What is the appropriate treatment for gynecomastia?

Treatment of Gynecomastia

For most cases of gynecomastia, watchful waiting after addressing underlying causes (discontinuing offending medications or treating hormonal disorders) is the recommended first-line approach, with surgical treatment reserved for persistent cases lasting beyond 12 months that cause significant distress. 1, 2

Initial Management Algorithm

Step 1: Address Reversible Causes

• Discontinue any medications known to cause gynecomastia (spironolactone, antiandrogens, 5-alpha reductase inhibitors, GnRH agonists, ketoconazole, anabolic steroids) 3, 2
• For heart failure patients on spironolactone who develop gynecomastia, switch to eplerenone which has significantly lower risk 3
• Treat underlying hormonal disorders identified during workup (hypogonadism, hyperprolactinemia, thyroid disease) 1, 2
• Refer patients with elevated baseline estradiol to an endocrinologist for hormonal evaluation 1

Step 2: Observation Period

• Implement watchful waiting for 6-12 months after addressing reversible causes 1, 2
• Physiologic gynecomastia (pubertal) resolves spontaneously in >90% of cases within 24 months 2
• Noncyclical breast pain resolves spontaneously in up to 50% of patients 1
• Gynecomastia persisting beyond 12 months becomes fibrotic and less responsive to medical therapy 4, 2

Step 3: Medical Therapy (Limited Role)

Medical therapy is NOT recommended for general use but may be considered in select cases of persistent, painful gynecomastia of recent onset (<12 months): 2

• Estrogen receptor modulators (SERMs) may be considered for testosterone-deficient patients with low or low-normal LH levels 1
• The European Association of Andrology does NOT recommend routine use of SERMs, aromatase inhibitors, or non-aromatizable androgens 2
• Testosterone treatment should ONLY be offered to men with proven testosterone deficiency, not for gynecomastia treatment itself 1, 2
• Men who develop gynecomastia on testosterone therapy should undergo monitoring as symptoms sometimes resolve spontaneously 1

Step 4: Surgical Treatment

Surgery is the treatment of choice for patients with long-lasting gynecomastia (>12 months) that causes significant physical or psychological distress: 2, 5

• Surgical options include liposuction for predominantly fatty tissue or excision for glandular tissue 2
• The extent and type of surgery depend on breast size and adipose tissue amount 2
• Surgery should be pursued early before fibrosis develops, as fibrotic tissue is less responsive to all treatments 4, 6

Special Clinical Scenarios

Prostate Cancer Patients on Androgen Deprivation Therapy

• Preventive breast irradiation (8-15 Gy in 1-3 fractions) should be given 1-2 weeks BEFORE starting antiandrogen therapy to prevent painful gynecomastia (incidence up to 80% on estrogen therapy) 3, 1

Fertility Concerns

• Men with gynecomastia interested in fertility should have reproductive health evaluation performed PRIOR to treatment 1

Testosterone Deficiency

• Measure serum estradiol in testosterone-deficient patients BEFORE starting testosterone therapy if they present with breast symptoms 1

Critical Pitfalls to Avoid

• Do not pursue medical therapy in gynecomastia lasting >12 months due to fibrosis making it unresponsive 4, 2
• Do not use testosterone to treat gynecomastia itself—only treat if proven testosterone deficiency exists 1, 2
• Do not routinely use SERMs or aromatase inhibitors as they are not recommended for general gynecomastia management 2
• Failing to identify and discontinue offending medications is a common missed opportunity for resolution 3, 2
• Treatment should be patient-directed and pursued early before fibrosis develops 4, 6