What is the treatment approach for gynecomastia in males?

Treatment Approach for Gynecomastia in Males

The treatment of gynecomastia in males should begin with identifying and addressing underlying causes, followed by watchful waiting for spontaneous resolution, and proceeding to medical or surgical interventions only for persistent cases that cause significant discomfort or psychological distress. 1

Diagnostic Evaluation

Initial Assessment

• Differentiate true gynecomastia (glandular breast tissue enlargement) from pseudogynecomastia (fatty tissue deposition) 1
• Physical examination of breast and genitalia, including testicular ultrasound 2
• Evaluate for concerning features that warrant further investigation:
  • Nipple discharge or retraction
  • Axillary adenopathy
  • Suspicious masses 1

Laboratory Testing

• Consider the following tests when underlying pathology is suspected:
  • Testosterone, estradiol, SHBG
  • LH, FSH, TSH, prolactin
  • hCG, AFP
  • Liver and renal function tests 2

Imaging

• For men ≥25 years with breast pain: diagnostic mammography or digital breast tomosynthesis 1
• Ultrasound for indeterminate or suspicious findings on mammogram 1
• Core needle biopsy for suspicious lesions 1, 2

Treatment Algorithm

Step 1: Address Underlying Causes

• Medication-induced gynecomastia:
  • Spironolactone is most strongly associated with gynecomastia (10% of male patients) 1, 3
  • Consider switching to eplerenone (25-50 mg daily initially) as a lower-risk alternative 1
  • Review and discontinue other contributing medications when possible 4

Step 2: Watchful Waiting

• Recommended after treating underlying pathology or discontinuing causative substances 2
• Pubertal gynecomastia resolves spontaneously in >90% of cases within 24 months 2

Step 3: Medical Therapy for Persistent Cases

• Testosterone replacement only for men with proven testosterone deficiency 2
• Note: Selective estrogen receptor modulators (SERMs), aromatase inhibitors, and non-aromatizable androgens are not generally recommended 2

Step 4: Surgical Management

• Consider for long-standing gynecomastia (>12-24 months) that doesn't respond to medical therapy 1, 2
• Surgical options include:
  • Liposuction
  • Direct excision
  • Combined approaches 1, 5
• Subcutaneous mastectomy combined with ultrasound-assisted liposuction shows good results for grade II and III gynecomastia 5

Special Considerations

Risk Factors for Gynecomastia

• Advanced age
• Liver disease
• Renal insufficiency
• Obesity
• Concurrent use of multiple medications that can cause gynecomastia
• Pre-existing hormonal imbalances 1

Monitoring

• Regular monitoring for medication side effects 1
• For patients on spironolactone: monitor serum potassium within 1 week of initiation or titration and regularly thereafter 3

Common Pitfalls to Avoid

• Failing to distinguish gynecomastia from male breast cancer (rare but important)
• Assuming medication-induced gynecomastia precludes further investigation 2
• Delaying treatment of persistent, painful gynecomastia, which can lead to psychological distress 6, 7
• Overlooking underlying serious conditions (45-50% of adult cases may have an underlying pathology) 2