Gynecomastia resident survival guide

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Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]


Gynecomastia is a benign male breast enlargement. It can be physiological, such as in infancy, puberty and old age or pathological, which is due to obesity, steroid use, pharmacologic agents, medical conditions including chronic liver and renal failure or hypogonadism. The diagnosis is primarily clinical.Laboratory investigations done are blood hormone levels, renal function tests and liver function tests and imaging such as ultrasound or mammography. Treatment is aimed at treating the underlying condition.Pharmacologic options include SERMs, androgens and aromatase inhibitors. Surgery is usually reserved for patients with either psychological stresses, extensive gynecomastia or failure of medical treatment.


Life-threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no known life-threatening causes of gynecomastia.

Common Causes

Less Common Causes[10]

To review a complete list of gynecomastia causes, click here.

Genetic Causes


Shown below is an algorithm summarizing the diagnosis of gynecomastia according to the Endocrine Society and European Association of Andrology. [11] [12] ("Gynecomastia - American Family Physician".)

Gynecomastia (Breast tissue enlargement)
Physiological; resolves within 4 weeks
Drugs (see list above)
Discontinue implicated drug
Weight loss
Features of malignancy
Mammography; Breast USG; Biopsy
Testicular mass
Testicular USG
True Gynecomastia
Luteinizing hormone (LH)
ProlactinFollicle Stimulating Hormone (FSH)
Beta- hCG
Thyroid function tests
Liver function tests
Renal function tests
If deranged,correct underlying disease
• Low testosterone
• High LH
• Low testosterone
• Low LH
• High Estradiol
• Low LH
• High Prolactin
• High beta-hCG
Primary hypogonadism
Secondary hypogonadism
Testicular USG
MRI head for
Pituitary adenoma
Empty sella
Testicular USG
Sertoli or Leydig cell tumor
Evaluate for
Adrenal neoplasm
• Exogenous estrogen use
Obesity (excess aromatase)
Germ cell tumor
If normal; evaluate for
• Extragonadal germ cell tumor
• Non-trophoblastic beta hCG secreting tumors


Evaluation of Gynecomastia

❑ Obtain a detailed history
❑ Examine the breasts to rule out malignancy
❑ Stop drugs that may cause gynecomastia

Obtain laboratory tests

❑ Beta hCG
Luteinizing hormone (LH)
Follicle Stimulating Hormone (FSH)

Treat underlying disorders

❑ Follow the algorithm for diagnosis to treat the underlying disorder or tumor

Shown below is an algorithm summarizing the treatment of gynecomastia according to the Endocrine Society and European Association of Andrology. [11] [12] ("Gynecomastia - American Family Physician".)

• Discontinue the causative drug
• Treat the underlying cause
Observe for 3 months
If pain/tenderness; proceed with medical therapy
Androgens and testosterone
Aromatase inhibitors in prostate cancer
Selective estrogen receptor modulators (SERMs)
Tamoxifen (10-20 mg once daily for 3-9 months)
Raloxifene (60 mg once daily for 3-9 months)
Surgery if:
• Persistent for > 12 months
Fibrotic gynecomastia
• Failure of medical therapy



  • Do not treat the gynecomastia without evaluating for an underlying cause.


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  2. 2.0 2.1 2.2 Braunstein GD (2007). "Clinical practice. Gynecomastia". N Engl J Med. 357 (12): 1229–37. doi:10.1056/NEJMcp070677. PMID 17881754.
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  5. Vandeven H, Pensler J. PMID 28613563. Missing or empty |title= (help)
  6. 6.0 6.1 De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Swerdloff RS, Ng J. PMID 25905330. Vancouver style error: initials (help); Missing or empty |title= (help)
  7. Ladizinski B, Lee KC, Nutan FN, Higgins HW, Federman DG (2014). "Gynecomastia: etiologies, clinical presentations, diagnosis, and management". South Med J. 107 (1): 44–9. doi:10.1097/SMJ.0000000000000033. PMID 24389786.
  8. Wagner MS, Wajner SM, Maia AL (2008). "The role of thyroid hormone in testicular development and function". J Endocrinol. 199 (3): 351–65. doi:10.1677/JOE-08-0218. PMC 2799043. PMID 18728126.
  9. Cavanaugh J, Niewoehner CB, Nuttall FQ (1990). "Gynecomastia and cirrhosis of the liver". Arch. Intern. Med. 150 (3): 563–5. PMID 2310274.
  10. 10.0 10.1 Shozu M, Sebastian S, Takayama K, Hsu WT, Schultz RA, Neely K; et al. (2003). "Estrogen excess associated with novel gain-of-function mutations affecting the aromatase gene". N Engl J Med. 348 (19): 1855–65. doi:10.1056/NEJMoa021559. PMID 12736278.
  11. 11.0 11.1 Kanakis GA, Nordkap L, Bang AK, Calogero AE, Bártfai G, Corona G; et al. (2019). "EAA clinical practice guidelines-gynecomastia evaluation and management". Andrology. 7 (6): 778–793. doi:10.1111/andr.12636. PMID 31099174.
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