Evaluation of Gynecomastia - Flowchart
Evaluation of Gynecomastia - Flowchart Gynecomastia Gynecomastia
«Flowchart»

Gynecomastia

Gynecomastia

Gynecomastia

History

Physical examination

History

Physical examination

History

Physical examination

Mammography, biopsy

Mammography, biopsy

Mammography, biopsy

Asymmetric, fixed unilateral gynecomastia (± discharge)

Asymmetric, fixed unilateral gynecomastia (± discharge)

Asymmetric, fixed unilateral gynecomastia (± discharge)

Yes

Yes

Yes

No

No

No

End

End

End

Consider trial of discontinuing medications

Consider trial of discontinuing medications

Consider trial of discontinuing medications

Renal disease
Liver disease
Hyperthyroidism
HIV
Cushing syndrome
Obesity

Renal disease
Liver disease
Hyperthyroidism
HIV
Cushing syndrome
Obesity

Renal disease
Liver disease
Hyperthyroidism
HIV
Cushing syndrome
Obesity






Evidence of underlying medical disease?

Evidence of underlying medical disease?

Evidence of underlying medical disease?

Yes

Yes

Yes

No

No

No

Recheck in 6 mo

Recheck in 6 mo

Recheck in 6 mo

Pubertal with normal history, physical examination

Pubertal with normal history, physical examination

Pubertal with normal history, physical examination

Yes

Yes

Yes

No

No

No

Idiopathic gynecomastia

Idiopathic gynecomastia

Idiopathic gynecomastia

Primary hypogonadism

Primary hypogonadism

Primary hypogonadism

Androgen insensitivity syndrome

Androgen insensitivity syndrome

Androgen insensitivity syndrome

Secondary hypogonadism

Secondary hypogonadism

Secondary hypogonadism

See Section I "Prolactinoma"

See Section I "Prolactinoma"

See Section I "Prolactinoma"

Check prolactin

Check prolactin

Check prolactin

NL

NL

NL

High

High

High

Testicular germ cell tumor

Testicular germ cell tumor

Testicular germ cell tumor

Chest x-ray CT/MRI of abdomen/pelvis

Chest x-ray CT/MRI of abdomen/pelvis

Chest x-ray CT/MRI of abdomen/pelvis

Leydig/Sertoli cell tumor

Leydig/Sertoli cell tumor

Leydig/Sertoli cell tumor

↑ Extraglandular aromatase activity

↑ Extraglandular aromatase activity

↑ Extraglandular aromatase activity

↑

Adrenal mass

Adrenal mass

Adrenal mass

Medications/drugs (e.g., 5-alpha reductase inhibitors, digoxin, anabolic steroids)?

Medications/drugs (e.g., 5-alpha reductase inhibitors, digoxin, anabolic steroids)?

Medications/drugs (e.g., 5-alpha reductase inhibitors, digoxin, anabolic steroids)?

Yes

Yes

Yes

No

No

No

Ultrasound of testes

Ultrasound of testes

Ultrasound of testes

ࣷ mass

ࣷ mass

ࣷ ࣷ mass ࣷ

ࣸ mass

ࣸ mass

ࣸ ࣸ mass ࣸ

Ultrasound of testes

Ultrasound of testes

Ultrasound of testes

ࣷ mass

ࣷ mass

ࣷ ࣷ mass ࣷ

ࣸ mass

ࣸ mass

ࣸ ࣸ mass ࣸ

Adrenal CT

Adrenal CT

Adrenal CT

ࣷ mass

ࣷ mass

ࣷ ࣷ mass ࣷ

NL

NL

NL

Check T, hCG, LH, estradiol

Check T, hCG, LH, estradiol

Check T, hCG, LH, estradiol

Low T
↑ LH

Low T
↑ LH


↑ Low T

NL or ↑ T
↑ LH

NL or ↑ T
↑ LH

↑
↑ NL

NL or ↓ T
↓ LH

NL or ↓ T
↓ LH

↓
↓ NL or Decreased T

↑ hCG

↑ hCG

↑ Increased hCG

↑ Estradiol

↑ Estradiol

↑ Increased Estradiol

All normal

All normal

All normal

Acute gynecomastia or >5 cm?

Acute gynecomastia or >5 cm?

Acute gynecomastia or >5 cm?

Yes

Yes

Yes

No

No

No