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

Management of Gynecomastia

Clinical Diagnosis Without Imaging

Most men with gynecomastia can be diagnosed based on clinical findings alone without any imaging studies. 1, 2

Key Clinical Features to Identify

• True gynecomastia presents as a soft, rubbery, or firm mobile mass directly under the nipple, often painful especially when present for less than 6 months 1
• Pseudogynecomastia is fatty tissue deposition rather than glandular enlargement, particularly common in patients with elevated BMI 1, 2
• Bilateral presentation occurs in approximately 50% of patients 1, 2
• Palpate for a solid tissue mass below the nipple-areolar complex to distinguish true from pseudogynecomastia 3

Red Flags Requiring Immediate Imaging

Proceed directly to imaging if any of the following are present:

• Unilateral mass that is hard, fixed, or eccentric to the nipple 1
• Bloody nipple discharge 1
• Retracted skin or nipple 1
• Clinical inability to differentiate benign disease from breast cancer 1, 2

When Imaging Is Indicated

Age-Based Imaging Algorithm

For men younger than 25 years with indeterminate masses:

• Ultrasound is the initial imaging study 4, 1, 2
• If ultrasound shows suspicious features, follow with mammography or digital breast tomosynthesis before recommending biopsy 4

For men 25 years and older with indeterminate masses:

• Bilateral mammography or digital breast tomosynthesis is the initial imaging study 4, 1, 2
• Mammography has 92-100% sensitivity, 90-96% specificity, and 99-100% negative predictive value 1
• Ultrasound may follow if mammogram is indeterminate or suspicious 1

Important Caveat

Avoid unnecessary imaging in clear cases of gynecomastia, as this leads to additional unnecessary benign biopsies 1, 5

Laboratory Evaluation

Hormonal Assessment

Measure serum estradiol in all testosterone-deficient patients who present with breast symptoms or gynecomastia before starting testosterone therapy. 1

Order the following tests:

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

Refer all men with elevated baseline estradiol measurements to an endocrinologist to determine the underlying hormonal cause 1

Additional Evaluation Components

• Calculate BMI or measure waist circumference to assess for underlying systemic conditions 1
• Examine body hair patterns in androgen-dependent areas to evaluate for hypogonadism 1
• Perform complete testicular examination assessing size, consistency, masses, and varicocele 1
• Assess prostate size and morphology 1
• Examine for visual field changes (bitemporal hemianopsia) suggesting pituitary disorders 1
• Review medication history for temporal relationship between drug initiation and gynecomastia onset 5
• Assess for liver disease, renal dysfunction, thyroid disease, and hyperprolactinemia 5

Treatment Algorithm

Step 1: Observation for Physiologic Gynecomastia

Spontaneous resolution occurs in up to 50% of patients with noncyclical breast pain. 1

• Monitor testosterone-deficient patients who develop gynecomastia on testosterone treatment, as symptoms sometimes abate 1
• Gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy 5

Step 2: Medical Therapy for Persistent, Painful Gynecomastia

Estrogen receptor modulators may be considered for testosterone-deficient patients with low or low-normal LH levels. 1

• Drug therapy with tamoxifen may be considered at an early stage 3
• Note: Anastrozole has NOT been demonstrated to be effective for pubertal gynecomastia in adolescent boys in placebo-controlled trials 6
• Men interested in fertility should have reproductive health evaluation (testicular exam, FSH measurement) performed prior to treatment 1

Step 3: Surgical Management

For gynecomastia persisting over 12 months, surgical excision is the treatment of choice. 3

Surgical indications:

• Restoration of male chest shape 7
• Diagnostic evaluation of suspected breast lesions 7
• Persistent enlargement causing embarrassment or distress 7

Special Population: Antiandrogen Therapy

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

Biopsy Approach for Suspicious Lesions

When to Biopsy

Proceed to biopsy after completing age-appropriate imaging that shows suspicious features 1

Biopsy Technique

Image-guided core needle biopsy is the procedure of choice, superior to fine-needle aspiration in sensitivity, specificity, and correct histological grading. 1

Ultrasound guidance is preferred due to patient comfort, real-time needle visualization, absence of ionizing radiation, and sampling accuracy 1

Guidance method selection:

• Lesions visible on ultrasound: ultrasound-guided core biopsy 1
• Lesions only visible on mammography: stereotactic-guided core biopsy 1
• Lesions only visible on DBT: DBT-guided core biopsy 1

Post-biopsy requirements:

• Place marker clip to confirm tissue sampling and aid correlation 1
• Perform post-biopsy imaging to document marker placement 1

High-Risk Populations

Be particularly vigilant in:

• Men with BRCA2 mutations (significantly higher risk of male breast cancer) 2, 5
• Klinefelter syndrome patients (relative risk 24.7 for gynecomastia) 5
• Older men (median age for male breast cancer is 63 years) 1, 2
• Patients with liver cirrhosis 5

Common Pitfalls to Avoid

• Failing to distinguish true gynecomastia from pseudogynecomastia, especially in obese patients 5
• Ordering imaging in clinically obvious gynecomastia cases 1, 5
• Missing medication-induced causes by inadequate medication history 5
• Delaying treatment beyond 12 months when medical therapy is most effective 5