Differentiating Pseudogynecomastia from Glandular Gynecomastia in an Elderly Male on Finasteride
The differentiation is made primarily through physical examination: true glandular gynecomastia presents as a palpable, firm, rubbery, or soft mobile mass of glandular tissue directly under the nipple, while pseudogynecomastia consists only of excess fatty tissue without palpable glandular tissue. 1
Clinical Examination Technique
Physical examination should confirm the presence of palpable glandular tissue to discriminate true gynecomastia from lipomastia (pseudogynecomastia). 2
Key Physical Findings:
True glandular gynecomastia: Palpate for a soft, rubbery, or firm mobile mass directly under the nipple that represents actual breast glandular tissue 1
Pseudogynecomastia: Only adipose tissue is present without discrete glandular tissue, commonly seen in patients with elevated body mass index 1
Pain assessment: True gynecomastia is more likely to be painful than pseudogynecomastia, especially if present for less than 6 months 1
Context of Finasteride Use
This patient's 12-month finasteride exposure is directly relevant, as gynecomastia occurs in 0.5-2.2% of finasteride patients versus 0.1-1.1% with placebo, representing a 2-4% increased absolute risk. 1, 3 The medication causes hormonal changes that can trigger true glandular proliferation, not just fat deposition. 1
When Imaging is Indicated
Most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging. 1 However, imaging becomes necessary when:
Mammography:
When pseudogynecomastia is identified as the sole imaging finding, mammography may obviate further unnecessary interventions for falsely presumed gynecomastia. 1
Three mammographic patterns distinguish true gynecomastia: (1) nodular (subareolar nodule), (2) dendritic (subareolar flame-shaped tissue), and (3) diffuse glandular (resembling heterogeneously dense female breast) 1, 4
Mammography is not routinely indicated when physical examination findings are consistent with gynecomastia or pseudogynecomastia 1
Ultrasound:
Breast imaging may offer assistance where the clinical examination is equivocal 2
Florid gynecomastia appears as a disk-shaped, hypoechoic area underlying the areola on ultrasound, with echogenicity increasing as fibrosis develops 4
Ultrasound is not routinely indicated when clinical findings are consistent with gynecomastia or pseudogynecomastia 1
Critical Considerations in Elderly Males
Although gynecomastia may present at any age, breast cancers usually occur in older men (median age of 63 years). 1 This makes the distinction particularly important in your elderly patient:
Approximately 50% of men with breast cancer may have coexisting gynecomastia 1
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 1
If the clinical picture is suspicious for a malignant lesion, core needle biopsy should be performed 2
Common Pitfalls to Avoid
Do not assume all breast enlargement in obese patients is pseudogynecomastia—palpation is essential to detect underlying glandular tissue 1
Do not order routine imaging when physical examination is conclusive—this leads to unnecessary interventions and benign biopsies 1
In elderly males, maintain higher suspicion for malignancy given age-related increased breast cancer risk 1
Remember that finasteride-induced gynecomastia represents true glandular proliferation due to hormonal effects, not simply weight gain 1, 3
Management Algorithm Based on Findings
After confirming true glandular gynecomastia (versus pseudogynecomastia), watchful waiting is recommended after discontinuation of substances associated with gynecomastia. 2 In this case, consider:
Discontinuing finasteride if the gynecomastia is bothersome to the patient 2, 5
Surgical treatment is the therapy of choice for patients with long-lasting gynecomastia that does not regress after medication discontinuation 2
Medical therapy with selective estrogen receptor modulators or aromatase inhibitors is not justified in general 2