Synopsis
Confirm true glandular breast enlargement, detect breast or testicular malignancy and endocrine disease, remove reversible causes, and treat persistent pain or distress through an appropriate breast pathway.
- True gynaecomastia is benign proliferation of glandular breast tissue, usually felt as a rubbery or firm concentric subareolar disc; adipose enlargement without gland is pseudogynaecomastia.
- Physiological gynaecomastia occurs in newborns, puberty and later life, but the age does not remove the need to investigate a suspicious eccentric mass or systemic clue.
- The mechanism is increased oestrogen effect relative to androgen action from gonadal failure, liver or thyroid disease, tumours, medicines or exogenous hormones.
- Take a complete prescribed, over-the-counter, private and substance history, including spironolactone, anti-androgens, finasteride, antipsychotics, anabolic steroids, cannabis and supplements.
- A unilateral tender subareolar disc can still be benign; cancer is more concerning when hard, irregular, eccentric, fixed or associated with nipple, skin or nodal change.
- Examine testes because an hCG- or oestrogen-producing testicular tumour can present through breast enlargement before the patient reports a testicular symptom.
- Laboratory testing is targeted by age, duration and findings; testosterone with LH and FSH, oestradiol, hCG, prolactin, thyroid, liver and renal tests are not an automatic panel for every pubertal case.
- New tender glandular tissue may respond to removal of the cause or specialist medical treatment, while long-standing fibrotic tissue is less likely to regress pharmacologically.
- Persistent pain, marked asymmetry or psychological distress deserves active care and a surgical discussion where appropriate, although NHS commissioning criteria vary locally.
Key red flags
A hard irregular eccentric mass, skin dimpling, nipple inversion, unilateral bloody discharge or axillary nodes is suspicious and needs urgent breast referral.
A firm intratesticular mass, asymmetry, heaviness or recent rapid gynaecomastia can reflect hCG or oestrogen production and requires urgent testicular assessment.
Jaundice, spider naevi, ascites, muscle loss or testicular atrophy suggests liver disease; tremor, weight loss, heat intolerance and tachycardia suggests thyrotoxicosis.
Investigation priorities
Distinguish gland, fat and suspicious masses and identify a gonadal source.
Management branches
A person presents with unilateral or bilateral breast swelling, tenderness or a lump.
- Clarify duration, pain, nipple change, weight change, puberty, sexual and fertility symptoms, organ disease, family cancer risk, radiotherapy, medicines, anabolic agents, alcohol and supplements.
- Examine both breasts and nodes and distinguish subareolar gland from diffuse fat or an eccentric lesion; examine testes and secondary sexual characteristics with consent.
- Send any suspicious breast feature to the urgent NICE breast pathway and any testicular mass to urgent urology rather than ordering a routine endocrine panel first.
- For a typical benign presentation, decide whether age and history support observation or targeted testosterone, gonadotrophin, hCG, oestradiol, prolactin, thyroid, liver and renal testing.