eMedicine Specialties > Endocrinology > Gonads
Gynecomastia: Treatment & Medication
Updated: Sep 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Generally, no treatment is required for physiologic gynecomastia.
- A major factor that should influence the initial choice of therapy is the duration of gynecomastia. It is unlikely that any medical therapy will result in significant regression in the late fibrotic stage (a duration of 12 mo or longer). As a result, medical therapies, if used, should be tried early in the condition's course.
- Pubertal gynecomastia resolves spontaneously within several weeks to 3 years in approximately 90% of patients. Breasts greater than 4 cm in diameter may not completely regress.
- Identifying and managing an underlying primary disorder often alleviates breast enlargement.
- If hypogonadism (primary or secondary) is the cause of gynecomastia, parenteral or transdermal testosterone replacement therapy is instituted. However, testosterone does have the potential to exacerbate gynecomastia through the aromatization of the exogenous hormone into estradiol.
- For patients with idiopathic gynecomastia or with residual gynecomastia after treatment of the primary cause, medical or surgical treatment may be considered.
- Clomiphene,10 an antiestrogen, can be administered on a trial basis at a dose of 50-100 mg per day for up to 6 months. Approximately 50% of patients achieve partial reduction in breast size, and approximately 20% of patients note complete resolution. Adverse effects, while rare, include visual problems, rash, and nausea.
- Tamoxifen, an estrogen antagonist, is effective for recent-onset and tender gynecomastia when used in doses of 10-20 mg twice a day.11 Up to 80% of patients report partial to complete resolution. Tamoxifen is typically used for 3 months before referral to a surgeon. Nausea and epigastric discomfort are the main adverse effects.12
- Other drugs used less frequently include danazol and testolactone13 :
- Danazol, a synthetic derivative of testosterone, inhibits pituitary secretion of LH and follicle-stimulating hormone (FSH), which decreases estrogen synthesis from the testicles. The dose used for gynecomastia is 200 mg twice a day. Complete resolution of breast enlargement has been reported in 23% of cases. Adverse effects include weight gain, acne, muscle cramps, fluid retention, nausea, and abnormal liver function test results.
- Testolactone, a peripheral aromatase inhibitor, has been used with varying success rates in doses of 150 mg 3 times per day for 6 months. Nausea, vomiting, edema, and worsening of hypertension have been reported with its use.
Surgical Care
- Reduction mammoplasty is considered for patients with macromastia or long-standing gynecomastia or in persons in whom medical therapy has failed.1 It is also considered for cosmetic reasons (and for accompanying psychosocial reasons).14,15,16,17,18
- If surgery is necessary for patients with pseudogynecomastia, liposuction may be warranted.
- More extensive plastic surgery may be required in patients with marked gynecomastia or who have developed excessive sagging of the breast tissue due to weight loss.
- Complications of surgery include sloughing of tissue due to a compromised blood supply, contour irregularity, hematoma or seroma formation, and permanent numbness in the nipple-areolar area.
- A Chinese study indicated that endoscopic subcutaneous mastectomy, without skin excision, could be an effective treatment for gynecomastia.19 In a report on the procedure's use in 65 patients (125 breasts) with gynecomastia, grade IIB or III, the authors stated that only a few operative complications occurred, including 2 cases of partial nipple necrosis and 1 case of subcutaneous hydrops. They also reported that postsurgical chest contour was satisfactory in all patients, and that no recurrences were seen during the 3- to 36-month follow-up period.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Steroid hormones
These agents are used to inhibit the effects of estrogen.1,10,11,12,13,20
Testosterone (Androderm, Andropository)
Predominant male sex hormone used for replacement therapy in male hypogonadism.
Adult
200-300 mg (testosterone enanthate) IM q2-4wk
4-6 mg (scrotal patch) transdermally qd
5 mg (nonscrotal skin patch) transdermally qd
Pediatric
10-25 mg testosterone propionate 2-3 times/wk
May increase cyclosporine levels and cause toxicity; may increase PT and risk of bleeding in patients receiving oral anticoagulants
Documented hypersensitivity, breast cancer, prostate cancer, severe cardiac dysfunction, hepatic or renal disease
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Prostate hypertrophy or cancer; oligospermia (with prolonged use or excessive dosage); may accelerate bone maturation
Clomiphene (Clomid, Milophene, Serophene)
Stimulates release of pituitary gonadotropins.
