What is the initial approach to treating gynecomastia?

Initial Approach to Treating Gynecomastia

The initial approach to treating gynecomastia begins with clinical diagnosis without routine imaging, followed by identifying and addressing reversible causes (medications, underlying conditions), with observation being the preferred strategy for physiologic gynecomastia that typically resolves spontaneously. 1

Step 1: Clinical Diagnosis and Differentiation

• Most men with breast symptoms can be diagnosed based on clinical findings alone without imaging 1, 2
• Gynecomastia presents as a soft, rubbery, or firm mobile mass directly under the nipple, often painful when present for less than 6 months 1
• Differentiate true gynecomastia (glandular tissue enlargement) from pseudogynecomastia (fatty tissue deposition), especially in patients with elevated BMI 1, 2
• Gynecomastia is bilateral in approximately 50% of patients 1, 2

Common Pitfall: Failing to distinguish between true gynecomastia and pseudogynecomastia, especially in obese patients, can lead to inappropriate management 3

Step 2: Identify and Address Underlying Causes

Medication Review

• Evaluate medication history, including the temporal relationship between medication initiation and onset of gynecomastia 3
• Discontinue contributing medications when possible (e.g., spironolactone, chemotherapeutic agents) 3, 4

Assess for Underlying Medical Conditions

• Evaluate for hypogonadism, thyroid disease, liver disease (cirrhosis), or renal dysfunction 3
• Calculate BMI or measure waist circumference to assess for obesity-related causes 1
• Perform complete testicular examination to assess size, consistency, and presence of masses 1
• Examine for signs of hyperprolactinemia and other hormonal disorders 3

Laboratory Evaluation (When Indicated)

• Refer men with elevated baseline estradiol measurements to an endocrinologist to determine the underlying hormonal cause 1
• The endocrinologist will assess serum testosterone levels, serum estradiol levels, luteinizing hormone (LH) levels, and prolactin levels if testosterone is low with low/normal LH 1

Step 3: Treatment Algorithm Based on Clinical Context

Physiologic/Pubertal Gynecomastia

• Reassurance and observation is the best approach as pubertal gynecomastia resolves spontaneously in the majority of adolescents 5
• Noncyclical breast pain tends to be of shorter duration, with spontaneous resolution occurring in up to 50% of patients 1
• Early identification is crucial because gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy 3

Important Note: Anastrozole showed no efficacy in treating pubertal gynecomastia in a randomized controlled trial of adolescent boys and is not recommended 6

Persistent, Painful Gynecomastia in Adults

• Men with testosterone deficiency who develop gynecomastia should undergo a period of monitoring as symptoms sometimes abate 1
• For testosterone-deficient patients with low or low/normal LH levels, estrogen receptor modulators may be considered 1
• A short-term trial of medical therapy (antiestrogen therapy) is an option for adults with persistent painful gynecomastia and has shown good results 5, 7

Chronic, Bothersome Gynecomastia

• For chronic gynecomastia that does not resolve spontaneously or with medical therapy, surgical removal by plastic surgery is the treatment of choice 5, 7

Step 4: When to Image (Exception to Clinical Diagnosis)

Imaging is NOT routinely recommended for men with clinical findings consistent with gynecomastia 1

Proceed with imaging only if:

• Differentiation between benign disease and breast cancer cannot be made clinically, or if presentation is suspicious 1
• For men younger than 25: Ultrasound is the initial recommended imaging study 1, 2
• For men 25 and older: Mammography or digital breast tomosynthesis is recommended 1, 2

Critical Consideration: Male breast cancer is rare (accounting for <1% of all breast cancers, median age 63 years) but should be ruled out, especially in older men 1, 2

Special Populations

Patients Starting Antiandrogen Therapy

• 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 1

Men Interested in Fertility

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

High-Risk Patients

• BRCA2 mutation carriers and patients with Klinefelter syndrome have significantly higher risk of male breast cancer and warrant careful evaluation 3, 2

Common Pitfall: Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 3, 1