eplerenone dosing: initial 25-50 mg daily, maintenance 50-100 mg daily 2
   • Consider discontinuing other contributing medications when possible 2

2. Pain management options:

   • Acetaminophen is recommended as first-line analgesic for mild to moderate pain
   • NSAIDs can be used if no contraindications exist (use with caution due to GI, renal, and cardiovascular risks)
   • For severe pain, a multimodal analgesia approach may be necessary 2

For Persistent Painful Gynecomastia:

1. Medical therapy options:

   • Estrogen receptor modulators may be considered for short-term treatment of persistent painful gynecomastia 2
   • Regular monitoring for adverse effects is essential 2

2. Surgical intervention:

   • For long-standing painful gynecomastia (>12-24 months) that doesn't respond to medication changes
   • Options include liposuction, direct excision, or combined approaches 2

Diagnostic Approach for Painful Breast Conditions in Men

When a male patient presents with breast pain and suspected gynecomastia:

1. Initial imaging:

   • Diagnostic mammography or digital breast tomosynthesis (DBT) is recommended as the initial imaging study for males ≥25 years with breast pain 2
   • Ultrasound is indicated when mammogram is indeterminate or suspicious 2

2. Further evaluation:

   • Core needle biopsy for suspicious or indeterminate findings on imaging 2
   • Even circumscribed masses should be viewed with suspicion in male patients 2

Clinical Pearls and Pitfalls

• Don't miss breast cancer: While gynecomastia is benign, it's important to rule out male breast cancer, especially in unilateral cases with suspicious features like nipple discharge/retraction or axillary adenopathy 2

• Timing matters: Pubertal gynecomastia often resolves spontaneously, while medication-induced gynecomastia may improve with medication adjustment 2

• Consider underlying conditions: Gynecomastia can be a sign of cirrhosis, hypogonadism, or renal insufficiency, which require specific treatment 1

• Pain can be significant: Don't underestimate the impact of painful gynecomastia on quality of life and psychological well-being; treatment should be pursued early when pain is present 2