Gynaecomastia is a breast manifestation of a systemic problem. Secondary care referral and investigation is not necessary in the vast majority of cases.
Breast lumps in men (rather than generalised swelling of the breast tissue) require referral for specific investigation.
Gynaecomastia
Gynaecomastia is common, may be unilateral and is due to an imbalance of sex hormones.
Causes include:
- Physiological: puberty, old age
- Systemic illness: Liver disease, renal disease, testicular issues, obesity, previous radiotherapy or chemotherapy
- Pharmacological: Alcohol, cannabis, opiates, steroids, protein supplements, antiandrogens, digoxin, spironolactone, omeprazole, allopurinol and many others.
Predisposing causes can be address in Primary Care, and do not need referral to Breast Unit
Assessment
- Examine: Rule out discrete lumps or lymphadenopathy (that would require referral) rather than general swelling of breast tissue. Look for signs of systemic illness associated with gynaecomastia.
If no obvious cause is found then consider blood tests for:
- Cr+Es, LFTs, LH, FSH, oestradiol, testosterone, prolactin, beta-HCG, AFP, TFTs
- In Primary Care can use grouped tests in ICE by selecting Gynaecomastia under the Endocrinology Tab. Only Cr+Es will need to be added on to this list.
Management
In those with persistent swelling, not improved by addressing underlying factors, and who wish intervention then medication can be trialled:
- Tamoxifen 10mg once daily for 3-9 months
- Anastrozole 1mg daily for 3 months
This is an unlicensed indication. It is most useful for recent onset gynaecomastia and usually improves breast sensitivity. If prescription of a medication outwith it’s licensed indication is being considered, discussion with secondary care options is an option, should this be felt necessary for the small number of patients who may benefit.
Surgical intervention is considered via the exceptional aesthetic referral pathway via Plastic Surgery.
Please see this helpful video from Mr Matthew Barber, Consultant Breast Surgeon at EBU about Breast Lesions in Men
Breast Lumps in Men
Men with a breast lump (with or without gynaecomastia) should be referred to Breast Clinic. Those with a clinically obvious lipoma may not need further investigation.
J.B & M.B, L.P 07-11-23
Who to refer:
Urgent Referral
- Men with breast lumps (refer as USOC)
Who not to refer:
- Gynaecomastia without discrete lumps (though advice can be sought for those patients in whom medication is being considered)
- Those for who surgery is being considered – they should be referred to Plastic Surgery as detailed above
How to refer:
Edinburgh, Midlothian and East Lothian Patients
- For men with breast lumps please refer via SCI Gateway to WGH
Western General Hospital >> General Surgery – Breast >> LI Breast – Urgent
- For advice such as prescribing for Gynaecomastia please use advice pathway
Western General Hospital >> General Surgery – Breast >> LI Breast – Advice only
West Lothian Patients
- For men with breast lumps please refer via SCI Gateway to SJH
St John’s Hospital >> General Surgery – Breast >> LI Breast – Urgent
- For advice such as prescribing for Gynaecomastia please use advice pathway
St John’s Hospital >> General Surgery – Breast >> LI Breast – Advice only
See main page
Please see this helpful video from Mr Matthew Barber, Consultant Breast Surgeon at EBU about Breast Lesions in Men