Adult
50-100 mg PO qd; not to exceed 6 mo
Pediatric
Not established
Danazol may reduce response
Documented hypersensitivity, liver disease, abnormal uterine bleeding, uncontrolled thyroid or adrenal dysfunction, pituitary tumor and risk of hemorrhage into tumor
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Perform ophthalmic evaluation if patient develops visual symptoms
Tamoxifen (Nolvadex)
Competitively binds to estrogen receptor, producing a nuclear complex that decreases DNA synthesis and inhibits estrogen effects.
Adult
10-20 mg PO bid
Pediatric
Not established
May exacerbate hepatotoxic effects of allopurinol; may increase cyclosporine serum levels; increases anticoagulant effects of warfarin; aminoglutethimide reduces serum concentration; cyclophosphamide, methotrexate, and 5-FU increase thrombotic risk
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in leukopenia, thrombocytopenia, and hyperlipidemia; decreased visual acuity, corneal changes, and retinopathy may occur with >1 y of use; may induce ovulation
Danazol (Danocrine)
Synthetic steroid analog with strong antigonadotropic activity (inhibits LH and FSH) and weak androgenic action.
Adult
200 mg PO bid for 3 mo
Pediatric
Not established
May increase risk of carbamazepine and cyclosporine toxicity; may increase PT in patients receiving oral anticoagulants; inhibits response to clomiphene
Documented hypersensitivity, seizure disorders, renal or hepatic insufficiency, lactation, conditions influenced by edema
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Increased risk of bleeding in hemophilic patients; risk of fluid retention, especially with overt CHF or renal failure; caution in seizure disorders
Testolactone (Teslac)
Synthetic peripheral aromatase inhibitor that blocks production of estradiol and estrone from testosterone and androstenedione.
Adult
150 mg PO tid for up to 6 mo
Pediatric
Not established
May alter PT in patients taking oral anticoagulants
Documented hypersensitivity, males with breast cancer
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor liver function; edema may develop in patients with CHF or liver or renal insufficiency; may worsen hypertension; may exacerbate epilepsy and migraine; monitor INR closely in patients taking warfarin (possibly adjust dose)
More on Gynecomastia |
| Overview: Gynecomastia |
| Differential Diagnoses & Workup: Gynecomastia |
 Treatment & Medication: Gynecomastia |
| Follow-up: Gynecomastia |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Glass AR. Gynecomastia. Endocrinol Metab Clin North Am. Dec 1994;23(4):825-37. [Medline].
Braunstein GD. Gynecomastia. N Engl J Med. Feb 18 1993;328(7):490-5. [Medline].
Mahoney CP. Adolescent gynecomastia. Differential diagnosis and management. Pediatr Clin North Am. Dec 1990;37(6):1389-404. [Medline].
Mauras N. Treatment of adolescents with gynecomastia. J Pediatr. Apr 2005;146(4):576; author reply 576-7. [Medline].
Thompson DF, Carter JR. Drug-induced gynecomastia. Pharmacotherapy. Jan-Feb 1993;13(1):37-45. [Medline].
Eckman A, Dobs A. Drug-induced gynecomastia. Expert Opin Drug Saf. Nov 2008;7(6):691-702. [Medline].
Mathew J, Perkins GH, Stephens T, et al. Primary breast cancer in men: clinical, imaging, and pathologic findings in 57 patients. AJR Am J Roentgenol. Dec 2008;191(6):1631-9. [Medline].
Volpe CM, Raffetto JD, Collure DW, et al. Unilateral male breast masses: cancer risk and their evaluation and management. Am Surg. Mar 1999;65(3):250-3. [Medline].
MacIntosh RF, Merrimen JL, Barnes PJ. Application of the probabilistic approach to reporting breast fine needle aspiration in males. Acta Cytol. Sep-Oct 2008;52(5):530-4. [Medline].
