What is the treatment approach for gynecomastia (enlargement of breast tissue in males)?

Treatment Approach for Gynecomastia in Males

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

Initial Management Algorithm

Step 1: Address Reversible Causes First

The cornerstone of treatment is identifying and correcting underlying pathology or discontinuing causative substances. 1, 2

• Medication review is critical: Stop or switch medications known to cause gynecomastia, including spironolactone (switch to eplerenone for heart failure patients), antiandrogens, 5-alpha reductase inhibitors, GnRH agonists, ketoconazole, and digoxin 1, 3
• Treat underlying endocrine disorders: Correct hyperprolactinemia, hyperthyroidism, hypogonadism, or liver/renal dysfunction 1, 2
• Refer to endocrinology if elevated estradiol is detected to determine the hormonal cause 1
• Discontinue substances: Stop cannabis, anabolic steroids, or other contributing agents 3, 2

Step 2: Observation Period (Watchful Waiting)

After addressing reversible causes, observe for spontaneous resolution, which occurs in up to 50% of cases with noncyclical breast pain. 1

• Pubertal gynecomastia resolves spontaneously in over 90% of cases within 24 months 2
• Gynecomastia present for less than 6 months is more likely to be painful but also more likely to resolve 1
• Critical timing consideration: Gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy 4

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. 2

Testosterone Replacement

• Only offer testosterone to men with proven testosterone deficiency (low testosterone with low/normal LH) 1, 2
• Men who develop gynecomastia after starting testosterone should undergo monitoring as symptoms sometimes resolve spontaneously 1
• Estrogen receptor modulators may be considered in testosterone-deficient patients with low/normal LH 1

Medications Generally NOT Recommended

• Selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), and non-aromatizable androgens are not justified for routine use 2
• The evidence quality is low (⊕⊕○○) and these agents should not be used in general practice 2

Step 4: Surgical Treatment

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

• Surgical removal is indicated when gynecomastia does not resolve spontaneously or with medical therapy 5
• The extent and type of surgery depend on the size of breast enlargement and amount of adipose tissue 2
• Surgery should be pursued early if the patient desires it, as fibrotic tissue after 12 months responds poorly to medical management 4

Special Clinical Scenarios

Prophylactic Treatment for Antiandrogen Therapy

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

Fertility Considerations

Men with gynecomastia interested in fertility must have a reproductive health evaluation performed prior to any treatment. 1

Testosterone Deficiency with Gynecomastia

• Measure serum estradiol before starting testosterone therapy in men presenting with breast symptoms 1
• Refer to endocrinology for elevated estradiol to assess for testosterone deficiency, abnormal LH levels, and hyperprolactinemia 1

Common Pitfalls to Avoid

• Do not pursue unnecessary imaging in clinically obvious gynecomastia, as this leads to additional unnecessary benign biopsies 1, 4
• Do not use medical therapy routinely—the evidence does not support SERMs or AIs in general practice 2
• Do not delay addressing underlying causes—early identification allows for targeted intervention before fibrosis develops 4
• Do not confuse pseudogynecomastia (fatty tissue) with true gynecomastia (glandular tissue), especially in obese patients with elevated BMI 1, 4
• Do not assume all breast enlargement is benign—male breast cancer is rare but must be ruled out, particularly in men over 63 years 1

Treatment Priority Framework

1. First priority: Identify and treat underlying pathology or discontinue causative medications 1, 2
2. Second priority: Observe for spontaneous resolution (up to 24 months in adolescents, variable in adults) 1, 2
3. Third priority: Consider testosterone replacement only if proven deficiency exists 1, 2
4. Final option: Surgical removal for persistent cases causing distress 2, 5