What is the initial approach to treating gynecomastia?

Initial Approach to Treating Gynecomastia

The initial approach to treating gynecomastia should be observation and reassurance in most cases, as the majority of gynecomastia cases are benign and will resolve spontaneously, particularly in adolescents. 1

Diagnostic Evaluation

• Most men with breast symptoms can be diagnosed based on clinical findings without imaging 2
• Gynecomastia presents as a soft, rubbery, or firm mobile mass directly under the nipple and is often painful, especially when present for less than 6 months 2
• Gynecomastia is bilateral in approximately 50% of patients 2
• Differentiate true gynecomastia from pseudogynecomastia (fatty tissue deposition rather than glandular tissue enlargement), especially in patients with elevated BMI 2

Initial Management Algorithm

Step 1: Determine if imaging is needed

• For men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended 2
• If the differentiation between benign disease and breast cancer cannot be made clinically, or if presentation is suspicious, proceed with imaging 2
• For indeterminate breast masses:
  • Men younger than 25: Ultrasound is the initial recommended imaging study 2
  • Men 25 and older: Mammography or digital breast tomosynthesis is recommended 2

Step 2: Identify and address underlying causes

• Evaluate for medications that may cause gynecomastia (e.g., spironolactone) and consider discontinuation if possible 3
• Check for underlying conditions such as hypogonadism, hyperthyroidism, liver disease, or testicular tumors 4, 5
• Selected laboratory tests may be needed based on clinical suspicion of underlying causes 6

Step 3: Treatment options

• For pubertal gynecomastia: Reassurance and observation as most cases resolve spontaneously within 1-2 years 5
• For persistent painful gynecomastia: Consider a short-term trial of medical therapy 5
  • Antiestrogen therapy may be helpful in men with endogenous overproduction of estrogens 3
  • Androgen administration might be beneficial for men with hypogonadism 3
• For chronic, bothersome gynecomastia (present >1 year): Surgical removal is the treatment of choice as fibrosis may make medical treatment less effective 5, 1

Important Considerations

• Gynecomastia is not considered a premalignant condition; routine screening is not cost-effective 1
• Early intervention is important for better outcomes, as gynecomastia present for more than 1 year tends to develop fibrosis, making medical treatment less effective 1
• The main aim of any intervention is to relieve symptoms and exclude other etiological factors 4
• Breast cancer in males is rare (accounting for <1% of all breast cancers) but should be ruled out, especially in older men (median age 63 years) 2

Common Pitfalls to Avoid

• Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 2
• Delaying treatment in symptomatic patients may lead to fibrosis and make medical treatment less effective 1
• Failure to identify and address underlying medical conditions or medications that may be causing gynecomastia 3
• Not providing adequate reassurance to patients with pubertal gynecomastia, which typically resolves spontaneously 5