Plourde PV, Kulin HE, Santner SJ. Clomiphene in the treatment of adolescent gynecomastia. Clinical and endocrine studies. Am J Dis Child. Nov 1983;137(11):1080-2. [Medline].
Bedognetti D, Rubagotti A, Conti G, et al. An open, randomised, multicentre, phase 3 trial comparing the efficacy of two tamoxifen schedules in preventing gynaecomastia induced by bicalutamide monotherapy in prostate cancer patients. Eur Urol. May 19 2009;[Medline].
Boccardo F, Rubagotti A, Battaglia M, et al. Evaluation of tamoxifen and anastrozole in the prevention of gynecomastia and breast pain induced by bicalutamide monotherapy of prostate cancer. J Clin Oncol. Feb 1 2005;23(4):808-15. [Medline].
Jones DJ, Holt SD, Surtees P, et al. A comparison of danazol and placebo in the treatment of adult idiopathic gynaecomastia: results of a prospective study in 55 patients. Ann R Coll Surg Engl. Sep 1990;72(5):296-8. [Medline]. [Full Text].
Colombo-Benkmann M, Buse B, Stern J, et al. Indications for and results of surgical therapy for male gynecomastia. Am J Surg. Jul 1999;178(1):60-3. [Medline].
Davanco RA, Sabino Neto M, Garcia EB, et al. Quality of life in the surgical treatment of gynecomastia. Aesthetic Plast Surg. Oct 25 2008;[Medline].
Ridha H, Colville RJ, Vesely MJ. How happy are patients with their gynaecomastia reduction surgery?. J Plast Reconstr Aesthet Surg. Aug 28 2008;[Medline].
Benito-Ruiz J, Raigosa M, Manzano M, et al. Assessment of a suction-assisted cartilage shaver plus liposuction for the treatment of gynecomastia. Aesthet Surg J. Jul-Aug 2009;29(4):302-9. [Medline].
Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg. Jul 2009;124(1 Suppl):61e-68e. [Medline].
Fan L, Yang X, Zhang Y, et al. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: a report of 65 cases. Surg Laparosc Endosc Percutan Tech. Jun 2009;19(3):e85-90. [Medline].
Gruntmanis U, Braunstein GD. Treatment of gynecomastia. Curr Opin Investig Drugs. May 2001;2(5):643-9. [Medline].
Braunstein GD, Glassman HA. Gynecomastia. Curr Ther Endocrinol Metab. 1997;6:401-4. [Medline].
Neuman JF. Evaluation and treatment of gynecomastia. Am Fam Physician. Apr 1997;55(5):1835-44, 1849-50. [Medline].
Further Reading
Related eMedicine topics:
Breast Embryology
Breast Reduction, Liposuction Only
Disorders of the Breast
Gynecomastia [Plastic Surgery]
Klinefelter Syndrome
Prepubertal Testicular and Paratesticular Tumors
Clinical guidelines:
Practice advisory on liposuction. American Society of Plastic Surgeons - Medical Specialty Society. 2004 Apr. 13 pages. NGC:004125
Clinical trials:
Adaptation Among Adolescents and Adults With Klinefelter Syndrome
Keywords
gynecomastia, male breast, male breasts, gynecomastia surgery, male breast reduction, male breast cancer, gynecomastia treatment, gynecomastia cure, gynaecomastia, pseudogynecomastia, enlargement of the male breast, male breast surgery, male breast reduction surgery, breast lump, physiologic gynecomastia, pathologic gynecomastia, testicular neoplasm, lipomastia, macromastia, pubertal gynecomastia, florid gynecomastia, fibrous gynecomastia, feminization, granular glandular tissue, breast cancer, hypogonadism, Kallmann syndrome, Klinefelter syndrome, congenital anorchia, testicular trauma, testicular torsion, viralorchitis, pituitary tumor, hypopituitarism, renal failure, kidney failure, androgen insensitivity syndrome, 5-alpha-reductase deficiency syndrome, altered estrogen-androgen balance, mumps, sexual dysfunction, infertility, chronic liver disease, thyroid disease, renal disease, eunuchoid habitus, testicular tumors, extragonadal germ cell tumors, malnutrition, hyperthyroidism, adrenal tumors, familial gynecomastia
