What is the appropriate treatment approach for a male patient presenting with gynecomastia?

Gynecomastia Treatment

For most men with gynecomastia, watchful waiting after addressing underlying causes is the recommended approach, with surgical removal reserved for long-lasting cases that do not resolve spontaneously. 1, 2

Initial Management Algorithm

Step 1: Address Reversible Causes

• Discontinue offending medications or substances associated with gynecomastia (e.g., spironolactone, antiandrogens, anabolic steroids, marijuana) 2, 3
• Treat underlying pathology if identified (hyperthyroidism, testicular tumors, liver disease, hypogonadism) 2, 3
• Refer men with elevated baseline estradiol to an endocrinologist to determine the underlying hormonal cause 1

Step 2: Observation Period

• Implement watchful waiting for 6-24 months after treating underlying pathology or discontinuing aggravating substances 1, 2
• Spontaneous resolution occurs in up to 50% of cases with noncyclical breast pain 1
• Pubertal gynecomastia resolves spontaneously in more than 90% of cases within 24 months 2

Step 3: Medical Therapy (Limited Role)

Medical therapy is generally NOT recommended for routine gynecomastia treatment. 2

However, consider the following in specific circumstances:

• Testosterone replacement therapy should be offered ONLY to men with proven testosterone deficiency 1, 2
• Men with testosterone deficiency who develop gynecomastia on testosterone treatment should undergo monitoring as symptoms sometimes abate 1
• Selective estrogen receptor modulators (SERMs) may be considered for testosterone-deficient patients with low or low-normal LH levels 1
• The use of SERMs, aromatase inhibitors, and non-aromatizable androgens is NOT justified in general 2

Step 4: Surgical Treatment

Surgery is the therapy of choice for patients with long-lasting gynecomastia that does not regress spontaneously or following medical therapy. 2

• The extent and type of surgery depend on the size of breast enlargement and the amount of adipose tissue 2
• Surgical removal is indicated for chronic, bothersome gynecomastia causing significant psychosocial distress 4

Special Populations

Preventive Treatment for Antiandrogen Therapy

• For patients starting antiandrogen therapy, administer breast irradiation (8-15 Gy in 1-3 fractions) 1-2 weeks before initiation to prevent painful gynecomastia 1

Fertility Considerations

• Men with gynecomastia who are interested in fertility should have a reproductive health evaluation (testicular exam, FSH measurement) performed prior to treatment 1

Testosterone-Deficient Patients

• Measure serum estradiol in all testosterone-deficient patients who present with breast symptoms or gynecomastia before commencing testosterone therapy 1
• Testosterone-deficient patients with low or low-normal LH are candidates for selective estrogen receptor modulator use, particularly those wishing to preserve fertility 1

Common Pitfalls to Avoid

• Do not routinely use medical therapy (SERMs, aromatase inhibitors) as first-line treatment—the evidence does not support this approach 2
• Do not perform unnecessary imaging in clear cases of gynecomastia, as this can lead to additional unnecessary benign biopsies 5, 1
• Do not start testosterone therapy without first measuring estradiol in men presenting with gynecomastia 1
• Do not assume all breast enlargement is benign—rule out male breast cancer, especially in older men (median age 63 years) with unilateral, hard, fixed, or eccentric masses 1, 6

Treatment Timeline

The approach differs based on duration and patient age:

• Physiologic gynecomastia (infancy, puberty): Reassurance and observation, as spontaneous resolution is expected 2, 4
• Recent-onset adult gynecomastia (<6 months): Address underlying causes, then observe for 6-24 months 1, 2
• Long-standing gynecomastia (>12-24 months): Consider surgical removal if symptomatic or causing psychosocial distress 2, 4