Management of gynecomastia
- Glenn D Braunstein, MD
Glenn D Braunstein, MD
- Professor of Medicine Emeritus, David Geffen School of Medicine at UCLA
- Bradley D Anawalt, MD
Bradley D Anawalt, MD
- Chief of Medicine, University of Washington Medical Center
- Professor and Vice Chair of Medicine
- University of Washington
Gynecomastia, a benign proliferation of the glandular tissue of the male breast, is caused by an increase in the ratio of estrogen to androgen activity. It is categorized as physiologic (occurring normally during infancy, puberty, and older age) or pathologic (due to drugs or disorders such as androgen deficiency, testicular tumors, hyperthyroidism, and chronic kidney disease). In adult men seeking consultation for gynecomastia, approximately 40 percent of cases of gynecomastia are due to persistent pubertal gynecomastia or medications and 25 percent are idiopathic (table 1) .
True gynecomastia should be differentiated from pseudogynecomastia, which refers to fat deposition without glandular proliferation. Gynecomastia must also be differentiated from breast carcinoma, which is far less common.
The management of gynecomastia will be reviewed here. An overview of gynecomastia in children and adolescents and the epidemiology, causes, and evaluation of gynecomastia in adults are discussed separately. (See "Gynecomastia in children and adolescents" and "Epidemiology, pathophysiology, and causes of gynecomastia" and "Clinical features, diagnosis, and evaluation of gynecomastia in adults".)
The management of gynecomastia depends upon its etiology, duration, severity, and the presence or absence of tenderness.
●A careful breast examination is the first step to distinguishing true gynecomastia (enlargement of the glandular tissue) from pseudogynecomastia (excessive adipose tissue) (figure 1). Additional details on the breast examination and evaluation of the patient with gynecomastia are reviewed separately. (See "Clinical features, diagnosis, and evaluation of gynecomastia in adults", section on 'Evaluation'.)
- Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med 2007; 357:1229.
- TREVES N. Gynecomastia; the origins of mammary swelling in the male: an analysis of 406 patients with breast hypertrophy, 525 with testicular tumors, and 13 with adrenal neoplasms. Cancer 1958; 11:1083.
- Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc 2009; 84:1010.
- Gruntmanis U, Braunstein GD. Treatment of gynecomastia. Curr Opin Investig Drugs 2001; 2:643.
- Gikas P, Mokbel K. Management of gynaecomastia: an update. Int J Clin Pract 2007; 61:1209.
- Dobs AS, Meikle AW, Arver S, et al. Pharmacokinetics, efficacy, and safety of a permeation-enhanced testosterone transdermal system in comparison with bi-weekly injections of testosterone enanthate for the treatment of hypogonadal men. J Clin Endocrinol Metab 1999; 84:3469.
- Testosterone treatment of men with alcoholic cirrhosis: a double-blind study. The Copenhagen Study Group for Liver Diseases. Hepatology 1986; 6:807.
- Kuhn JM, Roca R, Laudat MH, et al. Studies on the treatment of idiopathic gynaecomastia with percutaneous dihydrotestosterone. Clin Endocrinol (Oxf) 1983; 19:513.
- Eberle AJ, Sparrow JT, Keenan BS. Treatment of persistent pubertal gynecomastia with dihydrotestosterone heptanoate. J Pediatr 1986; 109:144.
- Lawrence SE, Faught KA, Vethamuthu J, Lawson ML. Beneficial effects of raloxifene and tamoxifen in the treatment of pubertal gynecomastia. J Pediatr 2004; 145:71.
- Parker LN, Gray DR, Lai MK, Levin ER. Treatment of gynecomastia with tamoxifen: a double-blind crossover study. Metabolism 1986; 35:705.
- McDermott MT, Hofeldt FD, Kidd GS. Tamoxifen therapy for painful idiopathic gynecomastia. South Med J 1990; 83:1283.
- Ting AC, Chow LW, Leung YF. Comparison of tamoxifen with danazol in the management of idiopathic gynecomastia. Am Surg 2000; 66:38.
- Khan HN, Rampaul R, Blamey RW. Management of physiological gynaecomastia with tamoxifen. Breast 2004; 13:61.
- Hanavadi S, Banerjee D, Monypenny IJ, Mansel RE. The role of tamoxifen in the management of gynaecomastia. Breast 2006; 15:276.
- Braunstein GD. Aromatase and gynecomastia. Endocr Relat Cancer 1999; 6:315.
- Cordova A, Moschella F. Algorithm for clinical evaluation and surgical treatment of gynaecomastia. J Plast Reconstr Aesthet Surg 2008; 61:41.
- American Society of Plastic Surgeons 2015 Plastic Surgery Statistics. https://www.plasticsurgery.org/news/plastic-surgery-statistics (Accessed on February 06, 2017).
