Gynecomastia Workup

  • Author: George Ansstas, MD; Chief Editor: George T Griffing, MD   more...
 
Updated: Apr 16, 2012
 

Approach Considerations

Patients with physiologic gynecomastia do not require further evaluation. Similarly, asymptomatic and pubertal gynecomastia do not require further tests and should be reevaluated in 6 months. Further evaluation is necessary in patients with the following:

  • Breast size greater than 5 cm (macromastia)
  • A lump that is tender, of recent onset, progressive, or of unknown duration
  • Signs of malignancy (eg, hard or fixed lymph nodes or positive lymph node findings)

A serum chemistry panel may be helpful in evaluating for renal or liver disease. Free or total testosterone, luteinizing hormone (LH), estradiol, and dehydroepiandrosterone sulfate levels are used to evaluate a patient with possible feminization syndrome. Obtain thyroid-stimulating hormone (TSH) and free thyroxine levels if hyperthyroidism is suspected.

Imaging studies

Order a mammogram if 1 or more features of breast cancer are apparent upon clinical examination.[14] This can be followed by fine-needle aspiration or breast biopsy, as the case merits.[15, 16]

Obtain a testicular ultrasonogram if the serum estradiol level is elevated and the clinical examination findings suggest the possibility of a testicular neoplasm.

Breast imaging, through mammography or ultrasonography, may be controversial, because gynecomastia is much more common than male breast cancer. The positive predictive value of imaging in males is 55% using mammography and 17% using ultrasonography.[17]

Histologic findings

Characteristic findings include proliferation of ductules and stroma (consisting of connective-tissue elements such as fibroblasts, collagen, and myofibroblasts) and occasional acini. Gynecomastia of short duration consists of a prominent ductular component with loose stroma. Long-standing gynecomastia consists of dense stroma with few ductules.

Vascular findings

Ramadan et al, assessing breast vascularity in 54 male patients, aged 11-27 years, with gynecomastia, concluded that vascular structures ought to be considered a component of gynecomastia. Using ultrasonographic scanning, the authors found a strong correlation between the progression of breast development and that of arterial and venous blood flow.[18]

Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

George Ansstas, MD  Instructor, Department of Internal Medicine, Washington University School of Medicine

George Ansstas, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Ansstas, MD  Resident Physician, Department of Internal Medicine, St Louis University Hospital

Disclosure: Nothing to disclose.

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Mark R Allee, MD Associate Professor, Department of Medicine, University of Oklahoma College of Medicine

Mark R Allee, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Mary Zoe Baker, MD Professor, Department of Medicine, Section of Endocrinology, Metabolism and Hypertension, University of Oklahoma College of Medicine; Medical Director, Medicine Specialty Clinic, General Medicine Clinic and Medicine Residents' Clinic, University of Oklahoma Physicians

Mary Zoe Baker, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Chemical Society, and American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References

  1. Glass AR. Gynecomastia. Endocrinol Metab Clin North Am. Dec 1994;23(4):825-37. [Medline].

  2. Braunstein GD. Gynecomastia. N Engl J Med. Feb 18 1993;328(7):490-5. [Medline].

  3. Den Hond E, Dhooge W, Bruckers L, et al. Internal exposure to pollutants and sexual maturation in Flemish adolescents. J Expo Sci Environ Epidemiol. Mar 3 2010;[Medline].

  4. Durmaz E, Ozmert EN, Erkekoglu P, et al. Plasma phthalate levels in pubertal gynecomastia. Pediatrics. Jan 2010;125(1):e122-9. [Medline].

  5. Mahoney CP. Adolescent gynecomastia. Differential diagnosis and management. Pediatr Clin North Am. Dec 1990;37(6):1389-404. [Medline].

  6. Mauras N. Treatment of adolescents with gynecomastia. J Pediatr. Apr 2005;146(4):576; author reply 576-7. [Medline].

  7. Ormandy CJ, Hall RE, Manning DL, et al. Coexpression and cross-regulation of the prolactin receptor and sex steroid hormone receptors in breast cancer. J Clin Endocrinol Metab. Nov 1997;82(11):3692-9. [Medline].

  8. Gutzman JH, Miller KK, Schuler LA. Endogenous human prolactin and not exogenous human prolactin induces estrogen receptor alpha and prolactin receptor expression and increases estrogen responsiveness in breast cancer cells. J Steroid Biochem Mol Biol. Jan 2004;88(1):69-77. [Medline].

  9. Tseng A Jr, Horning SJ, Freiha FS, Resser KJ, Hannigan JF Jr, Torti FM. Gynecomastia in testicular cancer patients. Prognostic and therapeutic implications. Cancer. Nov 15 1985;56(10):2534-8. [Medline].

  10. Shozu M, Sebastian S, Takayama K, et al. Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene. N Engl J Med. May 8 2003;348(19):1855-65. [Medline].

  11. Thompson DF, Carter JR. Drug-induced gynecomastia. Pharmacotherapy. Jan-Feb 1993;13(1):37-45. [Medline].

  12. Eckman A, Dobs A. Drug-induced gynecomastia. Expert Opin Drug Saf. Nov 2008;7(6):691-702. [Medline].

  13. Henley DV, Lipson N, Korach KS, Bloch CA. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med. Feb 1 2007;356(5):479-85. [Medline].

  14. 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].

  15. 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].

  16. 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].

  17. Carlson HE. Approach to the patient with gynecomastia. J Clin Endocrinol Metab. Jan 2011;96(1):15-21. [Medline].

  18. Ramadan SU, Gokharman D, Kacar M, et al. Assessment of vascularity with color Doppler ultrasound in gynecomastia. Diagn Interv Radiol. Mar 2010;16(1):38-44. [Medline]. [Full Text].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

  24. 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].

  25. Ridha H, Colville RJ, Vesely MJ. How happy are patients with their gynaecomastia reduction surgery?. J Plast Reconstr Aesthet Surg. Aug 28 2008;[Medline].

  26. 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].

  27. Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg. Jul 2009;124(1 Suppl):61e-68e. [Medline].

  28. El Noamani S, Thabet AM, Enab AA, et al. High Grade Gynecomastia: Surgical Correction and Potential Impact on Erectile Function. J Sex Med. Mar 2 2010;[Medline].

  29. Laituri CA, Garey CL, Ostlie DJ, et al. Treatment of adolescent gynecomastia. J Pediatr Surg. Mar 2010;45(3):650-4. [Medline].

  30. 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].

  31. Gruntmanis U, Braunstein GD. Treatment of gynecomastia. Curr Opin Investig Drugs. May 2001;2(5):643-9. [Medline].

 
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Adolescent gynecomastia.
Prominent areolae with dense subareolar ductal tissue.
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