Gynecomastia: Causes, Evaluation, and When to Seek Treatment

Gynecomastia is benign proliferation of male breast glandular tissue (≥2 cm subareolar). It affects 30–65% of males at some life stage. Distinct from pseudogynecomastia (fat only).

Physiologic Peaks

• Neonatal: Maternal estrogen; resolves in weeks
• Puberty: 50–60% of boys; transient (6–18 months); reassurance usually sufficient
• Aging: >50 years; ↑ body fat (aromatase), ↓ testosterone, medications

Pathologic Causes (If Persistent, Asymmetric, Painful, or Outside Physiologic Windows)

Evaluation

1. History: onset, duration, medications, substances, systemic symptoms
2. Exam: glandular vs. fatty; symmetry; testicular exam; lymph nodes; liver
3. Labs if indicated: Testosterone, LH, FSH, estradiol, β-hCG, TSH, LFTs, renal, prolactin
4. Imaging: Testicular US if mass; mammography if suspicious

Treatment

• Observation: Physiologic, <1 year, <4 cm, asymptomatic
• Treat underlying cause: Stop offending drug, treat endocrine disorder
• Medical (early, <1 year, tender): Tamoxifen 10–20 mg/day × 3–6 mo; raloxifene; aromatase inhibitors
• Surgical: Persistent >1 year, >4 cm, painful, psychologic distress. Subcutaneous mastectomy ± liposuction

Most gynecomastia is benign and self-limited. Evaluation excludes serious causes; treatment targets persistence or distress.

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Category	Examples
Hormonal	Testicular tumors (Leydig, Sertoli), adrenal tumors, hyperthyroidism, pituitary adenoma, liver cirrhosis (↓ estrogen clearance), kidney failure
Medications (20–25% of cases)	Spironolactone, finasteride, cimetidine, ketoconazole, GnRH analogs, anti-androgens, some antipsychotics, risperidone, calcium channel blockers, isoniazid
Substances	Alcohol, marijuana, heroin, anabolic steroids (withdrawal)
Genetic	Klinefelter (XXY), aromatase excess, androgen insensitivity