New guideline recommendations for addressing gynecomastia

The European Academy of Andrology (EAA) has issued a new guideline with 15 recommendations for managing these clinical cases.

Surgery is only the last resort

The European Academy of Andrology (EAA) has issued a new guideline with 15 recommendations for managing these clinical cases.

The male breast, also known as gynecomastia, most frequently occurs in severely overweight men, with a manifest testosterone deficiency (hypogonadism) and partly also due to medication. This condition has a characteristic change in the shape of the male breast that reminisces the female breast shape.

Gynecomastia is a benign increase in the breast tissue of a man. The clinical incidence is not uncommon, affecting between 32% and 65% of men depending on their age. While the "male breast" in children and adolescents usually disappears by itself at the end of puberty, it is much more persistent in adult men. In about every second affected adult male there is also an underlying disorder/illness.

The aim of the breast examination in men with gynecomastia is to diagnose the underlying causes of the condition and, if necessary, to derive therapy options from them. It is also important to distinguish benign gynecomastia from malignant tumors of the breast, which can also affect men in rare cases.

The fifteen recommendations for the correct management of gynecomastia set out by the EAA are: 

1. Clarification of the underlying patho(physio)logy, irrespective of possible drug-related causes.
2. The first exclusion of lipomastia, testicular carcinoma or breast carcinoma should be performed by general practitioners or non-specialists.
3. Further diagnostics are to be carried out by specialists/andrologists.
4. The anamnesis should include information on the onset and duration of gynecomastia, sexual development and function, and the use of medications that promote gynecomastia.
5. Examination for under-virilization or systemic disease as the cause of the symptoms.
6. Additional glandular tissue should be palpable in order to clearly distinguish gynecomastia from lipomastia and at the same time exclude malignant causes.
7. A comprehensive examination also includes palpation of the testicles and groin region in order to exclude testicular tumors and atrophy.
8. The testicular examination will be supplemented by sonography, as palpation is not sensitive enough for the detection of testicular tumors.
9. In addition, various hormones such as testosterone (T), estradiol (E2), sex hormone binding globulin (SHBG), luteinizing hormone (LH), follicle stimulating hormone (FSH), thyrotropin (TSH), prolactin, human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP) and liver and kidney function tests should be determined.
10. In cases of doubt, the breast should be subjected to medical imaging on the male patient.
11. Suspicious lesions in the chest area are to be biopsied.
12. After treatment of the underlying pathologies or after removal of the beneficial medication, "watchful waiting" is indicated.
13. Testosterone treatment should only be given to men who have been shown to be hypogonadal.
14. Selective estrogen receptor modulators (SERM), aromatase inhibitors (AI) and non-aromatizable androgens are currently not recommended for the treatment of gynecomastia.
15. The surgical therapy of gynecomastia should always be the last resort of choice and should only be applied to those men who have been suffering from the "male breast" for a long time and have proved to be largely "resistant to therapy".

Source:
Kanakis GA et al., EAA clinical practice guidelines-gynecomastia evaluation and management. Andrology 2019; https://onlinelibrary.wiley.com/doi/abs/10.1111/andr.12636