Gynaecomastia ✅
🚨 Male breast masses in older men must be considered malignant until proven otherwise → urgent referral to a breast clinic according to NICE suspected cancer referral guidance.
Gynaecomastia is the benign proliferation of glandular breast tissue in males and may be physiological, drug-induced, or secondary to systemic disease.
📖 Overview
- Gynaecomastia: benign enlargement of male glandular breast tissue (distinct from fat deposition in obesity).
- Common causes include physiological hormonal imbalance, medications, endocrine disease, or systemic illness.
- Important to distinguish from male breast cancer, which is typically unilateral, firm, and eccentric from the nipple.
🩺 Clinical Features
- Breast swelling, usually tender and rubbery, centred beneath the areola.
- Often bilateral and symmetrical in physiological or drug-induced cases.
- Look for endocrine features:
- Hypogonadism – testicular atrophy, infertility, low libido.
- Pituitary disease – galactorrhoea, headaches, visual disturbance.
- Systemic disease – jaundice (liver disease), weight loss (thyrotoxicosis), oedema (renal disease).
📊 Common Causes
| Cause |
Clinical Clues |
Key Tests |
Management |
| 👦 Pubertal |
Bilateral, adolescence, self-limiting |
Clinical assessment |
Reassurance |
| 💊 Drug-induced |
Spironolactone, cimetidine, anti-androgens |
Medication review |
Stop or substitute drug |
| 🧬 Hypogonadism |
Testicular atrophy, infertility |
↓ Testosterone, ↑ LH/FSH |
Treat cause ± testosterone therapy |
| 🍺 Liver disease |
Signs of chronic liver disease |
LFTs, imaging |
Manage liver disease |
| 🔥 Hyperthyroidism |
Weight loss, tremor, tachycardia |
TSH suppressed, ↑ T4 |
Treat thyrotoxicosis |
| 🎱 Testicular tumour |
Testicular mass |
Scrotal ultrasound, tumour markers |
Urgent urology referral |
🧪 Investigations
- Blood tests: testosterone, LH, FSH, prolactin, oestradiol, hCG.
- Thyroid function tests.
- Liver function tests and renal profile.
- Scrotal ultrasound if testicular tumour suspected.
- Breast ultrasound ± mammography if malignancy suspected.
- Biopsy if the mass is unilateral, firm, fixed, or associated with nipple discharge or skin changes.
⚕️ Management
- Treat the underlying cause.
- Stop or substitute causative medications.
- Hormonal therapy if hypogonadism is present.
- Reassurance for physiological pubertal gynaecomastia.
- Surgical management (subcutaneous mastectomy) for persistent symptomatic cases.
- Urgent referral for suspected malignancy.
💡 Exam Tip:
Tender bilateral breast enlargement in adolescents → usually physiological.
A firm unilateral breast lump in an older man → consider breast cancer until proven otherwise.
📚 References (NICE)
