How should I evaluate and manage gynecomastia in a young male?

Evaluation and Management of Gynecomastia in Young Males

Most young males with gynecomastia can be diagnosed clinically without imaging, and physiologic pubertal gynecomastia resolves spontaneously in 50% of cases within 2-3 years, requiring only reassurance and observation unless suspicious features are present. 1

Initial Clinical Assessment

Physical Examination Findings to Document

• Palpate for a soft, rubbery, or firm mobile mass directly under the nipple to confirm true gynecomastia rather than pseudogynecomastia (fatty tissue only), which is especially important in patients with elevated BMI 1
• Assess whether the gynecomastia is unilateral or bilateral (bilateral in approximately 50% of cases) 1
• Note if the mass is painful (pain is common when present for less than 6 months and suggests active proliferation) 1
• Examine for suspicious features: hard consistency, fixed to chest wall, eccentric location away from nipple, skin retraction, or nipple retraction 1
• Perform complete testicular examination to assess testicular size, consistency, masses, and presence of varicocele 1
• Evaluate body habitus and calculate BMI to assess for obesity-related hormonal changes 1
• Assess virilization status by examining body hair patterns in androgen-dependent areas to evaluate for hypogonadism 1

Critical History Elements

• Duration of breast enlargement (pubertal gynecomastia typically appears between ages 13-14 and resolves by age 16-17) 2, 3
• Medication and substance use: specifically ask about anabolic-androgenic steroids, cannabis, alcohol, herbal products, and prescription medications 4, 5
• Symptoms of hypogonadism: decreased libido, erectile dysfunction, loss of body hair 1
• Symptoms suggesting underlying disease: liver disease symptoms, renal insufficiency, hyperthyroidism 3, 6

Imaging Decision Algorithm

When NO Imaging is Needed

For young males with clinical findings consistent with physiologic pubertal gynecomastia (bilateral, soft, mobile, subareolar tissue without suspicious features), no imaging is routinely recommended because it leads to unnecessary benign biopsies without improving outcomes 1, 7

When Imaging IS Indicated

Proceed with imaging if:

• Differentiation between benign disease and breast cancer cannot be made clinically 1
• Unilateral presentation with hard, fixed, or eccentric mass 1
• Bloody nipple discharge present 1
• Skin or nipple retraction 1

Imaging Modality Selection by Age

• For males younger than 25 years: Ultrasound is the initial imaging study of choice 1, 7
• If ultrasound shows suspicious features: Proceed to mammography or digital breast tomosynthesis before considering biopsy, as gynecomastia can appear suspicious on ultrasound but benign on mammography 7

Laboratory Evaluation

When to Order Labs

Laboratory testing is indicated when:

• Gynecomastia persists beyond expected physiologic duration (>2-3 years) 2
• New-onset gynecomastia in males over age 26 8
• No clear physiologic or medication-related cause identified 6
• Symptoms or signs of hypogonadism present 1

Specific Laboratory Tests to Order

Initial hormonal panel:

• Morning total testosterone (primary baseline test) 1
• Serum estradiol (measure in all patients before considering hormonal therapy) 1, 4
• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to distinguish primary from secondary hypogonadism 1, 4
• If testosterone is low with low/normal LH, add serum prolactin to exclude hyperprolactinemia 1, 4

Additional screening based on history:

• Liver function tests if alcohol use or signs of liver disease 4, 6
• Renal function tests if symptoms suggest renal insufficiency 3, 6
• Thyroid function tests if signs of hyperthyroidism 6
• Human chorionic gonadotropin (hCG) if testicular mass present 6

When Free Testosterone is Needed

When total testosterone results are borderline, measure free testosterone by equilibrium dialysis or calculate using total testosterone, SHBG, and albumin 1

Management Algorithm

Step 1: Address Reversible Causes

• Discontinue contributing medications or substances (cannabis, alcohol, anabolic steroids, medications) 4, 3
• Treat underlying conditions (liver disease, renal insufficiency, hyperthyroidism, hypogonadism) 3

Step 2: Observation Period for Physiologic Gynecomastia

For pubertal gynecomastia without pathologic features, reassurance and observation for 2-3 years is the standard of care, as spontaneous resolution occurs in up to 50% of cases 1, 4, 2

Step 3: Endocrinology Referral Criteria

Mandatory referral to endocrinology for:

• Elevated baseline estradiol measurements 1, 4
• Confirmed hypogonadism requiring hormonal evaluation 1
• Complex hormonal abnormalities (abnormal LH, FSH, or prolactin) 1

Step 4: Medical Therapy Consideration

For persistent, painful gynecomastia that does not resolve after observation:

• Estrogen receptor modulators (tamoxifen or raloxifene) may be considered in testosterone-deficient patients with low or low-normal LH 1, 6, 5
• Treatment is most effective during the acute proliferative phase (first 6 months when tissue is tender) 1
• Trial duration: up to 3 months 6

Step 5: Surgical Referral

Consider surgical intervention for:

• Persistent gynecomastia causing significant psychological distress after failed medical management 3, 5
• Gynecomastia present for >12 months (fibrotic tissue less responsive to medical therapy) 3

Special Considerations for Young Males

Fertility Preservation

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

Substance Use Counseling

Chronic cannabis use, especially when initiated during adolescence, may significantly affect hormonal systems and contribute to gynecomastia 4

Alcohol can cause gynecomastia through two pathways:

1. Indirect pathway: Liver disease impairs hepatic clearance of steroid precursors, raising estrogen/androgen ratio 4
2. Direct pathway: Alcohol suppresses testicular testosterone production and hypothalamic-pituitary function 4

Psychological Impact Assessment

The impact of gynecomastia on the adolescent's mental health should be assessed, as psychological distress may warrant earlier intervention even when the condition is physiologically benign 5

Common Pitfalls to Avoid

• Ordering imaging in clear cases of physiologic pubertal gynecomastia leads to unnecessary benign biopsies without improving outcomes 1, 7
• Failing to perform testicular examination may miss testicular tumors producing hCG or estrogen 1
• Not inquiring about anabolic steroid, cannabis, or herbal supplement use misses common reversible causes 4, 5
• Initiating medical therapy too late (after 12 months when fibrosis has occurred) reduces treatment efficacy 3
• Missing male breast cancer (rare but median age 63 years; higher risk with BRCA2 mutations or Klinefelter syndrome) 1, 7