Can this condition be attributed to idiopathic, benign gynecomastia?

Idiopathic Benign Gynecomastia: Diagnosis and Management

This case represents idiopathic benign gynecomastia, and no further investigations are necessary based on the comprehensive workup already completed. 1

Diagnostic Assessment

• The patient's presentation is consistent with idiopathic gynecomastia, which accounts for approximately 46% of all gynecomastia cases 2
• Gynecomastia is the most common cause of male breast enlargement and is often bilateral (approximately 50% of cases), as seen in this patient 1
• The ultrasound findings showing bilateral fibroglandular tissue with BIRADS-2 classification confirms benign gynecomastia, which is more pronounced on the right side 3
• The normal hormone profile (LH, FSH, TSH, DHEA-S, Testosterone, Free testosterone, Prolactin, estradiol) effectively rules out hormonal causes of gynecomastia 1
• Normal scrotal ultrasound with appropriate testicular size and morphology further supports the idiopathic nature of this condition 4

Key Considerations

• The patient's BMI of 28 may be contributing to his condition, as higher BMI is associated with more prominent gynecomastia 2
• The persistence of gynecomastia beyond the typical resolution timeframe (6 months to 2 years) suggests this is a chronic case of idiopathic gynecomastia 5
• The BIRADS-2 classification on ultrasound confirms benign findings without need for further imaging or biopsy 3

Management Recommendations

• No further investigations are necessary as the comprehensive workup has ruled out pathological causes 1
• For persistent idiopathic gynecomastia that causes psychological distress or physical discomfort, consider these options:

Medical Management

• Tamoxifen therapy (10 mg daily) could be considered if the patient is bothered by the condition, with approximately 90% resolution rate in idiopathic cases 6
• However, medical therapy is less likely to be effective in chronic established cases like this one (present for >2 years) 5

Surgical Management

• If the condition causes significant psychological distress or physical discomfort, surgical options include:
  • Liposuction for predominant fatty component
  • Direct excision when glandular tissue is predominant, as in this case 5

Follow-up Recommendations

• Annual clinical examination is sufficient to monitor for any changes 1
• No routine imaging is necessary unless there are changes in clinical presentation 3
• Reassure the patient about the benign nature of the condition, as gynecomastia is not a risk factor for male breast cancer 3

Common Pitfalls to Avoid

• Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 1
• Overlooking the psychological impact of gynecomastia, especially in young adults 5
• Attempting medical therapy in chronic established cases, which has limited efficacy 5