Gynecomastia is a benign enlargement of the male breast (usually bilateral, but sometimes unilateral) caused by proliferation of the glandular component of the breast. It is clinically defined by the presence of a rubbery or firm mass extending concentrically from the nipple. Gynecomastia should be distinguished from pseudogynecomastia (lipomastia), which is characterized by fat accumulation without glandular proliferation.
Symptoms of Gynecomastia
A comprehensive history should be obtained addressing the following
- Age and duration of onset of the disease
- Any recent change in nipple size and any pain or discharge from the nipples
- History of mumps, testicular trauma, alcohol abuse or drug abuse
- Family history of gynecomastia
- History of sexual dysfunction, infertility or hypogonadism
The physical examination should include the following:
- Thorough examination of the breasts with attention to size and consistency
- Assessment for any nipple discharge or axillary lymphadenopathy
- Test to distinguish between true gynecomastia and pseudogynecomastia
- Evaluation of glandular tissue
- Examination of the testicles with attention to size and consistency as well as nodules or asymmetry
- Observation of any signs of feminization
- Checking for any stigma of chronic liver disease, thyroid disease or kidney disease
Hematoma, lipoma, male sexual dysfunction and neurofibroma may be included in the differential diagnosis.
Diagnosis of Gynecomastia
Patients with physiologic gynecomastia do not need further evaluation. Similarly, asymptomatic and pubertal gynecomastia does not require further testing and should be reassessed in 6 months. Further evaluation is necessary in the following cases:
- Breast size greater than 5 cm (macromastia)
- A tender, new onset, progressive or lump of unknown duration
- Signs of malignancy (for example, hard or fixed lymph nodes or positive lymph node findings)
Laboratory tests that may be considered include
- Serum chemistry panel
- Free or total testosterone, luteinizing hormone (LH), estradiol and dehydroepiandrosterone sulfate levels
- Thyroid stimulating hormone (TSH) and free thyroxine levels
Imaging studies that may be helpful include
- Mammography: If one or more features of breast cancer are evident on clinical examination, and then indicated by fine needle aspiration or breast biopsy as appropriate.
- Testicular ultrasonography: Indicated when serum estradiol level is high and clinical examination findings suggest the possibility of testicular neoplasm
- Breast ultrasonography (although the positive predictive value of imaging in men is low)
- Computed tomography (CT) scan: Gynecomastia is usually reported on CT scans
Gynecomastia Management
General management considerations are as follows:
- As a rule, no treatment is needed for physiological gynecomastia
- Pubertal gynecomastia resolves spontaneously in most patients within a few weeks to 3 years; breasts larger than 4 cm in diameter may not regress completely
- Identifying and managing an underlying primary disorder usually alleviates breast enlargement
- Medical or surgical treatment may be considered in patients with idiopathic gynecomastia or gynecomastia with residual breast tissue after treatment of the primary cause.
- If medical treatments are used, they should be tried early in the course of the condition
Gynecomastia Treatment
Pharmacological agents used totreat gynecomastia include
- Clomiphene
- Tamoxifen
- Danazol (used less frequently)
Surgical approaches that may be considered include
- Reduction mammoplasty: Macromastia is considered in cases of long-standing gynecomastia or failed medical treatment, as well as for cosmetic reasons
- More extensive plastic surgery: May be considered in cases of significant gynecomastia or excessive sagging of breast tissue due to weight loss
- Endoscopic subcutaneous mastectomy without skin excision
Surgical complications may include the following:
- Shedding of tissue due to impaired blood flow
- Contour irregularity
- Hematoma or seroma formation
- Permanent numbness in the nipple-areolar region
