Treatment of Gynecomastia

For further information on gynecomastia surgery reference can be made to the following pages:
Gynecomastia Surgery
Gynecomastia Causes
Gynecomastia Examination

The treatment of gynecomastia depends on the severity and whether an identifiablecause is present. If a possible cause has been identified, then therapy should be directed at correction of that cause. Gynecomastia will almost always resolve with the treatment of the underlying disorder or withdrawal of the causative medication. Resolution can be seen within a few weeks.

If no cause is identified, if the underlying disease cannot be treated, or if the causative medication cannot be discontinued, then the goal of treatment depends on the severity of the condition. Because most cases of gynecomastia are associated with hormonal imbalances or drugs and because gynecomastia itself carries no serious significance (assuming serious causes have been ruled out), reassurance is the first line of therapy, and in many cases patients desire no further intervention.

The risk of male breast cancer does not appear to be increased in patients with gynecomastia, except in patients with KS. For patients who have symptomatic gynecomastia, treatment is primarily surgical, although some medical therapies have been proposed. Unfortunately there are few well-designed prospective trials of medical therapies for gynecomastia.

Treatment of gynecomastia – Medical Therapy

Clomiphene citrate is an anti-oestrogen that acts at the level of the hypothalamic-pituitary axis to increase gonadotropin secretion. Although it may be successful, particularly in the adolescent population, the side effects may be severe (gastrointestinal reactions, rashes, visual disturbances), and in this population spontaneous resolution often occurs. It is therefore not indicated in the treatment of gynecomastia.

Likewise, percutaneous dihydrotestosterone heptanoate has been shown to reduce gynecomastia in pubertal patients but has never been tested in prospective randomized trials and again, spontaneous resolution is common in this population, so its true efficacy is unknown.

Danazol (Danocrine) is the 2,3,isoxazol derivative of 17a-ethyl testosterone and has been tested in patients with gynecomastia of varying causes with response rates of 77% to 100%. Treatment lasts for 3 to 16 weeks with dose schedules of 100 to 400 mg/day for adults or 200 to 300 mg/day for adolescents. Side effects include acne, weight gain, fluid retention, muscle weakness, and cramps.

Finally, tamoxifen can be effective in treating gynecomastia, but the long-term effects of tamoxifen in men are not well studied. Doses of 10 to 20 mg/d for 3 to 9 months have been used, with resolution in up to 90% of men. It can be considered in patients who have severe idiopathic gynecomastia after a thorough, exhaustive workup has failed to identify any underlying causes. If the gynecomastia recurs upon stopping the tamoxifen, a second course of therapy may be attempted.

Medical therapies are most effective in men with new-onset gynecomastia. With longstanding gynecomastia, the stroma is more fibrotic and less likely to resolve. Surgery is the preferred treatment in these patients, as well as in patients who decline or fail medical therapy.

Treatment of gynecomastia – Surgery

Most patients with gynecomastia prefer surgical therapy given the rapid cosmetic improvement and the avoidance of medications (many patients are taking several other medications already for their underlying conditions). The primary treatment of gynecomastia is surgical, consisting of a subcutaneous mastectomy. Simple mastectomy is not indicated. Patients must be aware that they may be trading one cosmetic deformity for another.

For most patients with a small amount of gynecomastia, a periareolar incision can be used to excise the breast tissue. A small disk of breast tissue should be left underneath the nipple to prevent the sunken nipple deformity.

For patients with more extensive gynecomastia, excess skin may need to be removed to restore the contour of the breast. Several techniques have been described to accomplish this. However, in these more extreme cases, or in cases in which there is both an excess of breast tissue and fat, liposuction may be a useful alternative to surgery.

Clinical Classification of Gynecomastia

Grade Definition

I Mild breast enlargement without skin redundancy
IIa Moderate breast enlargement without skin redundancy
IIb Moderate breast enlargement with skin redundancy
III Marked breast enlargement with skin redundancy and ptosis

Ref: Essentials of Breast Surgery, Michael S. Sabel, 2009