Evaluation and Management of Left Breast Tenderness in a 24-Year-Old Male
In a 24-year-old male with breast tenderness, clinical examination alone is typically sufficient for diagnosis without routine imaging, as gynecomastia is the most common cause and can be diagnosed clinically. 1
Initial Clinical Assessment
Perform a focused physical examination to characterize the breast finding:
- Palpate for a soft, rubbery, or firm mobile mass directly under the nipple, which is the classic presentation of gynecomastia 1
- Assess whether the finding is unilateral or bilateral (gynecomastia is bilateral in approximately 50% of cases) 2
- Determine if the tenderness is associated with a discrete mass or diffuse breast enlargement 1
- Distinguish true gynecomastia (glandular tissue) from pseudogynecomastia (fatty tissue deposition), particularly important if the patient has elevated BMI 2
- Note the duration of symptoms, as gynecomastia present for less than 6 months is more likely to be painful 1
When Imaging is NOT Needed
No imaging is routinely indicated if clinical findings are consistent with gynecomastia or pseudogynecomastia. 1, 2 This approach avoids unnecessary interventions and additional benign biopsies that can result from imaging in straightforward cases 2
When to Proceed with Imaging
If the clinical breast examination is indeterminate or cannot reliably distinguish between benign disease and breast cancer, imaging should be performed before considering biopsy. 1
Age-Appropriate Imaging Algorithm for Males Under 25:
For men younger than 25 years with an indeterminate palpable breast mass, ultrasound is the recommended initial imaging study. 1, 2, 3 This recommendation is based on the extremely low incidence of breast cancer in young men (only 1% of male breast cancers occur in men under 30 years of age) 1
However, if ultrasound demonstrates suspicious or indeterminate features, mammography or digital breast tomosynthesis (DBT) must be performed before making a biopsy recommendation. 1, 3 This sequential approach is critical because gynecomastia and oil cysts can appear suspicious on ultrasound but are typically diagnosed as benign on mammography 1
Important Clinical Context
The rationale for this conservative approach in young males is compelling:
- Breast cancer is exceedingly rare in this age group, with only 6% of male breast cancers occurring in men under 40 years and 1% in men under 30 years 1
- Most symptomatic young men have gynecomastia, which is often painful and self-limited 1
- Noncyclical breast pain (typical of gynecomastia) spontaneously resolves in up to 50% of patients 2
Common Pitfalls to Avoid
- Do not order routine imaging for clinically obvious gynecomastia, as this leads to unnecessary benign biopsies without improving outcomes 2
- Do not skip mammography if ultrasound findings are suspicious in younger men, as this can delay diagnosis of the rare but important case of malignancy 3
- Do not assume bilateral presentation excludes cancer, though synchronous bilateral breast carcinoma in males is extremely rare 1
When to Consider Endocrine Evaluation
If gynecomastia is confirmed and persistent, refer to an endocrinologist for hormonal evaluation, particularly if there are signs of hormonal imbalance. 2 The endocrinologist will assess serum testosterone, estradiol, luteinizing hormone (LH), and prolactin levels 2
Management of Confirmed Gynecomastia
For physiologic gynecomastia causing pain, initial management is observation, as symptoms often spontaneously resolve in up to 50% of patients 2. Medical therapy with estrogen receptor modulators may be considered for persistent, painful gynecomastia in testosterone-deficient patients 2