Gynecomastia is the benign proliferation of male breast glandular tissue, resulting in breast enlargement. It can range from subclinical, barely palpable tissue to pronounced breast enlargement. Typically bilateral, gynecomastia may present with tenderness, and in some cases, galactorrhea.

Pathophysiology

Normal male breast development is hormonally regulated:

• Estrogens, growth hormone, corticosteroids: Stimulate ductal proliferation.

• Progesterone, prolactin: Stimulate alveolar lobule development.

Gynecomastia results from an imbalance between estrogenic and androgenic activity, often combined with increased prolactin. Etiologies include:

• Physiologic: Neonatal, pubertal, geriatric.

• Pathologic: Endocrine disorders, hepatic dysfunction, renal failure, hormone-secreting tumors, genetic syndromes.

• Drug-induced: Medications or substances affecting hormone synthesis, metabolism, or receptor activity.

Clinical History

• Onset, duration, and progression of breast enlargement.

• Associated breast symptoms: tenderness, pain, nipple discharge (color, consistency).

• Drug history: prescription, over-the-counter, herbal, and recreational substances.

• Associated systemic features: testicular pain/mass, erectile dysfunction, libido changes, hair loss patterns.

• Prior surgical interventions or radiation exposure.

Physical Examination

1. Breast inspection:

   • Symmetry, size, contour.

   • Skin changes: dimpling, ulceration, pigmentation, nipple retraction.

   • Palpation: firm nodules vs. glandular tissue, tenderness.

2. Genitourinary examination:

   • Testicular size, symmetry, consistency, nodules.

   • Penis evaluation: hypospadias, micropenis, or other abnormalities.

3. Systemic signs:

   • Evidence of liver disease, Cushingoid features, thyroid dysfunction, or genetic syndromes.

Differential Diagnosis & Medical Causes

Investigations

• Hormonal profile: Testosterone, estradiol, LH, FSH, prolactin, hCG, thyroid function.

• Imaging: Breast ultrasound or mammography if malignancy suspected; testicular ultrasound for tumors.

• Additional workup: Liver function tests, renal function, pituitary imaging if indicated.

Management

Non-pharmacologic:

• Observation for physiologic gynecomastia; may resolve spontaneously in adolescents or neonates.

• Cold compresses and analgesics for discomfort.

• Psychological support for body image concerns.

Pharmacologic:

• Selective estrogen receptor modulators (SERMs): Tamoxifen can reduce breast tissue size and tenderness.

• Aromatase inhibitors: Testolactone may reduce estrogen formation in select cases.

Surgical:

• Indicated if pharmacologic therapy fails, or if gynecomastia is severe, painful, or associated with malignancy.

• Options: subcutaneous mastectomy, liposuction-assisted mastectomy.

Special Considerations

• Pediatric patients: Neonatal galactorrhea resolves spontaneously; adolescent gynecomastia is usually transient.

• Geriatric patients: Consider polypharmacy, decreased testosterone levels, and comorbidities.

• Drug-induced gynecomastia may regress after discontinuation of the offending agent.

• Emotional and psychosocial counseling is essential for affected individuals.

References

1. Block, S. L. (2012). The possible link between gynecomastia, topical lavender, and tea tree oil. Pediatric Annals, 41, 56–58.

2. Deepinder, F., & Braunstein, G. D. (2012). Drug-induced gynecomastia: An evidence-based review. Expert Opinion on Drug Safety, 11, 779–795.

3. Braunstein, G. D. (2007). Gynecomastia. New England Journal of Medicine, 357(12), 1229–1237.

4. Niewoehner, C. B., & Schorer, A. (2008). Gynecomastia in adolescents. American Family Physician, 77(5), 635–640.