Breast disease in men

Gynaecomastia is a breast manifestation of a systemic problem. Secondary care referral and investigation is not necessary in the majority of cases.

Breast lumps in men (rather than generalised swelling of the breast tissue) require referral for assessment.

Gynaecomastia is common, may be unilateral and is due to an imbalance of sex hormones.

Causes include:

Physiological: puberty, old age, obesity
Systemic illness: Liver disease, renal disease, testicular issues, obesity, previous radiotherapy or chemotherapy
Pharmacological: Alcohol, cannabis, opiates, steroids, protein supplements, antiandrogens, digoxin, spironolactone, omeprazole, allopurinol and many others.

Predisposing causes can be addressed in Primary Care, and do not need referral to Breast Unit.

Breast Lumps in Men

Men with a breast lump (with or without gynaecomastia) should be referred to Breast Clinic. Those with a clinically obvious lipoma may not need further investigation.

Who to refer, who not to refer, how to refer

Who to refer:

Urgent Referral

Men with breast lumps (refer as USOC)

Who not to refer:

In order for patients to have surgical intervention, the patient would need to have a diagnosis of gyn, reversible causes addressed and a maximum BMI of 27
Gynaecomastia without discrete lumps (though advice can be sought for those patients in whom medication is being considered)
Those for who surgery is being considered – they should be referred to Plastic Surgery via the exceptional aesthetic referral pathway

How to refer:

For men with breast lumps please refer via SCI Gateway to BGH

Borders General Hospital >> General Surgery – Breast >> LI Breast – Urgent

For advice such as prescribing for Gynaecomastia please use advice pathway

Borders General Hospital >> General Surgery – Breast >> LI Breast – Advice only

For consideration of surgical intervention for gynaecomastia please refer to plastic surgery

Lothian >> Lothian Non-GP Locations/Providers >> St John’s Hospital >> Plastic Surgery >> LI Basic Sign Referral

Primary care management

Management

In those with persistent swelling, not improved by addressing underlying factors, and who wish intervention then medication can be trialled:

Anastrozole 1mg daily for 3 months

Surgical intervention is considered via the exceptional aesthetic referral pathway via Plastic Surgery.

Please see this helpful video from Mr Matthew Barber, Consultant Breast Surgeon at EBU about Breast Lesions in Men

Please differentiate ‘generalised breast plate swelling and discomfort’ from, ‘discrete lump with/without skin involvement’; skin involvement or skin tethering associate with a breast plate lump indicates urgent referral to breast clinic whereas the former is either physiological or iatrogenic and necessitating reassurance or routine referral to breast clinic when no known cause for symptom.

Please consult the BNF for medications with side effect of gynaecomastia, for example Omeprazole, Finasteride etc.

Please examine the breast plates and rule out discrete lumps or lymphadenopathy (that would require referral) rather than general swelling of breast tissue. Look for signs of systemic illness associated with gynaecomastia.

If no obvious cause is found, then consider blood tests for:

Cr+Es, LFTs, LH, FSH, oestradiol, testosterone, prolactin, beta-HCG, AFP, TFTs

In Primary Care can use grouped tests in ICE by selecting Gynaecomastia under the Endocrinology Tab. Only Cr+Es will need to be added on to this list.

Resources and links

Breastcancernow.org

Gynaecomastia (CsfD national pathway)

Last reviewed: 15/08/2024

Next review date: 15/08/2025

Author(s): Dominique Twelves.

Author email(s): dominiquetwelves@borders.scot.nhs.uk.