Abnormal increase in the size of glandular breast tissue in a male patient. The diagnosis is clinical, but investigation is required to determine the underlying cause.

Discuss diagnosis, offer counselling

If hypogonadism has been identified as the cause of gynaecomastia, psychological as well as genetic counselling may be helpful. Fertility should also be discussed early with the patient and their family where appropriate.

Discuss the likelihood of successful treatment in all cases. Discuss the natural history of physiological gynaecomastia at the outset, and explain that treatment is rarely required for this condition.

Where other non endocrine causes such as malignancy have been identified, early referral is essential.

Likely causative medications or diet identified

Gynaecomastia should reverse after withdrawal of the offending drug or dietary component. However, this should not preclude a full evaluation to ensure no other sinister pathology is missed, and patients should be warned that normalisation of the breast may take many months or years in some cases.

Physiological, pubertal and idiopathic gynaecomastia

Physiological gynaecomastia occuring during puberty regresses spontaneously in the vast majority of cases.

Idiopathic gynaecomastia will sometimes improve as pectoral muscle bulk increases. For this reason, some patients may find a high protein diet with isometric weight training improves symptoms.

Medical therapy with clomiphene or tamoxifen are occasionally used for persistant severe idiopathic gynaecomastia, athough surgical treatment is usually preferable. 

Hyperprolacinaemia detected

Elevated prolactin will require thorough evaluation to identify its cause and determine the most appropriate treatment - see prolactinoma.

Gynaecomastia should respond rapidly to a fall in serum prolactin.

Hypogonadism confirmed

Discuss treatment aims, timescales and outcomes

Pubertal induction aims to replicate the natural process of puberty and should occur over approximately the same timescale - approximately two years. Late onset hypogonadism, and hypergonadotropic hypogonadism can often be treated much more quickly with typical adult doses from the outset.

Patients should be warned that symptoms of gynaecomastia may be exacerbated at the start of testosterone replacement therapy.

Initiate testosterone treatment

In the case of absent puberty, initiate very low dose testosterone therapy, and warn patient of expected psychological and physical effects.

Typical starting dose in a testosterone naive patient is approximately 20% of an adult dose. This has traditionally been given as 50mg testosterone undecanoate monthly.

In late onset hypogonadism, it may be appropriate to start with adult doses.

Dose titration

Monthly testosterone treatment is then typically increased by a further 50mg every six months according to clinical response.

Alternatives include low dose depot testosterone, or topical gel, again, starting with approximately 20% of the usual adult dose, increasing by the same amount every six months until adult doses are reached.

Treatment monitoring

Routine monitoring of serum testosterone levels is not necessary until the expected adult dose is reached.

Peak and trough levels may then be useful to confirm the appropriateness of the final dose in patients taking monthly testosterone undecanoate. Peak 7 days post injection should typically be 25-30nmol/l, with a predose trough level of 8-12nmol/l. Subsequently, the dose should not be altered unless the clinical response is suboptimal, or in the light of changes in serum monitoring of prostate specific antigen, full blood count, liver function, or pre dose testosterone levels.

In patients taking depot preparations, a random or pre dose level of 15-20nmol/l, and for patients taking daily topical preparations, a level of 15-20nmol/l 4-6 hours post application of the gel is usually suficient.

Warn patients that testicular volume is not likely to change

Testicular volume may be enhanced during gonadotropin treatment used in the induction of spermatogenesis, however, this tends to reverse on treatment cessation.

Synthetic implants can be considered to restore testicular volume where required.

Alternative treatments

Once the patient is virilised appropriately and established on a full adult dose, discuss alternative modes of treatment. Daily gel or depot preparations of testosterone are well tolerated and give a smooth serum profile which some patients find more acceptable.

Optimise final dose and preparation, according to patient preference, symptoms and serum levels.

Annual monitoring

Testosterone levels are usually checked on an annual basis only after the dose has been optimised. This should be taken 4-6 hours after gel application, or generlaly pre dose in patients taking testosterone injections to ensure testosterone levels are not excessive.

Prostate specific antigen, full blood count and liver function tests should also be performed annually. Consider dose reduction, treatment cessation and onward referral if abnormalities arise.

Follow up

Offer life long follow up to all patients, though patients with gonadal failure, and isolated hypogonadotropic hypogonadism may be discharged to their general practitioner.

Consider periodic monitoring of bone densitometry where indicated. Consider repeat basal and dynamic pituitary function in patients with suspected pituitary disease, and follow up as per underlying condition.

Kallmann's syndrome

Offer genetic counselling.

Ensure that an MRI scan of the pituitary and olfactory bulbs has been performed, and that pituitary function, karyotype and where necessary pelvic ultrasound scan have all been reviewed to exclude other diagnoses.

Arrange a renal ultrasound scan, as abnormalities of the urogenital tract may be associated with this condition. 

Arrange an echocardiogram and cardiology review where indicated, as multiple congenital heart defects including ventricular and atrial septal defects and rhythm disturbances have been decribed in a small subset of patients with Kallmann's syndrome.

Arrange neurology review in those patients with other neurological sequellae such as epilepsy.

Treat with standard pubertal induction and long term testosterone replacement therapy as for other causes of hypogonadism.

Offer life long follow up.

Klinefelter's syndrome

Offer genetic counselling to all patients diagnosed with this condition. Psychological counselling may also be beneficial in some cases, and other psychological, psychiatric, or learning difficulties should be treated on their own merits.

Medical treatment is the same as for any other patient presenting with hypogonadism.

Follow up should be life long.