Gynecomastia: Etiology, Evaluation, and Treatment Algorithm

Pathophysiology

Imbalance between estrogenic and androgenic stimulation of breast tissue. Can be physiological (neonatal, pubertal, aging) or pathological.

Common Causes

Evaluation

• History (meds, substances, symptoms), physical (true vs. pseudo-gynecomastia, testicular exam).
• Labs: T, LH, FSH, estradiol, β-hCG, TSH, LFTs, renal function, prolactin.
• Imaging if mass suspicious (US, mammogram).

Treatment

1. Address reversible cause (med change, treat underlying disease).
2. Observation for pubertal (resolves 6–24 months in 90%).
3. Medical (off-label): Tamoxifen 10–20 mg/day × 3–6 months, raloxifene, aromatase inhibitors – for painful/persistent.
4. Surgical: Subcutaneous mastectomy ± liposuction for established, fibrotic, or distressing cases.

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Category	Examples
Physiological	Neonatal (maternal hormones), pubertal (transient estradiol↑), aging (↓T, ↑aromatization, ↑SHBG)
Medications	Spironolactone, finasteride, cimetidine, ketoconazole, GnRH agonists, antipsychotics (risperidone), antidepressants, anabolic steroids, calcium channel blockers
Systemic disease	Cirrhosis, chronic kidney disease, hyperthyroidism, hypogonadism, testicular tumors, adrenal tumors, malnutrition/refeeding
Substances	Alcohol, marijuana, heroin, amphetamines, lavender/tea tree oil (prepubertal)