What is the treatment for male bilateral idiopathic gynecomastia?

Treatment of Male Bilateral Idiopathic Gynecomastia

For bilateral idiopathic gynecomastia, watchful waiting is the recommended initial approach after ruling out underlying pathology, as spontaneous resolution occurs in up to 50% of cases; medical therapy with selective estrogen receptor modulators (SERMs) like tamoxifen may be considered for persistent, painful cases, while surgical excision is reserved for long-lasting gynecomastia that fails to resolve spontaneously or with medical management. 1, 2

Initial Management Algorithm

Step 1: Confirm Idiopathic Nature

Before initiating treatment, ensure proper diagnostic workup has been completed to confirm the gynecomastia is truly idiopathic 2:

• Medication review: Discontinue or substitute any causative medications (spironolactone, antiandrogens, ketoconazole, 5-alpha reductase inhibitors, GnRH agonists, cannabis) 3
• Laboratory evaluation: Measure testosterone, estradiol, SHBG, LH, FSH, TSH, prolactin, hCG, AFP, and liver/renal function tests to exclude secondary causes 2
• Endocrine referral: Men with elevated baseline estradiol require mandatory endocrinology referral 1
• Physical examination: Assess testicular size/masses (aided by testicular ultrasound), body habitus, virilization status, and prostate morphology 1, 2

Step 2: Observation Period (First-Line Treatment)

Watchful waiting is the recommended initial management for idiopathic gynecomastia 1, 2, 4:

• Noncyclical breast pain resolves spontaneously in up to 50% of patients 1
• Duration of observation should be individualized but typically extends several months 2
• Men with testosterone deficiency who develop gynecomastia on testosterone therapy should undergo monitoring as symptoms sometimes abate 1

Step 3: Medical Therapy for Persistent Cases

Medical therapy is NOT routinely recommended for idiopathic gynecomastia in general 2:

• The European Association of Andrology does not recommend the use of SERMs, aromatase inhibitors, or non-aromatizable androgens for gynecomastia treatment in general 2
• However, a trial of tamoxifen for up to 3 months may be attempted during the acute stage of gynecomastia 5
• Estrogen receptor modulators may be considered specifically for testosterone-deficient patients with low or low-normal LH levels 1

Important caveat: Medical therapy is most effective in early-stage gynecomastia (present <12 months); gynecomastia persisting beyond 12 months often becomes fibrotic and less responsive to medical therapy 6

Step 4: Surgical Management

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

• Indications include: persistent enlargement causing embarrassment/distress, long duration (typically >12 months), or significant breast enlargement with skin redundancy 2, 7
• The complete circumareolar approach with purse-string suture creates optimal aesthetic results in patients with moderate to severe ptotic glandular enlargement combined with skin redundancy and areolar enlargement 7
• The extent and type of surgery depend on the size of breast enlargement and the amount of adipose tissue 2

Special Considerations

Testosterone Deficiency

• Testosterone treatment should be offered ONLY to men with proven testosterone deficiency 1, 2
• Serum estradiol should be measured in testosterone-deficient patients who present with gynecomastia prior to starting testosterone therapy 1

Fertility Concerns

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

Prophylactic Measures

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

Common Pitfalls to Avoid

• Do not initiate medical therapy without proper diagnostic workup: Up to 45-50% of adult gynecomastia cases have an underlying pathology that requires specific treatment 2
• Do not perform unnecessary imaging in clear cases: Clinical examination is sufficient for most cases; imaging leads to additional unnecessary benign biopsies 1
• Do not delay surgical referral in long-standing cases: Fibrotic tissue after 12 months responds poorly to medical therapy 6
• Do not prescribe testosterone without documented deficiency: Testosterone treatment is only indicated for proven testosterone deficiency 1, 2