GP management of gynaecomastia

How to examine and manage gynaecomastia in primary care. By Dr Kamilla Porter

Gynaecomastia can occur at any age and can be physiological or pathological (Photograph: SPL)
Gynaecomastia can occur at any age and can be physiological or pathological (Photograph: SPL)

Gynaecomastia is defined as the benign enlargement of male breast tissue, where firm subareolar  gland and ductal tissue will be palpable on examination, as opposed to breast enlargement caused by excess adipos e tis sue, which is referred to as pseudogynaecomastia.

 Gynaecomastia is common, with an incidence of more than 30%. It can occur at any age and may be physiological or pathological (see box below).

1. Physiological gynaecomastia
Prominent breast tissue in newborn males is extremely common, resulting from transfer of maternal estrogens, and can last several weeks.

About 60% of boys up to the age of 14 years have gynaecomastia which may affect one breast more than the other; by age 20, prevalence is 19%.1

Gynaecomastia is more common in men aged over 50, owing to the general decline in testosterone levels and a tendency towards weight gain in later life. In overweight men, breast tissue is stimulated by excess estrogen resulting from the conversion of testosterone to estradiol by the enzyme aromatase found in adipose tissue.

HORMONE TEST RESULT POSSIBLE DIAGNOSES
Hormone test result Possible diagnoses
All normal Idiopathic gynaecomastia
Low testosterone with elevated LH Primary hypogonadism; Klinefelter’s syndrome
Low testosterone with normal LH Pituitary/hypothalamic disease
Elevated testosterone with elevated estradiol Androgen exposure; testicular tumour
Elevated estradiol with elevated SHBG Estrogen exposure; testicular/adrenal tumour
Elevated DHEA Adrenal tumour
Elevated beta-hCG Testicular/ectopic tumour
Elevated prolactin Pituitary tumour; drug-related cause

 

2.Pathological gynaecomastia
Any condition or medication associated with low levels of testosterone (whether true reduction or due to high SHBG levels), significant conversion of testosterone to estrogen, or raised estrogen levels can result in gynaecomastia.

3. Symptoms and signs
Being aware of the causes of gynaecomastia will assist with appropriate history-taking and examination. It is important to ascertain the duration and course of symptoms, and note any history of sexual dysfunction as well as medications and any recreational drugs, especially alcohol (as a risk factor for cirrhosis) and anabolic steroids.

Consider the latter cause in a young man whose family report changes in behaviour and character. A rapid enlargement of breast tissue with no causative drugs would raise the suspicion of a hormone-secreting tumour.

Gynaecomastia is often asymptomatic but occasionally, men complain of irritation and some chafing of the breast and less commonly, of tenderness.

Ideally, breast examination should be carried out with the patient supine. Thumb and forefinger should be placed over the outer and inner breast margins and brought together in a pinching movement. This will result in a disc of breast tissue under the nipple and areola area. A diameter of under 2cm is considered within normal limits; above 2cm is consistent with the definition of gynaecomastia.

A general physical examination should also be undertaken to look for signs of hyperthyroidism, chronic liver disease and hypogonadism, and include measurement of BMI. Testicular examination should be done to assess size, because small testicles suggest hypogonadism, and to check for masses or abnormal consistency, suggestive of testicular cancer.

Gynaecomastia is usually bilateral and although about 10% of cases can involve just one breast, always consider the possibility of breast cancer in a unilateral presentation. If an unusual mass, distorted nipple or areola, skin abnormality or axillary lymphadenopathy are found, the patient should be referred urgently to the breast cancer clinic.

4. Investigations
Further investigation will depend on history and examination findings. Gynaecomastia is often an incidental finding on examination, particularly in overweight older patients, and in general, such patients do not require further evaluation.2

Blood tests are not necessary in pubertal boys or in men on medications associated with gynaecomastia. However, if the underlying cause is not obvious, appropriate baseline blood tests would include TFT, U&Es and LFTs. If these are normal, consider a hormone blood screen, which might include testosterone, LH, FSH, estradiol, beta-hCG, alpha-fetoprotein, SHBG, prolactin and dehydroepiandrosterone (DHEA); see table for an interpretation of results.

Mammography will not be required unless cancerous changes are suspected. Breast ultrasound may be undertaken if surgery is planned, to distinguish adipose tissue from gynaecomastia.

If there is testicular pain or a mass, testicular ultrasound is indicated and chest X-ray should be performed if lung cancer is suspected.

Depending on the hormonal profile, chromosomal karyotyping may be carried out. A hard irregular breast mass, nipple discharge, skin abnormality or chest wall mass all warrant a core biopsy.

Key points
  • Ascertain the duration and course of symptoms.
  • Breast examination should be performed with the patient supine.
  • Mammography is not required unless cancerous changes are suspected.
  •  Do not underestimate the impact of gynaecomastia on a patient's social and personal life.

5. Management
If the underlying cause is still unclear after primary care investigations, consider referring the patient to the breast clinic. A quarter of cases turn out to be idiopathic.

In drug-induced gynaecomastia, the offending agent should be withdrawn. Where an underlying disorder has been identified, treating the condition should result in resolution of the gynaecomastia, especially if onset is recent.

In patients with physiological gynaecomastia, especially adolescent boys, reassurance can be given that most cases are transitory, with more than 90% resolving within three years. For those who remain distressed by their symptoms despite reassurance, tamoxifen 10mg daily for six months could be of benefit. However, it is important to inform patients that this is an unlicensed use.

The impact of gynaecomastia on a patient's social and personal life should not be underestimated. Most regions now have stringent local guidelines limiting cosmetic procedures on the NHS, but where a patient experiences significant pain or profound psychological distress, surgical removal of breast tissue may be undertaken.

Surgical removal may involve liposuction or subcutaneous mastectomy. The risks of surgery include haematoma, infection, scarring, sensory changes, breast asymmetry and a poor cosmetic result.

  • Dr Porter is a GP in Rochford, Essex

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

References
1. Niewoehner CB, Schorer AE. Gynaecomastia and breast cancer in men. BMJ 2008; 336: 709-13.

2. Best Practice: gynaecomastia. www.bestpractice.bmj.com; last updated September 2011.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Before commenting please read our rules for commenting on articles.

If you see a comment you find offensive, you can flag it as inappropriate. In the top right-hand corner of an individual comment, you will see 'flag as inappropriate'. Clicking this prompts us to review the comment. For further information see our rules for commenting on articles.

comments powered by Disqus