How is iatrogenic gynecomastia treated?

Treatment of Iatrogenic Gynecomastia

Discontinuation of the causative medication should be the first-line approach for iatrogenic gynecomastia, followed by selective estrogen receptor modulators (SERMs) if symptoms persist, with surgery reserved for cases that don't respond to medical therapy.

Causes and Evaluation

• Iatrogenic gynecomastia is commonly caused by medications that create hormonal imbalance at the breast tissue level, typically through estrogen excess and/or androgen deficiency 1
• Common medications associated with gynecomastia include:
  • Spironolactone
  • Hormonal therapies
  • Various other drugs that affect hormone balance 2
• Proper evaluation should include:
  • Detailed medication history to identify potential causative agents 2
  • Physical examination to confirm true glandular tissue enlargement (versus lipomastia) 2
  • Laboratory tests (when needed) including testosterone, estradiol, LH, FSH, and other hormones to assess underlying hormonal imbalances 2

Treatment Algorithm

First-Line Approach

• Discontinue the causative medication when possible 2
• Monitor for spontaneous regression, which often occurs within several months after medication discontinuation 2

Second-Line Approach (if discontinuation isn't possible or effective)

• Selective estrogen receptor modulators (SERMs):
  • Tamoxifen is most commonly used, though not FDA-approved for this indication 2
  • Note: Tamoxifen is contraindicated in patients with endometrial stromal sarcoma as it may be pro-estrogenic in this setting 3

Third-Line Approach

• Aromatase inhibitors may be considered in select cases, though evidence for their use is limited 2
• Testosterone replacement should only be offered to men with proven testosterone deficiency 2

Surgical Management

• Surgery is the therapy of choice for patients with long-lasting gynecomastia that doesn't respond to medical therapy 2
• Surgical options include:
  • Liposuction (for predominantly fatty tissue)
  • Subcutaneous mastectomy (for predominantly glandular tissue)
  • Combined approaches 2

Special Considerations

• Psychological impact should be considered, as gynecomastia can cause significant emotional distress 4
• Treatment should be pursued early to minimize both physical discomfort and psychological distress 4
• In cases where the causative medication cannot be discontinued (e.g., essential treatment for another condition), the benefits of continuing the medication must be weighed against the physical and psychological impact of gynecomastia 1

Monitoring and Follow-up

• Regular follow-up is recommended to:
  • Assess response to treatment
  • Monitor for potential recurrence
  • Address any psychological concerns 2
• Suspicious breast lesions should be evaluated with appropriate imaging and possibly biopsy to rule out male breast cancer 2