🚨 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)

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Gynaecomastia ✅