Treatment of gynecomastia

A 19-year-old gentleman came to see me for unilateral gynecomastia. He has had it since age 13, and there were no signs that it is going to regress. Besides the cosmetic concerns, it has been painful, limiting his ability to perform his physically active job. He has already seen a surgeon and is planning to have this surgically corrected. He was sent to me to be certain there were no other factors that should be addressed first.

Gynecomastia is common in young males with a reported prevalence of 4% to 65%. The cause is not fully understood. It is thought that changes in estrogen to androgen around the time of puberty play an important role, but other causative factors have also been suggested. In most cases this is benign physiologic gynecomastia, which is self limited and resolves with time. In as many as 10% of cases, however, it does not resolve.

Pathologic causes of gynecomastia must always be screened for. Low levels of androgen can cause gynecomastia. This includes hypogonadism such as due to Klinefelter’s syndrome. Increased estrogen levels may also stimulate breast development. Estrogen levels may be increased due to increased aromatization, which can occur in liver disease, hyperthyroidism and obesity. Gynecomastia is sometimes the presenting sign of several types of malignancy including testicular cancer and adrenal neoplasms.

Another important cause of gynecomastia is medications. This list is extensive and includes anti-androgens such as finasteride and spironolactone; cardiovascular drugs including amiodarone, angiotensin-converting enzyme inhibitors, calcium channel blockers and digoxin; neuro-psychiatric medications such as diazepam, haloperidol, opioids, phenytoin and tricyclic antidepressants; exogenous hormone therapy including estrogen and gonadotropins; anti-neoplastic therapy; anti-ulcer medications such as cimetidine and metoclopramide; and antimicrobials such as highly active antiretroviral therapy and ketoconazole. For more information and a complete list, please review the references below.

Drugs of abuse have also been implicated. Gynecomastia has been associated with the use of alcohol, methadone, heroin, marijuana, amphetamine as well as anabolic steroids. Certain herbal preparations containing estrogenic activity have also been reported to possibly cause gynecomastia.

My patient did not have evidence of pathologic causes of gynecomastia and denied exposure to medications or illicit drugs. He will be undergoing surgical correction in the near future.

Medical therapy has been suggested for some patients. Potential therapies include blocking the effects of estrogen on the breast with clomiphene, tamoxifen or raloxifene, androgen therapy such as danazol, or decreasing the production of estrogen with testolactone (Teslac, Bristol Myers Squibb). Although case reports and some unblinded studies have suggested benefit, more rigorously controlled studies have been inconclusive.

My own experience with medical treatment of gynecomastia has been limited. Most of the cases I managed have been either benign physiologic gynecomastia which resolved with time and reassurance or were due to medication or an underlying pathologic process which we addressed. Others were already so advanced that surgery was the most reasonable option.

I am curious, however. Have any of you had experience with medical management of gynecomastia? If so, with which medications and what was the outcome?

For more information:
Curr Opin Pediatr. 2008;20:375-382.
Curr Opin Pediatr. 2008;20:465-470.
J Pediatr. 2004;145:71-6.