Clinical Diagnosis of Gynecomastia
Gynecomastia can be diagnosed clinically in most cases without imaging, presenting as a soft, rubbery, or firm mobile mass directly under the nipple that is often painful, especially when present for less than 6 months. 1
Physical Examination Components
- Gynecomastia presents as a palpable, discrete mass of glandular tissue centered under the nipple-areolar complex 1
- The condition is bilateral in approximately 50% of patients 1
- Careful differentiation between true gynecomastia (glandular tissue enlargement) and pseudogynecomastia (fatty tissue deposition) is essential, especially in patients with elevated BMI 1
- Evaluate general body habitus and calculate BMI or measure waist circumference to assess for underlying systemic conditions 1
- Assess virilization status by examining body hair patterns in androgen-dependent areas to evaluate for hypogonadism 1
- Perform complete testicular examination to assess size, consistency, presence of masses, and evaluate for varicocele 1
- Examine prostate size and morphology for abnormalities that might indicate prostate pathology 1
- Check for visual field changes (bitemporal hemianopsia) that might suggest pituitary disorders associated with gynecomastia 1
Diagnostic Algorithm
Step 1: Clinical Assessment
- Determine if the breast enlargement is true gynecomastia or pseudogynecomastia through physical examination 1, 2
- Assess for signs of underlying conditions such as liver disease, hypogonadism, or thyroid disorders 3
- Evaluate medication history, noting temporal relationship between medication initiation and onset of gynecomastia 3
Step 2: Determine if Imaging is Needed
- For men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended 1
- If differentiation between benign disease and breast cancer cannot be made clinically, or if presentation is suspicious, proceed with imaging 1
- For indeterminate breast masses:
Step 3: Laboratory Evaluation (if indicated)
- Patients with elevated baseline estradiol measurements should be referred to an endocrinologist 1
- 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
Risk Factors to Consider
- Hormonal disorders such as hyperprolactinemia 3
- Liver cirrhosis 3
- Klinefelter syndrome (significantly increases risk with a relative risk of 24.7) 3
- Obesity (contributes to pseudogynecomastia but can also increase true gynecomastia through peripheral conversion of androgens to estrogens) 3
- Pre-existing gynecomastia 3
- BRCA2 mutation carriers (higher risk of male breast cancer and gynecomastia) 3
- Family history of male breast disorders 3
Common Pitfalls to Avoid
- Failing to distinguish between true gynecomastia and pseudogynecomastia, especially in obese patients 3
- Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 1, 3
- Overlooking medication-induced causes, which are common and potentially reversible 4, 5
- Neglecting to consider rare but serious causes such as testicular or adrenal tumors 3
- Forgetting that breast cancer in males is rare (accounting for <1% of all breast cancers) but should be ruled out, especially in older men (median age 63 years) 1
Special Considerations
- Physiologic gynecomastia is common in newborns, adolescents, and older men and is often self-limited 4
- Gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy 3
- At least 30% of males will be affected by gynecomastia during their lifetime 2
- Pubertal gynecomastia resolves spontaneously in the majority of adolescents 6
- The likelihood of pathology is increased in patients over 26 years of age who present with new-onset gynecomastia 7