What is the initial evaluation and treatment approach for a male patient presenting with gynecomastia?

Gynecomastia Evaluation in Males

Initial Clinical Assessment

Most men with breast symptoms can be diagnosed based on clinical findings alone without imaging. 1

Physical Examination Findings to Identify

• Palpate for a soft, rubbery, or firm mobile mass directly under the nipple (classic gynecomastia presentation), which is often painful especially when present <6 months 1
• Differentiate true gynecomastia (glandular tissue) from pseudogynecomastia (fatty tissue) by palpating for firm subareolar tissue versus soft adipose tissue, particularly in patients with elevated BMI 1, 2
• Assess bilaterality as gynecomastia is bilateral in approximately 50% of patients 1
• Examine for suspicious features including unilateral mass, hard consistency, fixed or eccentric location, bloody nipple discharge, or skin/nipple retraction—these require immediate imaging 1

Complete Physical Examination Components

• Calculate BMI or measure waist circumference to assess for obesity and systemic conditions 2
• Perform complete testicular examination assessing size, consistency, masses, and varicocele presence 1
• Assess virilization status by examining body hair patterns in androgen-dependent areas 1
• Evaluate prostate size and morphology for abnormalities 1
• Check visual fields for bitemporal hemianopsia suggesting pituitary disorders 1

History Taking Priorities

• Medication review including temporal relationship between medication initiation and gynecomastia onset (chemotherapeutic agents, spironolactone, antiandrogens are common culprits) 2
• Assess for underlying conditions: hypogonadism, hyperprolactinemia, thyroid disease, liver cirrhosis, renal dysfunction 1, 2
• Family history of male breast disorders or BRCA2 mutations (significantly increases risk) 2
• Screen for Klinefelter syndrome (relative risk 24.7 for gynecomastia) 2

Imaging Decision Algorithm

When NO Imaging is Needed

For men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended. 1 This avoids unnecessary benign biopsies 3, 2

When Imaging IS Indicated

Proceed with imaging if differentiation between benign disease and breast cancer cannot be made clinically, or if presentation is suspicious. 1

Age-Based Imaging Protocol:

Men <25 years with indeterminate mass:

• Ultrasound is the initial recommended imaging study 1
• If suspicious features on ultrasound, perform mammography or digital breast tomosynthesis (DBT) before biopsy recommendation 3

Men ≥25 years with indeterminate mass:

• Mammography or DBT is recommended as the initial imaging study 3, 1
• Mammography has sensitivity 92-100%, specificity 90-96%, and negative predictive value 99-100% 1
• Bilateral mammography is routinely performed to assess symmetry and detect rare contralateral carcinoma 3

Laboratory Evaluation

Initial Hormonal Assessment

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

Complete Laboratory Panel

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

When Testicular Pathology Suspected

• High-frequency (>10 MHz) testicular ultrasound as first-line imaging for suspected testicular tumors causing gynecomastia 4
• Serum tumor markers (AFP, hCG, LDH) before any orchidectomy 4

Referral Algorithm

Men with elevated baseline estradiol measurements must be referred to an endocrinologist to determine the underlying hormonal cause. 1 This is mandatory, not optional.

Management Approach

Observation Period

For physiologic gynecomastia, spontaneous resolution occurs in up to 50% of patients. 1 Men with testosterone deficiency who develop gynecomastia on testosterone treatment should undergo monitoring as symptoms sometimes abate 1

Medical Therapy Considerations

Estrogen receptor modulators may be considered for testosterone-deficient patients with low or low-normal LH levels. 1 However, hormone therapy has only a 30% response rate and should not be considered in chronic established cases beyond 12 months (becomes fibrotic and less responsive) 2, 5

Preventive Measures

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

Special Population Considerations

Men interested in fertility should have reproductive health evaluation (testicular exam, FSH measurement) performed prior to treatment. 1

Common Pitfalls to Avoid

• Failing to distinguish true gynecomastia from pseudogynecomastia in obese patients leads to inappropriate management 2
• Ordering imaging in clear clinical cases leads to unnecessary benign biopsies 3, 2
• Delaying treatment beyond 12 months when medical therapy becomes ineffective due to fibrosis 2
• Starting testosterone therapy without measuring baseline estradiol in patients with breast symptoms 1
• Forgetting that male breast cancer is rare (median age 63 years, <1% of all breast cancers) but must be excluded in suspicious presentations 3, 1