What are the treatment options for gynecomastia in men?

Treatment of Gynecomastia in Men

For persistent, painful gynecomastia of recent onset (less than 12 months), tamoxifen is the medical treatment of choice, while gynecomastia persisting beyond 12 months requires surgical excision as it becomes fibrotic and unresponsive to medical therapy. 1, 2

Initial Management Approach

Step 1: Determine Duration and Reversibility

• Observation is appropriate for physiologic gynecomastia (neonatal, pubertal, or senescent), as spontaneous resolution occurs in up to 50% of cases, particularly in adolescents where most cases resolve without intervention 1, 3, 4

• Identify and eliminate causative factors first: discontinue offending medications (spironolactone, antiandrogens, ketoconazole, 5-alpha reductase inhibitors, GnRH agonists), treat underlying conditions (hyperthyroidism, liver disease, hypogonadism), and address drug abuse 5, 2, 6

• For patients on spironolactone who develop gynecomastia, switch to eplerenone which has significantly lower risk of this adverse effect 5

Step 2: Medical Therapy (For Duration <12 Months)

Tamoxifen is FDA-approved and effective for treating gynecomastia, particularly in men with metastatic breast cancer and those at high risk for breast cancer 7, 2

• Tamoxifen works as an estrogen receptor modulator and should be considered for testosterone-deficient patients with low or low-normal LH levels 1

• Medical therapy is most effective when initiated early, as gynecomastia persisting beyond 12 months becomes fibrotic and less responsive to pharmacologic intervention 1, 2

• For men with testosterone deficiency who develop gynecomastia on testosterone replacement therapy, undergo a monitoring period as symptoms sometimes spontaneously resolve 1

Step 3: Prophylactic Treatment (Prevention Context)

For patients starting antiandrogen therapy for prostate cancer, prophylactic breast irradiation (8-15 Gy in 1-3 fractions) should be administered 1-2 weeks before treatment initiation to prevent painful gynecomastia 1

• This is particularly important as gynecomastia incidence can reach 80% in men receiving estrogen therapy for prostate cancer 5

• Prophylactic breast irradiation reduces gynecomastia risk in patients on antiandrogen therapy 8

Step 4: Surgical Management (For Duration >12 Months)

Surgical excision is the definitive treatment for chronic gynecomastia (>12 months duration) that is bothersome or fails to resolve with medical therapy 2, 4

• Surgery is indicated when gynecomastia causes significant psychosocial distress, physical discomfort, or cosmetic concerns 2, 9

• Multiple surgical techniques are available depending on the grade and extent of gynecomastia 2

• Surgical removal provides high patient satisfaction when preceded by thoughtful evaluation 2

Special Populations and Considerations

Endocrine Evaluation

• Refer men with elevated baseline estradiol to an endocrinologist to determine the underlying hormonal cause 1

• Measure serum estradiol in testosterone-deficient patients who present with breast symptoms or gynecomastia prior to starting testosterone therapy 1

• The endocrinologist will assess testosterone levels, estradiol, LH, and prolactin (if testosterone is low with low/normal LH) 1

Fertility Considerations

• Men with gynecomastia who are interested in fertility should undergo reproductive health evaluation prior to treatment 1

Underlying Pathology Assessment

• Evaluate for serious underlying conditions: testicular tumors, adrenal tumors, liver cirrhosis, Klinefelter syndrome (relative risk 24.7), and hyperprolactinemia 10

• Assess body habitus, BMI, virilization status, testicular examination (size, consistency, masses, varicocele), and visual fields for pituitary disorders 1

Common Pitfalls to Avoid

• Do not perform routine imaging in clinically obvious gynecomastia, as this leads to unnecessary benign biopsies 1

• Distinguish true gynecomastia from pseudogynecomastia (fatty tissue deposition), especially in obese patients, as treatment approaches differ 1, 10

• Do not delay treatment beyond 12 months if medical therapy is being considered, as fibrotic changes render pharmacologic treatment ineffective 1, 2

• Always rule out male breast cancer, particularly in older men (median age 63 years), though it accounts for <1% of all breast cancers 1

• Avoid coadministration of tamoxifen with anastrozole, as this reduces anastrozole plasma concentrations by 27% 7