Once symptoms of Gynecomastia are seen, patient needs to be evaluated in detail to exclude breast cancer. Although breast cancer is rare in men, it still needs careful attention. (1, 2, 3, 4)
Medical history and physical examination
Diagnosis begins with taking a medical history and doing a detailed physical examination.
First questions that need to be evaluated are if both breasts are involved, age, duration of the condition, progression of the swelling, other symptoms and if any drugs are being taken.
Often patients with hormonal problems show up with Gynecomastia affecting both breasts.
In addition, adolescent pubertal boys and elderly men sometimes show Gynecomastia.
In boys the symptoms often disappear by itself without treatment.
Questions to evaluate the adequate growth and development of other secondary sexual characters in the adult patient with Gynecomastia is also important. Symptoms of decreased libido or erectile dysfunction may point towards low testosterone.
Progression of Gynecomastia
Progression of the swelling – whether it is increasing, decreasing or remaining the same - needs to be known.
Rapid growth of the breast tissues may point towards an underlying cancer.
There are a host of drugs and medications that may lead to Gynecomastia. Knowledge of these drugs as well as their discontinuation may be important.
If the condition resolves after the drug is withdrawn then the causality of the Gynecomastia due to the offensive drug may be confirmed.
Other diseases and Gynecomastia
The patient would be asked about other diseases that lead to Gynecomastia. This includes asking about liver, kidney, malnutrition and thyroid diseases – like chronic weight loss, fatigue, anorexia along with jaundice, skin changes and pallor, hair loss (indicative of malnutrition), easy fractures (indicative of hormonal deficiencies), heat intolerance and diarrhea (over active thyroid) etc.
Physical examination is important in diagnosing other causes of Gynecomastia. The doctor may assess:
- general physical well being
- neck for goitre (indicative of hyperthyroidism)
- abdomen for liver enlargement, ascitis (in liver diseases) etc.
The secondary sexual characteristics like pubic hair, and axillary hair, penis and testes would be examined thoroughly for changes in patterns, tumors, masses and abnormalities of development respectively. The axially is also checked for enlargement of lymph nodes.
True Gynecomastia and False Gynecomastia
On examination of the breast it is checked if the swelling is fatty tissue (not truly Gynecomastia) or breast tissue.
In case of former, the feeling between the palpating thumb and forefinger is soft and meets no resistance of an intervening mass until the nipple is reached.
In case of a true Gynecomastia there is a feeling of a mass between the fingers.
Sometimes tests may be ordered. These include hormone level tests. Blood levels of testosterone and Estrogen may provide clues regarding hormone misbalance that may have caused Gynecomastia.
Other hormones like LH (Leutanizing Hormone), FSH (Follicle Stimulating Hormone) and human chorionic gonadotropin (hCG) may also be recommended.
An ultrasound examination of the breast may be indicated. This is especially important in a localized lump in the breast. It can also show presence of boil or abscess that has led to the swelling of the breast.
Since both long standing liver and kidney disease lead to Gynecomastia in men, Liver and kidney function tests may detect underlying liver or kidney pathologies.
A mammogram may be needed to exclude breast cancer.
Other tests like Chest X rays, Computerized tomography (CT) scans and Magnetic resonance imaging (MRI) scans may be recommended if tumors and pathologies of other organs are suspected to be the cause behind the Gynecomastia.
Testes may be examined with Testicular ultrasounds and sometimes biopsies to rule out cancers and tumors. Those in whom a cause for the Gynecomastia is not found may need a follow up work up of all tests after 6 months.
Edited by April Cashin-Garbutt, BA Hons (Cantab)
What is Gynecomastia?