What should an elderly male taking testosterone gel do if he develops gynecomastia (breast tissue growth)?

Gynecomastia in Elderly Males on Testosterone Gel

If an elderly male develops gynecomastia while taking testosterone gel, first measure serum estradiol levels, then initiate a monitoring period as symptoms often spontaneously resolve, and if persistent or painful after observation, consider tamoxifen or discontinue testosterone therapy. 1, 2

Immediate Diagnostic Steps

Measure serum estradiol levels before making any treatment changes. Testosterone therapy can cause gynecomastia through peripheral aromatization of testosterone to estradiol, and elevated estradiol is the primary mechanism. 1, 2 Men with elevated baseline estradiol should be referred to an endocrinologist to determine the underlying hormonal cause. 1

Key Laboratory Tests to Order

• Serum estradiol (most important)
• Serum testosterone levels
• Luteinizing hormone (LH) if testosterone is low with low/normal LH
• Prolactin levels if indicated 1

Initial Management Algorithm

Step 1: Observation Period

Men who develop gynecomastia or breast symptoms on testosterone treatment should undergo a period of monitoring as symptoms sometimes spontaneously abate. 1 This is critical because noncyclical breast pain tends to be of shorter duration, with spontaneous resolution occurring in up to 50% of patients. 1

The observation period is particularly important because:

• Physiological gynecomastia is benign and self-limited in approximately 25% of cases 2
• Early intervention may be unnecessary and expose patients to additional medication risks
• The testosterone/estradiol ratio may normalize over time 3

Step 2: Medical Therapy for Persistent Symptoms

If gynecomastia persists beyond the observation period or is causing significant pain or distress, estrogen receptor modulators (specifically tamoxifen) may be considered. 1

Tamoxifen at 20 mg daily for 2-4 months is highly effective:

• Pain relief occurs in 83% of patients (10 of 12 with painful gynecomastia became pain-free) 3
• Partial or complete regression occurs in 88% of patients (14 of 16) 3
• No recurrence after discontinuation in the studied cohort 3
• Minimal side effects reported 3

Step 3: Consider Testosterone Discontinuation

If symptoms persist despite tamoxifen or if estradiol levels remain significantly elevated, discontinuation of testosterone therapy should be considered. 2 Treating the underlying cause (in this case, exogenous testosterone) might resolve gynecomastia, though the psychosocial burden may require careful consideration. 2

Clinical Differentiation Required

Distinguish true gynecomastia from pseudogynecomastia (fatty tissue deposition), especially in elderly patients with elevated BMI. 1, 4 True 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

When Imaging Is Indicated

Most men with breast symptoms can be diagnosed based on clinical findings without imaging. 1 However, if differentiation between benign disease and breast cancer cannot be made clinically, or if presentation is suspicious:

• For men 25 and older (which includes elderly patients): Mammography or digital breast tomosynthesis is the initial recommended imaging study. 1
• Male breast cancer is rare (median age 63 years) but must be ruled out in suspicious cases 1

Important Mechanism to Understand

Testosterone gel causes gynecomastia through peripheral aromatization of testosterone to estradiol. 4, 2 This creates an estrogen excess state despite adequate or supraphysiologic testosterone levels. The testosterone/estradiol ratio becomes significantly reduced, which is the key pathophysiologic mechanism. 3

Common Pitfalls to Avoid

• Do not order unnecessary imaging in clear cases of gynecomastia, as this can lead to additional unnecessary benign biopsies 1
• Do not immediately discontinue testosterone without a trial of observation, as many cases resolve spontaneously 1
• Do not fail to measure estradiol levels before initiating treatment, as this guides both diagnosis and management 1
• Do not assume all breast enlargement is gynecomastia in elderly obese patients—pseudogynecomastia from fatty tissue is common and requires different management 1, 4

Special Considerations for Elderly Patients

Elderly males are at higher risk for pathological gynecomastia compared to younger patients. In one study, 79% of patients under 20 years had physiological gynecomastia, but in elderly subjects, 80% (4 of 5) had pathological causes. 5 This makes the diagnostic workup particularly important in this age group.

Gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy, making early intervention more effective. 6