From the Guidelines
For a 23-year-old male with concerns about gynecomastia despite normal hormone levels and bloodwork, I recommend first consulting with a healthcare provider for a physical examination to determine if imaging is necessary, as most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging 1. Gynecomastia is the benign enlargement of male breast tissue that can occur even with normal hormone levels. Initial management typically involves addressing any modifiable factors such as discontinuing medications that might contribute (including anabolic steroids, certain antipsychotics, and some heart medications), reducing alcohol intake, and maintaining a healthy weight through diet and exercise.
Key Considerations
- For mild cases, observation is often appropriate as many cases resolve spontaneously.
- For persistent cases causing physical discomfort or psychological distress, medical treatment options include tamoxifen (10-20mg daily for 3-6 months) or raloxifene (60mg daily for 3-6 months), which are selective estrogen receptor modulators that can reduce breast tissue.
- For severe or long-standing gynecomastia, surgical options including liposuction or mastectomy may be considered. The condition often results from an imbalance between estrogen and testosterone effects on breast tissue, which can occur despite normal serum hormone levels due to local tissue sensitivity or metabolism.
Diagnostic Approach
- If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated, with ultrasound recommended as the initial imaging study in men younger than age 25, and mammography or digital breast tomosynthesis in men age 25 and older 1. Reassuringly, most cases of gynecomastia are benign, but evaluation is important to rule out rare but serious underlying conditions.
From the Research
Gynecomastia Evaluation and Management
- Gynecomastia is a benign proliferation of glandular tissue of the breast in males, with a reported prevalence of 32-65% depending on age and criteria used for definition 2.
- The condition can be classified into different types, including gynecomastia of infancy, puberty, and adulthood, each with distinct characteristics and management approaches 2, 3.
Diagnostic Approach
- A thorough medical history and physical examination, including breast and genitalia examination, are essential for evaluating gynecomastia 2, 4, 5.
- Laboratory investigations, such as hormone level tests, may be necessary to rule out underlying pathological conditions or reversible causes 2, 5.
- Breast imaging and core needle biopsy may be considered in cases where the clinical examination is equivocal or suspicious for a malignant lesion 2, 4.
Management Options
- Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with gynecomastia 2.
- Testosterone treatment may be offered to men with proven testosterone deficiency 2.
- Surgical treatment is the therapy of choice for patients with long-lasting gynecomastia that does not regress spontaneously or following medical therapy 2, 3, 6.
- Other treatment options, such as selective estrogen receptor modulators, aromatase inhibitors, and non-aromatizable androgens, are not recommended for general use in gynecomastia management 2.