Which specialist manages gynecomastia in adolescent or adult males presenting with breast enlargement?

Which Specialist Manages Gynecomastia

Men with elevated baseline estradiol measurements should be referred to an endocrinologist to determine the underlying hormonal cause of gynecomastia. 1

Initial Screening and Triage

• A general practitioner or non-specialist can perform initial screening to rule out lipomastia (pseudogynecomastia), obvious breast cancer, or testicular cancer. 2
• However, when a thorough diagnostic workup is warranted, it should be performed by a specialist. 2

Primary Specialist: Endocrinologist

The endocrinologist is the primary specialist for managing gynecomastia with hormonal causes. 1 This referral is mandatory in specific situations:

• All men with elevated baseline estradiol levels require endocrinology referral. 1
• Testosterone-deficient patients presenting with breast symptoms or gynecomastia should be referred to endocrinology, particularly before starting testosterone therapy. 1
• Men with low testosterone accompanied by low or normal LH levels need endocrine evaluation to assess for hyperprolactinemia and other hormonal imbalances. 1

What the Endocrinologist Will Assess

The endocrinologist will evaluate for:

• Testosterone deficiency 1
• Elevated estradiol levels 1
• Abnormal luteinizing hormone (LH) levels 1
• Hyperprolactinemia (if testosterone is low with low/normal LH) 1

Additional Specialists Based on Clinical Context

Plastic Surgeon

For chronic, bothersome gynecomastia that persists beyond observation or fails medical therapy, plastic surgery is the treatment of choice. 3 Surgical referral is appropriate for:

• Patients with long-lasting gynecomastia that does not regress spontaneously or following medical therapy 2
• Men experiencing significant psychosocial distress from persistent breast enlargement 4, 5
• Cases with moderate to severe ptotic glandular enlargement with skin redundancy 4

Urologist

The American Urological Association provides specific guidance on gynecomastia evaluation, including recommendations for testicular examination, hormonal assessment, and fertility considerations. 1 A urologist may be involved when:

• Testicular pathology is suspected (testicular masses, varicocele, testicular atrophy) 1, 2
• Men interested in fertility require reproductive health evaluation (testicular exam, FSH measurement) before treatment. 1
• Prostate abnormalities are detected during physical examination 1

Radiologist

For men 25 and older with indeterminate breast masses, mammography or digital breast tomosynthesis is the initial imaging study. 1 Radiology involvement is needed when:

• Clinical differentiation between benign disease and breast cancer cannot be made 1
• Suspicious features are present (unilateral mass, hard, fixed, or eccentric) 6
• Core needle biopsy with image guidance is required for suspicious lesions. 1

Common Pitfalls to Avoid

• Do not order unnecessary imaging in clear cases of gynecomastia, as this leads to additional unnecessary benign biopsies without improving outcomes. 1, 6
• Do not assume medication-induced gynecomastia excludes the need for detailed investigation in adult men, as underlying pathology may be present in 45-50% of cases. 2
• Always perform testicular ultrasound in addition to physical examination, as detection of testicular tumors by palpation alone has low sensitivity. 2

Algorithm Summary

1. Initial evaluation by primary care or general practitioner for obvious cases 2
2. Mandatory endocrinology referral for elevated estradiol, testosterone deficiency, or hormonal imbalance 1
3. Urology consultation if testicular pathology suspected or fertility concerns 1, 2
4. Radiology for imaging when clinical examination is indeterminate or suspicious 1, 6
5. Plastic surgery referral for persistent, bothersome gynecomastia after failed conservative management 2, 3