Gynaecomastia triage — pubertal reassurance, adult cause hunt, selective imaging and persistent-disease surgery

Examiner prompts with model answers

Definition and mechanism — gland with a ridge, imbalance behind it. Benign glandular proliferation presents as a firm or rubbery, discrete, symmetrical, movable subareolar ridge nonadherent to skin, driven by stimulatory oestrogen unopposed by inhibitory androgen at the breast — confirm gland versus lipomastia and name the imbalance before anything else.^[1][3]

Pubertal boy — reassure with numbers. Half of mid-pubertal boys develop it with more than 90% resolving within 24 months; physiological disease regresses with time so reassurance is all that is necessary, with cause-directed treatment only for pathological cases — support him psychologically and do not image or operate the recent bilateral tender breast.^[1][3][13]

Adult man — hunt the 43% with genitalia and panel. Adult-onset disease carries a detectable, often treatable cause in 43% versus 7.7% young-onset; take onset, puberty, sex and substances, examine breast for gland versus cancer, examine genitalia for tumour or atrophy with testicular ultrasound, and send testosterone, estradiol, SHBG, LH, FSH, TSH, prolactin, hCG, AFP plus liver and renal tests.^[7][1]

Drugs — definite stops, probable reviews. Drugs cause 10-25% with mostly poor-quality reports; definite drugs are spironolactone, cimetidine, ketoconazole, hGH, estrogens, hCG, anti-androgens, GnRH analogs and 5-α reductase inhibitors, while probable drugs include risperidone, verapamil, nifedipine, omeprazole, alkylators, efavirenz, anabolic steroids, alcohol and opioids — stop the definite, review the probable, then watchfully wait.^[8][1]

Imaging — equivocal gets a scan, suspicious gets a needle. Image only when examination is equivocal and biopsy suspicious lesions directly; 557 imaged men gave 0.89% cancer with 80% sensitivity and 99% specificity so routine imaging is discouraged — the boy gets none, the equivocal adult gets mammography or ultrasound, the suspicious lump gets core biopsy.^[11][1]

Persistent painful disease — tamoxifen before knife, surgery for the long-standing. Painful disease at 10 mg tamoxifen for 3 months gave 10 responses in 13 men with one calf-tenderness stoppage, safe and effective before surgery; surgery is for long-standing non-regressing disease, best by liposuction plus adenectomy — reassure the recent, medicate the painful persistent, resect the fibrous remainder.^[9][1]

Cancer boundary — not premalignant, old-age lump is the real story. Gynaecomastia is not premalignant; male cancer peaks at 71, is usually a late lump or nipple inversion with more than 40% stage III-IV, runs BRCA2 over BRCA1, and hyperoestrogenic states but not gynaecomastia raise risk — say the boundary plainly and refer the BRCA2 family, not the gynaecomastia boy.^[16][1]