Breast Enlargement in Men
Differential Diagnosis
Common Diagnoses
- Puberty
- Drugs (Spironolactone, Cimetidine, Digoxin, Cyproterone, Finasteride, Marijuana)
- Chronic Liver Disease (Especially Alcohol)
- Lung Carcinoma
- Hyperthyroidism
Occasional Diagnoses
- Hyperprolactinaemia
- Haemodialysis and Chronic Renal Failure
- Testicular Carcinoma
- Adrenal Carcinoma
- Cryptorchidism and other Causes of Hypogonadism
Rare Diagnoses
- Klinefelter’s Syndrome
- True Hermaphroditism and Male Pseudohermaphroditism
- Acromegaly
- Mccune–Albright Syndrome
- Hypernephroma
- Carcinoma
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Puberty | Drugs | Liver Disease | Lung Cancer | Hyperthyroidism | |
|---|---|---|---|---|---|
| Often Unilateral | Yes | No | No | No | No |
| Cough | No | No | No | Yes | No |
| Weight Loss | No | No | Possible | Yes | Yes |
| Generally Unwell | No | Possible | Yes | Yes | Yes |
| Other Physical Signs | No | Possible | Yes | Yes | Possible |
Possible Investigations
Likely:FBC, U&E, LFT, TFT.
Possible:Testosterone, CXR, tests of pituitary function
Small Print:Tumour markers, chromosome analysis, CT scan, biopsy
- FBC: Many chronic systemic illnesses can cause gynaecomastia. There may be an associated normochromic, normocytic anaemia. MCV may be raised in hypothyroidism and chronic liver disease.
- U&E and LFT: Will reveal chronic renal and liver disease.
- TFT: To diagnose thyroid abnormality.
- Testosterone: Reduced in hypogonadism and chronic illness including liver disease.
- CXR: If lung carcinoma a possibility.
- Tests of pituitary function (e.g. FSH, LH, prolactin and other more complex, hospital-based tests): To check for pituitary hormone abnormalities.
- Tumour markers (usually hospital-based): AFP and HCG act as tumour markers for testicular carcinoma.
- Chromosome analysis: For Klinefelter’s syndrome.
- CT scan (secondary care): May be necessary for testicular tumour staging and diagnosis of adrenal and renal tumours.
- Biopsy: If carcinoma suspected.
Top Tips
- Many male breast swellings are not true breast enlargement – possibilities include simple obesity, abscess, sebaceous cyst and lipoma.
- Pubertal boys will be very self-conscious about gynaecomastia. Reassure them that the problem is common and will resolve, and that they are not changing sex.
- Iatrogenic causes are common – check the drug history (including over-the-counter and illicit drugs).
Red Flags
- In a pubertal boy with a ‘normal’ and a ‘small’ testis, the ‘normal’ one may conceal a tumour. Check with an ultrasound if in doubt.
- Apparent unilateral gynaecomastia in an adult male may be due to breast carcinoma – refer urgently if there is a hard mass, you cannot feel glandular tissue behind the areola or you’re in any doubt.
- Gynaecomastia with a headache and visual disturbance may be caused by a pituitary tumour. Refer urgently.
- Clubbing of the fingers in a smoker with gynaecomastia is virtually pathognomic of bronchial carcinoma. Investigate urgently.