What are the treatment options for gynecomastia causing nipple pain?

Treatment of Gynecomastia Causing Nipple Pain

The first-line treatment for gynecomastia causing nipple pain is addressing underlying causes, including discontinuing contributing medications, followed by observation for potential spontaneous resolution, with medical therapy (estrogen receptor modulators) for persistent cases, and surgery as a last resort for chronic, bothersome cases that don't respond to other interventions. 1, 2

Initial Evaluation and Management

• Differentiate true gynecomastia (glandular tissue proliferation) from pseudogynecomastia (fatty tissue deposition), especially in patients with elevated BMI 1, 3
• Most cases can be diagnosed based on clinical findings without imaging, as gynecomastia typically presents as a soft, rubbery, or firm mobile mass directly under the nipple 1
• Gynecomastia is often painful, especially when present for less than 6 months 1
• Gynecomastia is bilateral in approximately 50% of patients 1

Treatment Algorithm

Step 1: Address Underlying Causes

• Discontinue use of contributing medications if possible 4
  • For patients on spironolactone who develop gynecomastia, switch to eplerenone which has significantly lower risk of this side effect 3
• Treat underlying medical conditions that may contribute to gynecomastia 4
• Patients with elevated baseline estradiol measurements should be referred to an endocrinologist 5

Step 2: Observation for Physiologic Gynecomastia

• Pubertal gynecomastia resolves spontaneously in the majority of adolescents, making reassurance and observation the best initial approach 2
• Noncyclical breast pain tends to be of shorter duration than cyclical mastalgia, with spontaneous resolution occurring in up to 50% of patients 5

Step 3: Medical Therapy for Persistent, Painful Gynecomastia

• For men with persistent painful gynecomastia, a short-term trial of medical therapy is an option 2
• Estrogen receptor modulators may be considered for testosterone deficient patients with low or low/normal LH levels 5
• Men with testosterone deficiency who develop gynecomastia/breast symptoms on testosterone treatment should undergo a period of monitoring as symptoms sometimes abate 5

Step 4: Surgical Management

• For chronic, bothersome gynecomastia that doesn't respond to medical therapy, surgical removal is the treatment of choice 2, 6
• Surgical options include:
  • Suction lipectomy (liposuction) alone if gynecomastia is entirely due to fat 7
  • Combined suction lipectomy with local excision of breast parenchyma if due to parenchymal hypertrophy 7
  • Skin excision is rarely necessary 7

Special Considerations

• Men with gynecomastia who are interested in fertility should have a reproductive health evaluation performed prior to treatment 5
• Serum estradiol should be measured in testosterone deficient patients who present with breast symptoms or gynecomastia prior to starting testosterone therapy 5
• For men who develop gynecomastia on androgen deprivation therapy for prostate cancer, treatment should be pursued early and directed by patient preference 4, 3

Common Pitfalls to Avoid

• Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 1
• Delaying treatment in cases causing significant physical discomfort or emotional distress 4
• Failing to rule out male breast cancer, especially in older men (median age 63 years) 1