What is the best course of action for a 27-year-old male with suspected gynecomastia and right breast inflammation and enlargement since age 14?

Evaluation and Management of Suspected Gynecomastia in a 27-Year-Old Male

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

Initial Assessment Approach

• Gynecomastia is the most common cause of breast enlargement, palpable mass, or pain in males and can be diagnosed based on clinical findings in most cases 2, 1
• The condition typically presents as a soft, rubbery, or firm mobile mass directly under the nipple and is often more painful than cancer, especially when present for less than 6 months 2
• Long-standing gynecomastia (since age 14 in this case) suggests a potential hormonal imbalance that requires endocrine evaluation 1, 3

Referral Algorithm

• The American Urological Association recommends that men with suspected hormonal imbalances be referred to an endocrinologist to determine the underlying cause of gynecomastia 1
• An endocrinologist will assess for potential hormonal abnormalities, including:
  • Testosterone deficiency
  • Elevated estradiol levels
  • Abnormal luteinizing hormone (LH) levels
  • Hyperprolactinemia 1, 3

Diagnostic Testing to Expect

• The endocrinologist will likely order:
  • Serum testosterone levels
  • Serum estradiol levels
  • Luteinizing hormone (LH) levels
  • Prolactin levels (if testosterone is low with low/normal LH) 1, 4
• Additional testing may include thyroid function tests to rule out hyperthyroidism as a potential cause 5, 3

Imaging Considerations

• For men with clinical findings consistent with gynecomastia, imaging is not routinely indicated 2, 1
• However, if differentiation between benign disease and breast cancer cannot be made clinically:
  • For men 25 and older (including this 27-year-old patient), mammography or digital breast tomosynthesis would be the recommended initial imaging study 1
  • Ultrasound may be used as a complementary imaging modality if needed 6

Common Pitfalls to Avoid

• Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 1
• Failing to identify underlying hormonal causes that may require specific treatment 3, 4
• Delaying treatment, as early intervention may provide better cosmetic and psychological outcomes, especially in cases of long-standing gynecomastia 5, 3

Treatment Options Following Endocrine Evaluation

• Treatment should be directed by the underlying cause identified by the endocrinologist 7, 4
• Options may include:
  • Discontinuation of contributing medications (if identified) 7, 4
  • Hormonal therapy (androgens for hypogonadism or antiestrogens for estrogen excess) 4
  • Surgical intervention may be considered if:
    • Medical therapy is unsuccessful
    • No regression occurs after observation
    • The condition worsens
    • Psychosocial problems arise due to the gynecomastia 5