Ep 32 – Gynaecomastia: investigation and management in primary care

In this episode, Kate discusses gynaecomastia and its investigation and management in primary care. She talks us through an infographic produced by The Association of Breast Surgery called Guidance on Gynaecomastia and considers the following important questions: “who do I need to be worried about?”, “what investigations should I consider?” and “when should I make a referral?”.

Key references discussed in the episode:

• Bromley HL et al. Br J Gen Pract. 2021;71(705):185-188. doi: 10.3399/bjgp21X715577.
• Association of Breast Surgery. Guidance on gynaecomastia: investigations recommended to be done in primary care. 2019.

Key take-home messages from the episode:

• Gynaecomastia can occur physiologically, secondary to medication and pathologically due to underlying health conditions including adrenal and testicular tumours, endocrine causes and systemic illness such as liver or renal disease, malnutrition or obesity.
• Physiological and drug-related causes do not need further investigation.
• Suspected breast cancers should be referred urgently (on a 2-week wait [2WW] pathway) to the breast clinic and suspected testicular tumours should be referred urgently (2WW) to urology.
• Further investigation should be undertaken for men without red flags who have: eccentric breast masses, rapid breast enlargement, a recent onset of gynaecomastia (in lean men over the age of 20), persistent painful gynaecomastia, massive gynaecomastia (in adolescents) and persistent gynaecomastia (in adolescents).
• Initial investigations include a 9 am testosterone, as well as thyroid function, liver function, beta-human chorionic gonadotropin and alpha-fetoprotein tests.
• If the testosterone, thyroid or liver function are abnormal then refer to endocrinology.
• If the beta-human chorionic gonadotropin or alpha-fetoprotein results are abnormal this should prompt an urgent (2WW) referral to urology and a testicular ultrasound scan.