Gynaecomastia

Scope

  • Gynaecomastia in young men may be pubertal, physiological, or drug related. These patients do not need referral and need reassurance.
  • Gynaecomastia in older men – review medication as this is commonly a side effect of their treatment for another condition.

Red Flags

A 2WW referral should be made;
  • For male patients, aged 50 years and older with a unilateral, firm suspicious mass with or without;
    • nipple distortion or associated skin changes,
    • nipple discharge +/- mass,
    • axillary lymphadenopathy,
    • history of ionizing radiation,
    • family history of breast cancer
    • Klinefelter's syndrome

Investigations

Investigations in patients presenting with symptoms and/or signs suggestive of breast cancer, prior to referral, is not recommended.

Blood tests are not necessary in pubertal boys nor in men on medication associated with gynaecomastia

For those with soft swelling which is unlikely to be due to breast malignancy consider:

  • Bloods (FBC/LFT/U&E/Oestradiol/FSH/LH/Testosterone/Sex Hormone Binding Globulin and Prolactin)

Referral to endocrinology is recommended in the event of any abnormality of these hormone profiles; see table below.

  • If there is testicular pain or a mass, testicular ultrasound is indicated.
  • Chest X-ray should be performed if lung cancer or metastases are suspected.
  • Beta Human Chorionic Gonadotrophin, Alpha Fetoprotein and Lactate Dehydrogenase should also be checked as outlined in the table below.
Hormone test result Possible diagnoses
All normalIdiopathic gynaecomastia
Low Testosterone with elevated LH Primary hypogonadism; Klinefelter's syndrome
Low Testosterone with normal LH Pituitary/hypothalamic disease
Elevated Testosterone with elevated OestradiolAndrogen exposure; testicular tumour
Elevated Oestradiol with elevated SHBG Oestrogen exposure; testicular/adrenal tumour
Elevated DHEA Adrenal tumour
Elevated β-hCG Testicular/ectopic tumour
Elevated Prolactin Pituitary tumour; drug-related cause

Management

  • Gynaecomastia in young men may be:
    • pubertal (physiological),
    • drug related e.g. Spironolactone, Digoxin, Phenothiazines, Epilim, PPIs, Cimetidine, Finasteride, Anabolic steroids, Cannabis

Once non-breast malignancies have been excluded (see table above), these patients can be reassured and do not require referral

  • Gynaecomastia in older men:
    • review medication as this is commonly a side effect of their treatment for another condition. e.g. Spironolactone, Digoxin, Phenothiazines, Epilim, PPIs, Cimetidine, Finasteride
    • stop drugs and review when clinically appropriate

Drug treatment of Gynaecomastia

  • In patients with physiological gynaecomastia, especially adolescent boys, reassurance can be given that most cases are transitory, with more than 90% resolving within three years.
  • Medical management is associated with a high success rate and avoids surgical intervention. However, once fibrosis occurs, it is largely ineffective. For advice on prescribing, please request advice via the Pre-Choice Triage service on e-Referrals.

Referral

Referral Criteria

  • Gynaecomastia in young men (less than 50 years) may be:
    • pubertal or physiological in older men,
    • drug related e.g. Spironolactone, Digoxin, Phenothiazines, Epilim, PPIs, Cimetidine, Finasteride, Anabolic steroids, Cannabis

Once non-breast malignancies have been excluded (see table above), these patients can be reassured and managed in primary care as outlined in the Management section. For advice on prescribing, please request advice via the Pre-Choice Triage service on e-Referrals.


  • A 2WW referral should be made;
    • For male patients, aged 50 years and older with a unilateral, firm suspicious mass with or without;
    • nipple distortion or associated skin changes,
    • nipple discharge +/- mass,
    • axillary lymphadenopathy,
    • history of ionizing radiation,
    • family history of breast cancer
    • Klinefelter's syndrome

Referral instructions

  • The GP should use e-Referral Service to book the appointment

Service: Surgery – 2WW
Clinic type: 2WW Breast
Service: Two Week Wait Breast -RDE-RH8

  • Tell the patient the appointment details

Referral forms

Supporting Information

Patient Information

Breast Cancer Care

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: November 2020

Last updated: 05-11-2020

 

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