Part of “CHAPTER 120 – GYNECOMASTIA“

The evaluation should focus initially on identifying patients in whom the breast enlargement is a manifestation of a treatable underlying disease. In particular, special emphasis must be given to excluding a neoplasm whose sole external manifestation may be gynecomastia. In this regard, a history of a recent onset of gynecomastia is particularly pertinent. In taking the patient’s history, one should pay particular attention to prescribed medications or illicit drugs known to be related to gynecomastia, pubertal development, symptoms of hypogonadism, fertility, and symptoms of a systemic disease (e.g., liver disease, thyrotoxicosis) that can be associated with gynecomastia. On physical examination, the patient should be carefully evaluated for secondary sexual characteristics, testicular size, presence of abdominal or testicular masses, and ambiguous genitalia, including hypospadias. One should verify gynecomastia (distinguish from fat) and its nature. Unilateral, very hard, nontender, irregular breast enlargement suggests the possibility of male breast cancer, which is extremely unusual before age 50. Sometimes, the history and physical examination alone suffice to establish rapidly the cause of gynecomastia (e.g., recent use of spironolactone, normal pubertal boy, longstanding cirrhosis with generalized feminization).