Draft an assessment and plan for an adult male with newly noted gynecomastia.

Assessment and Plan for Adult Male with Gynecomastia

Assessment

This patient presents with gynecomastia, which requires systematic evaluation to distinguish physiologic from pathologic causes, exclude malignancy, and identify reversible factors—particularly medications and underlying endocrine disorders. 1

Clinical Examination Findings to Document

• Characterize the breast tissue: True gynecomastia presents as soft, rubbery, or firm mobile mass directly under the nipple, often painful if present <6 months; distinguish from pseudogynecomastia (fatty tissue in obese patients) 1
• Laterality: Document whether unilateral or bilateral (bilateral in ~50% of cases) 1
• Red flags requiring immediate imaging: Hard, fixed, or eccentric mass; bloody nipple discharge; skin or nipple retraction 1
• Body habitus: Calculate BMI or measure waist circumference to assess for obesity-related pseudogynecomastia 2, 1
• Virilization status: Examine body hair patterns in androgen-dependent areas to evaluate for hypogonadism 1
• Complete testicular exam: Assess size, consistency, masses, and presence of varicocele 1
• Visual fields: Check for bitemporal hemianopsia suggesting pituitary pathology 1

Risk Factors to Assess

• Medication review: Evaluate temporal relationship between drug initiation and gynecomastia onset 2
  • High-risk medications: Spironolactone, antiandrogens (bicalutamide, flutamide), 5-alpha reductase inhibitors, GnRH agonists, ketoconazole, digoxin, estrogens, testosterone/anabolic steroids 3
  • Consider switching spironolactone to eplerenone if MRA needed 3
• Underlying conditions: Screen for liver cirrhosis, renal dysfunction, thyroid disease, hypogonadism, hyperprolactinemia 2
• Substance use: Cannabis, alcohol 3
• Genetic factors: Klinefelter syndrome (RR 24.7), BRCA2 mutation, family history of male breast disorders 2

Plan

Step 1: Determine Need for Imaging

For men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended, as this leads to unnecessary benign biopsies. 1

Proceed with imaging only if:

• Differentiation between benign disease and breast cancer cannot be made clinically 1
• Presentation is suspicious (unilateral, hard, fixed, eccentric mass, bloody discharge, skin/nipple retraction) 1

If imaging indicated:

• Age <25 years: Ultrasound first; add mammography/digital breast tomosynthesis (DBT) if suspicious features found 1
• Age ≥25 years: Mammography or DBT first (sensitivity 92-100%, specificity 90-96%, NPV 99-100%); ultrasound if indeterminate 1

Step 2: Laboratory Evaluation

Obtain morning total testosterone with a reliable assay as the primary baseline test. 1

Additional hormonal workup:

• If total testosterone borderline: Free testosterone by equilibrium dialysis or calculated using total testosterone, SHBG, albumin 1
• If testosterone low with low/normal LH: Measure serum prolactin to exclude hyperprolactinemia 1
• Measure LH and FSH: Distinguish primary (testicular) from secondary (hypothalamic-pituitary) hypogonadism 1
• Serum estradiol: Measure in all testosterone-deficient patients presenting with gynecomastia, especially before starting testosterone therapy 1

If elevated baseline estradiol: Mandatory endocrinology referral to determine underlying hormonal cause. 1

Step 3: Address Reversible Causes

• Discontinue contributing medications if clinically feasible 4
• Treat underlying conditions: Optimize management of liver disease, renal insufficiency, thyroid disorders 4
• Counsel on substance cessation: Cannabis, alcohol 3

Step 4: Observation vs. Treatment

For physiologic or idiopathic gynecomastia with recent onset (<12 months):

• Initial observation period recommended, as spontaneous resolution occurs in up to 50% of cases with noncyclical breast pain 1
• Gynecomastia persisting >12 months often becomes fibrotic and less responsive to medical therapy 2

For testosterone-deficient patients who develop gynecomastia on testosterone therapy:

• Undergo monitoring period as symptoms sometimes abate spontaneously 1

Step 5: Medical Therapy (If Persistent and Symptomatic)

Consider selective estrogen receptor modulators for:

• Testosterone-deficient patients with low or low-normal LH 1
• Patients with painful, persistent gynecomastia after observation period 1

Special consideration: Men interested in fertility should have reproductive health evaluation (testicular exam, FSH measurement) before treatment 1

Step 6: Surgical Referral

Reserve surgery for:

• Patients with persistent, symptomatic gynecomastia unresponsive to medical therapy 4
• Patients with significant psychological distress despite conservative management 4
• Fibrotic gynecomastia present >12 months (less responsive to medical therapy) 2

Common Pitfalls to Avoid

• Failing to distinguish true gynecomastia from pseudogynecomastia in obese patients—this changes management approach 2, 1
• Ordering unnecessary imaging in clinically obvious gynecomastia, leading to benign biopsies without improving outcomes 2, 1
• Missing medication-induced causes by not carefully reviewing temporal relationship between drug initiation and symptom onset 2
• Delaying endocrinology referral in patients with elevated estradiol—these patients require specialist evaluation 1