Initial Management of Gynecomastia
Most men presenting with gynecomastia symptoms can be diagnosed clinically without imaging, and initial management focuses on identifying reversible causes through targeted history, physical examination, and selective laboratory testing. 1
Clinical Presentation Recognition
Gynecomastia presents as a soft, rubbery, or firm mobile mass directly under the nipple and is often painful, especially when present for less than 6 months. 1 The condition is bilateral in approximately 50% of patients. 1
Critical first step: Differentiate true gynecomastia (glandular tissue proliferation) from pseudogynecomastia (fatty tissue deposition), particularly in patients with elevated BMI. 1, 2
Initial History and Physical Examination
Key History Elements to Obtain
Medication review: Identify drugs known to cause gynecomastia including spironolactone, antiandrogens, 5-alpha reductase inhibitors, GnRH agonists/antagonists, ketoconazole, digoxin, and anabolic steroids. 3, 2 Assess temporal relationship between medication initiation and symptom onset. 4
Substance use: Specifically ask about cannabis use, as chronic use (especially when started young) may affect hormonal systems. 2
Underlying conditions: Screen for liver cirrhosis, renal insufficiency, thyroid disease, and hypogonadism. 4, 5
Physical Examination Components
Calculate BMI or measure waist circumference to assess for obesity and pseudogynecomastia. 3, 1
Examine body hair patterns in androgen-dependent areas (face, chest, pubic region) to evaluate virilization status. 3
Perform complete testicular examination assessing size, consistency, and presence of masses or varicocele. 3
Assess prostate size and morphology for abnormalities. 3
Check visual fields for bitemporal hemianopsia suggesting pituitary disorders. 3
Laboratory Testing Algorithm
When to Order Labs
Order laboratory testing if:
- Clinical findings suggest hormonal imbalance
- Presentation is atypical or concerning
- No obvious medication or physiologic cause identified
Initial Laboratory Panel
Serum testosterone and estradiol: Measure in testosterone-deficient patients presenting with breast symptoms or gynecomastia prior to any testosterone therapy. 3
Luteinizing hormone (LH): Measure in patients with low testosterone to establish etiology. 3 Low or low-normal LH with low testosterone suggests secondary hypogonadism. 3
Prolactin: Measure in patients with low testosterone combined with low or low-normal LH levels. 3 If elevated, repeat measurement on a different day using an indwelling cannula (2-3 samples at 20-60 minute intervals) to exclude stress-related elevation. 3
Age-specific and sex-specific reference ranges: Use pediatric reference ranges for adolescents, as prolactin levels vary with age and sex. 3
Imaging Decision Algorithm
When Imaging is NOT Needed
No imaging is routinely recommended for men with clinical findings consistent with gynecomastia or pseudogynecomastia. 1 Unnecessary imaging in clear cases leads to additional unnecessary benign biopsies. 1, 4
When Imaging IS Indicated
Proceed with imaging if differentiation between benign disease and breast cancer cannot be made clinically, or if presentation is suspicious (hard, fixed mass; skin changes; nipple discharge; lymphadenopathy). 1
Age-based imaging approach:
- Men younger than 25 years: Ultrasound is the initial recommended study. 1
- Men 25 years and older: Mammography or digital breast tomosynthesis is recommended. 1
Referral Criteria
Endocrinology Referral
Refer to endocrinology if:
- Elevated baseline estradiol measurements 3, 1
- Persistently elevated prolactin levels (repeat testing confirms elevation) 3
- Total testosterone <150 ng/dL with low or low-normal LH (consider pituitary MRI regardless of prolactin level for non-secreting adenomas) 3
The endocrinologist will assess for testosterone deficiency, elevated estradiol, abnormal LH levels, and hyperprolactinemia. 1
Initial Management Based on Etiology
Medication-Induced Gynecomastia
Discontinue or substitute the offending medication when possible. 5
For patients on spironolactone who develop gynecomastia, switch to eplerenone which has significantly lower risk. 2 Note: Spironolactone-induced gynecomastia is common but does not usually require discontinuation in cirrhotic patients with ascites. 3
Tamoxifen 20 mg twice daily can reduce spironolactone-induced gynecomastia if medication cannot be stopped. 3
Physiologic Gynecomastia (Pubertal, Senescent)
Observation and reassurance is the recommended approach. 5, 6 Noncyclical breast pain tends to be of shorter duration with spontaneous resolution occurring in up to 50% of patients. 1
Testosterone Deficiency-Related Gynecomastia
Men developing gynecomastia/breast symptoms on testosterone treatment should undergo a period of monitoring as symptoms sometimes abate spontaneously. 3, 1
Estrogen receptor modulators may be considered for testosterone-deficient patients with low or low-normal LH levels. 3, 1
Important: Men interested in fertility should have reproductive health evaluation (testicular exam, FSH measurement) performed prior to testosterone treatment. 3, 1
Timeline Considerations
Early intervention is crucial: Gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy. 4, 7 Treatment should be pursued early and directed by patient symptoms and concerns. 5
Common Pitfalls to Avoid
Do not order routine imaging for clinically obvious gynecomastia—this leads to unnecessary biopsies. 1, 4
Do not miss medication causes: Carefully review all medications, supplements, and substances including cannabis. 2, 4
Do not forget to differentiate pseudogynecomastia in obese patients, as management differs. 1, 4
Do not delay endocrine referral when hormonal abnormalities are identified, particularly elevated estradiol or persistent hyperprolactinemia. 3, 1
Do not assume benignity in older men: Male breast cancer is rare but median age is 63 years—maintain appropriate clinical suspicion. 1