- Gioffrè Florio MA, Alfio AR, Famà F, et al. [Evaluation of complications and long-term results after surgery for gynaecomastia]. Chir Ital 2004; 56:113.
- El-Khatib HA. A single stage liposuction and dermopexy for grade 3b and grade 4 pseudogynecomastia after massive weight loss: an observational study. Int J Surg 2007; 5:155.
- Tashkandi M, Al-Qattan MM, Hassanain JM, et al. The surgical management of high-grade gynecomastia. Ann Plast Surg 2004; 53:17.
- Steele SR, Martin MJ, Place RJ. Gynecomastia: complications of the subcutaneous mastectomy. Am Surg 2002; 68:210.
- Mentz HA, Ruiz-Razura A, Newall G, et al. Correction of gynecomastia through a single puncture incision. Aesthetic Plast Surg 2007; 31:244.
- Lapid O, Jolink F, Meijer SL. Pathological findings in gynecomastia: analysis of 5113 breasts. Ann Plast Surg 2015; 74:163.
- Di Lorenzo G, Autorino R, Perdonà S, De Placido S. Management of gynaecomastia in patients with prostate cancer: a systematic review. Lancet Oncol 2005; 6:972.
- Chang A, Yeap B, Davis T, et al. Double-blind, randomized study of primary hormonal treatment of stage D2 prostate carcinoma: flutamide versus diethylstilbestrol. J Clin Oncol 1996; 14:2250.
- Dobs A, Darkes MJ. Incidence and management of gynecomastia in men treated for prostate cancer. J Urol 2005; 174:1737.
- Schröder FH, Collette L, de Reijke TM, Whelan P. Prostate cancer treated by anti-androgens: is sexual function preserved? EORTC Genitourinary Group. European Organization for Research and Treatment of Cancer. Br J Cancer 2000; 82:283.
- Dicker AP. The safety and tolerability of low-dose irradiation for the management of gynaecomastia caused by antiandrogen monotherapy. Lancet Oncol 2003; 4:30.
- Di Lorenzo G, Perdonà S, De Placido S, et al. Gynecomastia and breast pain induced by adjuvant therapy with bicalutamide after radical prostatectomy in patients with prostate cancer: the role of tamoxifen and radiotherapy. J Urol 2005; 174:2197.
- Perdonà S, Autorino R, De Placido S, et al. Efficacy of tamoxifen and radiotherapy for prevention and treatment of gynaecomastia and breast pain caused by bicalutamide in prostate cancer: a randomised controlled trial. Lancet Oncol 2005; 6:295.
- 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 2005; 23:808.
- Fradet Y, Egerdie B, Andersen M, et al. Tamoxifen as prophylaxis for prevention of gynaecomastia and breast pain associated with bicalutamide 150 mg monotherapy in patients with prostate cancer: a randomised, placebo-controlled, dose-response study. Eur Urol 2007; 52:106.
- 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 2010; 57:238.
- Serretta V, Altieri V, Morgia G, et al. A randomized trial comparing tamoxifen therapy vs. tamoxifen prophylaxis in bicalutamide-induced gynecomastia. Clin Genitourin Cancer 2012; 10:174.
- Tyrrell CJ, Payne H, Tammela TL, et al. Prophylactic breast irradiation with a single dose of electron beam radiotherapy (10 Gy) significantly reduces the incidence of bicalutamide-induced gynecomastia. Int J Radiat Oncol Biol Phys 2004; 60:476.
- Widmark A, Fosså SD, Lundmo P, et al. Does prophylactic breast irradiation prevent antiandrogen-induced gynecomastia? Evaluation of 253 patients in the randomized Scandinavian trial SPCG-7/SFUO-3. Urology 2003; 61:145.
- Chou JL, Easley JD, Feldmeier JJ, et al. Effective radiotherapy in palliating mammalgia associated with gynecomastia after DES therapy. Int J Radiat Oncol Biol Phys 1988; 15:749.
- Viani GA, Bernardes da Silva LG, Stefano EJ. Prevention of gynecomastia and breast pain caused by androgen deprivation therapy in prostate cancer: tamoxifen or radiotherapy? Int J Radiat Oncol Biol Phys 2012; 83:e519.
- Tunio MA, Al-Asiri M, Al-Amro A, et al. Optimal prophylactic and definitive therapy for bicalutamide-induced gynecomastia: results of a meta-analysis. Curr Oncol 2012; 19:e280.
- GENERAL PRINCIPLES
- APPROACH TO MANAGEMENT
- Stop offending drugs
- Observation only
- Treat underlying condition
- Pharmacologic therapy
- - Androgens
- - Selective estrogen receptor modulators (SERMs)
- - Aromatase inhibitors
- - Procedure
- - Outcome
- - Pathology
- Men with prostate cancer
- - Tamoxifen
- - Anastrozole
- - Radiotherapy
- - Tamoxifen versus radiotherapy
- - Surgical intervention
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS