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.^[1]This can be followed by fine-needle aspiration or breast biopsy, as the case merits.^{[2, 3]}

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.^[4] However, a study by Telegrafo et al in which ultrasonography was used to diagnosis and classify gynecomastia found the same results as when mammography was used, suggesting that ultrasonography can be employed as a primary imaging modality for determining the presence of gynecomastia and categorizing its shape.^[27]

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.^[28]

Treatment & Management

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