What is the appropriate referral for a 27-year-old male with chronic right breast inflammation and enlargement since adolescence?

Management of Male Breast Enlargement and Inflammation

For a 27-year-old male with right breast inflammation and enlargement since age 14, referral to an endocrinologist is the most appropriate first step for evaluation and management of suspected gynecomastia. 1

Diagnostic Considerations

• The patient's presentation of unilateral breast enlargement since adolescence with inflammation is most consistent with gynecomastia, which is the most common cause of breast enlargement in males 2, 1
• Gynecomastia typically presents as a soft, rubbery, or firm mobile mass directly beneath the nipple and may be painful, especially when present for less than 6 months 1
• Although gynecomastia is bilateral in approximately 50% of patients, unilateral presentation is also common 1

Referral Algorithm

Primary Referral: Endocrinologist

• An endocrinologist should evaluate the patient to determine the underlying hormonal cause of the gynecomastia 2, 1
• Men with elevated baseline estradiol measurements should specifically be referred to an endocrinologist as recommended by the American Urological Association 2
• The endocrinologist will assess for potential hormonal imbalances, including:
  • Testosterone deficiency 2
  • Elevated estradiol levels 2
  • Abnormal luteinizing hormone (LH) levels 2
  • Hyperprolactinemia 2

Diagnostic Testing to Expect

• The endocrinologist will likely order:
  • Serum testosterone levels 2
  • Serum estradiol levels (especially important in patients with breast symptoms or gynecomastia) 2
  • Luteinizing hormone (LH) levels 2
  • Prolactin levels if testosterone is low with low/normal LH 2

Secondary Referrals (if needed)

• If imaging is deemed necessary after endocrine evaluation:
  • For men 25 and older: Mammography or digital breast tomosynthesis is the recommended initial imaging study 2, 1
  • Ultrasound may be used as a supplementary imaging modality if needed 2, 1

Important Clinical Considerations

• Most cases of gynecomastia can be diagnosed based on clinical findings without imaging 1
• Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 1
• The long duration (since age 14) suggests a chronic condition rather than malignancy, but proper evaluation is still warranted 3
• Gynecomastia may be related to:
  • Hormonal imbalances (estrogen excess and/or androgen deficiency) 4
  • Medications or recreational drugs 3
  • Systemic disorders 3
  • Rarely, underlying malignancy 3

Treatment Considerations

• Treatment will depend on the underlying cause identified by the endocrinologist 5
• Options may include:
  • Observation if no serious underlying condition is found 3
  • Correction of underlying hormonal abnormalities 5
  • Discontinuation of contributing medications if identified 5
  • Consideration of antiestrogen therapy in cases of estrogen overproduction 5
  • Surgical referral may be considered for cosmetic concerns if medical management is unsuccessful 5

Pitfalls to Avoid

• Assuming breast enlargement is always benign without proper evaluation 1
• Initiating imaging studies before endocrine evaluation in a case with clear clinical features of gynecomastia 1
• Failing to consider medication-induced or systemic causes of gynecomastia 3, 4