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 resultPossible diagnoses
All normalIdiopathic gynaecomastia
Low Testosterone with elevated LHPrimary hypogonadism; Klinefelter's syndrome
Low Testosterone with normal LHPituitary/hypothalamic disease
Elevated Testosterone with elevated OestradiolAndrogen exposure; testicular tumour
Elevated Oestradiol with elevated SHBGOestrogen exposure; testicular/adrenal tumour
Elevated DHEAAdrenal tumour
Elevated β-hCGTesticular/ectopic tumour
Elevated ProlactinPituitary 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

  • 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 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 refer via e-Referral Service

  • Service: 2WW
  • Clinic type: 2WW Breast
  • Service: DRSS-Western-2WW Breast - Devon CCG-15N

Referral forms

Breast Cancer - No merge fields

Supporting Information

Further guidance

Breast Cancer Care

Pathway Group

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

Publication date: November 2020

 

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