How is physiologic gynecomastia vs pathophysiologic gynecomastia managed?

Management of Physiologic vs Pathophysiologic Gynecomastia

Physiologic gynecomastia should be managed with observation and reassurance, while pathophysiologic gynecomastia requires identification and treatment of the underlying cause. 1, 2

Diagnostic Evaluation

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

Physiologic Gynecomastia Management

• Physiologic gynecomastia occurs during three main phases: neonatal period, puberty, and senescence (aging) 2
• Pubertal gynecomastia resolves spontaneously in most adolescents, making reassurance and observation the best approach 2, 4
• Noncyclical breast pain tends to resolve spontaneously in up to 50% of patients 1
• For persistent painful physiologic gynecomastia, a short-term trial of medical therapy may be considered 2

Pathophysiologic Gynecomastia Management

Step 1: Identify Underlying Cause

• Evaluate medication history, noting temporal relationship between medication initiation and gynecomastia onset 3
• Assess for underlying medical conditions:
  • Hormonal disorders (hyperprolactinemia) 3
  • Liver cirrhosis 3
  • Klinefelter syndrome 3
  • Hypogonadism 3, 5
  • Thyroid disease 3
  • Renal dysfunction 3
• Consider genetic factors such as family history of breast disorders and BRCA2 mutations 3

Step 2: Treat Underlying Cause

• Discontinue contributing medications when possible 4
• Refer patients with elevated baseline estradiol to an endocrinologist 1
• Treat underlying disease as the primary approach 4
• For testosterone-deficient patients who develop gynecomastia on testosterone treatment, monitor as symptoms may abate 1

Step 3: Specific Treatments for Persistent Gynecomastia

• For persistent painful gynecomastia, consider:
  • Estrogen receptor modulators (tamoxifen) for testosterone-deficient patients with low/low-normal LH levels 1, 6
  • To prevent painful gynecomastia in patients starting antiandrogen therapy, breast irradiation (8-15 Gy in 1-3 fractions) should be given 1-2 weeks before initiation 7
• For chronic, bothersome gynecomastia (>12 months), surgical correction combining liposuction and mammary adenectomy is the treatment of choice 2, 6

Imaging Recommendations

• For men with clear clinical findings of gynecomastia, no imaging is routinely recommended 1
• If differentiation between benign disease and breast cancer cannot be made clinically:
  • Men younger than 25: Ultrasound is the initial recommended imaging study 1
  • Men 25 and older: Mammography or digital breast tomosynthesis is recommended 1

Common Pitfalls to Avoid

• Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 1, 3
• Failing to distinguish between true gynecomastia and pseudogynecomastia, especially in obese patients 3
• Delaying treatment of pathophysiologic gynecomastia, as gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy 3, 6
• Overlooking psychosocial effects, particularly among adolescents 8