Gynecomastia: Etiologies, Diagnosis, and Management
Gynecomastia: Etiologies, Diagnosis, and Management
Gynecomastia is typically benign in nature, but breasts sometimes can be tender, especially during adolescence. Most men seek reassurance that their condition is benign and that no intervention is required. Enlargement of breast tissue <4 cm is most likely to resolve spontaneously, whereas pubertal gynecomastia will resolve within months to years in nearly 90% of patients. Some individuals experience significant psychosocial distress; therefore, it is important to offer psychological support as part of any treatment regimen.
For patients who are symptomatic and require treatment, medications should be started early, because patients with gynecomastia for >12 months may have poor responses compared with those with disease lasting <12 months. This is the result of irreversible deposition of fibrous tissue in the breasts. There are no therapies for gynecomastia that have been approved by the Food and Drug Administration, but proposed treatments include anti-estrogens (eg, clomiphene), selective estrogen receptor blockers (eg, tamoxifen), synthetic testosterone derivatives (eg, danazol), aromatase inhibitors (eg, anastrazole), and parenteral or transdermal testosterone (Table 4). Of note, testosterone used for treating hypogonadism can sometimes lead to gynecomastia secondary to peripheral conversion to estrogen. Radiation also has been used as gynecomastia prophylaxis in patients with prostate cancer who are receiving estrogen therapy.
Gynecomastia caused by an underlying medical condition (eg, testicular cancer, hyperthyroidism) often can be reversed by treatment of the underlying cause, and discontinuation of the offending agent usually results in resolution of medication-induced gynecomastia. Obese patients should be counseled on weight loss strategies and low-fat diets or offered consultation with a nutritionist. Liposuction, endoscopic subcutaneous mastectomy, or reduction mammoplasty is indicated in cases of macromastia, long-standing cases of or refractory gynecomastia, or for cosmetic reasons.
Gynecomastia also can have psychosocial effects on patients. Young men with gynecomastia often are reticent to participate in athletic activities that may result in exposing the chest, they may avoid showers and swimming pools, and they may camouflage their bodies by wearing loose-fitting clothes. Posture also can be affected because patients tend to minimize the deformation by rolling their shoulders toward the midline and slouching forward; thus, these psychosocial issues may need to be addressed foremost in those patients. Although most patients do not require psychotherapy, they should be provided with reassurance about the self-limited nature of the condition, encouragement to participate in social and physical activities, and counseling on lifestyle modifications.
Treatment Options
Gynecomastia is typically benign in nature, but breasts sometimes can be tender, especially during adolescence. Most men seek reassurance that their condition is benign and that no intervention is required. Enlargement of breast tissue <4 cm is most likely to resolve spontaneously, whereas pubertal gynecomastia will resolve within months to years in nearly 90% of patients. Some individuals experience significant psychosocial distress; therefore, it is important to offer psychological support as part of any treatment regimen.
For patients who are symptomatic and require treatment, medications should be started early, because patients with gynecomastia for >12 months may have poor responses compared with those with disease lasting <12 months. This is the result of irreversible deposition of fibrous tissue in the breasts. There are no therapies for gynecomastia that have been approved by the Food and Drug Administration, but proposed treatments include anti-estrogens (eg, clomiphene), selective estrogen receptor blockers (eg, tamoxifen), synthetic testosterone derivatives (eg, danazol), aromatase inhibitors (eg, anastrazole), and parenteral or transdermal testosterone (Table 4). Of note, testosterone used for treating hypogonadism can sometimes lead to gynecomastia secondary to peripheral conversion to estrogen. Radiation also has been used as gynecomastia prophylaxis in patients with prostate cancer who are receiving estrogen therapy.
Gynecomastia caused by an underlying medical condition (eg, testicular cancer, hyperthyroidism) often can be reversed by treatment of the underlying cause, and discontinuation of the offending agent usually results in resolution of medication-induced gynecomastia. Obese patients should be counseled on weight loss strategies and low-fat diets or offered consultation with a nutritionist. Liposuction, endoscopic subcutaneous mastectomy, or reduction mammoplasty is indicated in cases of macromastia, long-standing cases of or refractory gynecomastia, or for cosmetic reasons.
Gynecomastia also can have psychosocial effects on patients. Young men with gynecomastia often are reticent to participate in athletic activities that may result in exposing the chest, they may avoid showers and swimming pools, and they may camouflage their bodies by wearing loose-fitting clothes. Posture also can be affected because patients tend to minimize the deformation by rolling their shoulders toward the midline and slouching forward; thus, these psychosocial issues may need to be addressed foremost in those patients. Although most patients do not require psychotherapy, they should be provided with reassurance about the self-limited nature of the condition, encouragement to participate in social and physical activities, and counseling on lifestyle modifications.