Gynaecomastia: when and why to refer to specialist care

Gynaecomastia is the commonest male breast complaint. Most cases are benign but the condition may signify a serious underlying illness. The challenge in primary care is to identify which patients with gynaecomastia are at greatest risk of pathological aetiology, so that they may be offered prompt specialty-appropriate referral and treatment. This article offers guidance on the assessment and management of patients with gynaecomastia, including when and why to refer to secondary care. Gynaecomastia refers to the enlargement of male glandular breast tissue. The condition develops because of an imbalance in the male oestrogen:testosterone ratio from a relative oestrogen excess or testosterone deficiency. Pseudo-gynaecomastia is caused by an excess of adipose tissue and does not warrant investigation or treatment. Gynaecomastia is frequently observed in general practice. Prevalence is between 35%–65% in males aged 50–69 years in the UK.1 Patients typically describe a soft swelling in one or usually both breasts. Tenderness, social embarrassment, or worry about cancer are typical reasons for presentation to primary care. Other men are asymptomatic and gynaecomastia may be noted incidentally on physical examination of the chest. Physiological gynaecomastia is common in newborns, adolescence, and senility. Most do not require investigation or referral. Neonatal gynaecomastia arises from the placental transfer of oestrogen. Over half of all adolescent boys will experience transient gynaecomastia during puberty due to a lag in testosterone secretion, with median age of onset at 14 years.2 Physiological gynaecomastia is common among males aged >50 years as testosterone levels fall with increasing age. Adult gynaecomastia is most commonly idiopathic (Figure 1). Male …