Referral Guidelines are peer reviewed guidelines developed to assist referring providers in their approach to a patient presenting with common signs or symptoms suggestive of an endocrine condition, and when to refer to Pediatric Endocrinology.
Symptoms/signs:
• Palpable subareolar breast tissue in male
• Breast tissue may be asymmetric, unilateral, or bilateral but appear at different times
Refer to Differential Diagnosis section
Blood tests:
• Consider evaluation in prepubertal males or if pubertal males with significant breast tissue (after consultation with Pediatric Endocrinologist)
o LFTs
o LH, FSH*
o Testosterone*
o Estradiol*
o DHEA-S
o TSH, Free T4
o hCG
o Prolactin
o Karyotype
Radiologic studies:
• Testicular ultrasound if testicular mass or elevated hCG
*Pubertal laboratory tests should be obtained in the early AM using sensitive pediatric assays only
Urgent:
Prepubertal males
Routine:
Pubertal males with significant or rapidly enlarging gynecomastia
- Previous growth data/growth charts
- Pertinent medical records
- Recent laboratory studies
- Pubertal gynecomastia
- Pseudogynecomastia due to obesity/lipomastia
- Hypogonadism
- Hyperthyroidism
- Exogenous exposures to lavender, tea-tree oil
- Medication Induced: Antipsychotics, Anabolic steroids, Alcohol or drugs of abuse including: marijuana, heroin, amphetamines
- Pathologic causes: hCG secreting tumors, testosterone or estrogen secreting tumors (Leydig cell tumor, adrenal tumor), liver disease (chronic)
- Breast masses: benign tumors (lipomas, neurofibromas, dermoid cysts), rarely carcinomas
- Benign, pubertal gynecomastia is the most common cause of gynecomastia and occurs in up to 2/3 of normal pubertal boys, with the majority of pubertal gynecomastia self-resolving by completion of puberty.
o Laboratory/radiologic evaluation is generally not needed in boys with suspected pubertal gynecomastia unless there is significant or rapidly changing breast development.
o Boys with suspected pubertal gynecomastia should be monitored for rapid progression of breast development.
- Gynecomastia results due to relative imbalance between testosterone and estradiol levels, transient estradiol excess or increased sensitivity of breast tissue to estrogen.
- Gynecomastia can be commonly associated with Klinefelter syndrome.
- No good treatment options exist, regardless of cause. Once growth and puberty is complete, referral for cosmetic surgery may be considered.
- Question From the Clinician: Adolescent Gynecomastia. Peds in Review. 2003 Sep; 24(9): 317-319. doi: 10.1542/pir.24-9-317
- Nordt CA, DiVasta AD. Gynecomastia in adolescents. Curr Opin Pediatr. 2008 Aug;20(4):375-82. doi:10.1097/MOP.0b013e328306a07c.
Kathryn Obrynba
June 23, 2021