Treatment

Generally gynaecomastia is a self limited benign condition (1).

• reassurance and periodic follow-up are recommended in patients without an underlying pathology during appropriate work-up
• if a specific cause of gynecomastia can be identified, it should be addressed e.g. -
  • offending medications should be withdrawn (1)
    • a reduction in tenderness softening of the glandular tissue will be evident within 1 month of discontinuation of the drug but in long standing cases (more than 1 year) due to the presence of fibrosis, substantial regression (spontaneously or with medical therapy) is unlikely (2)
  • underlying disorders should be treated, especially if onset of gynaecomastia is recent. eg, hyperthyroidism (1)

Treatment should be initiated in patients with persistent gynaecomastia or if it is associated with pain or psychological distress (1). Available treatment options include:

• pharmacological
  • is beneficial when started early before development of fibrosis
  • treatment options include:
    • estrogen receptor modifiers - tamoxifen or raloxifene
    • dihydrotestosterone
    • danazol
    • clomiphene
    • aromatase inhibitors - testolactone and anastrozole (1)
    • a UK guidance (4) regarding hormonal treated has stated:
      • the patient must be informed that this treatment is off-licence
      • it is most effective for recent onset gynaecomastia, i.e. before gynaecomastia becomes fibrotic, and alleviates mastalgia, not always regression of the mass.
        • Tamoxifen 10mg PO OD: 3-9 months
        • Anastrozole 1mg PO OD: 3 months.
• surgical
  • aims of surgery includes surgery include removing abnormal breast tissue, restoring the normal male breast contour, and reducing pain (3)
  • surgical techniques used include:
    • subcutaneous mastectomy with or without associated liposuction
    • liposuction - if enlargement is purely due to excess fatty tissue (without substantial glandular hypertrophy)
  • the complications of surgery include haematoma, infection, scarring, sensory changes, breast asymmetry and a poor cosmetic result (3).

Reference:

• (1) Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc. 2009;84(11):1010-5.
• (2) Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med. 2007;357(12):1229-37.
• (3) Niewoehner CB, Schorer AE. Gynaecomastia and breast cancer in men. BMJ. 2008 Mar 29;336(7646):709-13.
• (4) Association of Breast Surgery Summary Statement (June 2019). Investigation and management of gynaecomastia in primary and secondary care.