The Symptomatic Breast Speciality Delivery Group was established to support and look at new innovative ways to delivering Symptomatic Breast services across NHS Scotland.

Through development of Once for Scotland approaches for delivery of care, focus is being placed on looking at opportunities to develop clinical pathways to reduce unwarranted variation in delivery of quality healthcare and to sustainably improve waiting times for non-urgent care within breast services.

Speciality Delivery Groups have been established to engage and fully utilise the role of clinical leadership across NHS Scotland.

Development of the Gynaecomastia Pathway has been progressed through the Symptomatic Breast Speciality Delivery Group.

The recommendations have not followed the standard process used by the Scottish Intercollegiate Guidelines Network (SIGN) but are based on available guidance and expert opinion, with peer review to provide quality assurance.

This guidance will be reviewed and updated as new evidence emerges.

Gynaecomastia is a benign enlargement of the male breast with firm tissue extending concentrically beyond the nipple. It may unilateral, bi-lateral, painful or asymptomatic⁴.

A common theme during the Breast Speciality Delivery group meetings has focused on the referral of men with breast issues to secondary care services.

A consensus was formed around the principles that:

1. Gynaecomastia is a breast manifestation of a systemic problem. Secondary care referral and investigation is not necessary in the vast majority of cases and variation in practice and over investigation are common.
2. Breast lumps in men (rather than generalised swelling of the breast tissue) require specific investigation.

Examination

Should distinguish between general swelling of the breast tissue or a specific lump. Swelling of breast tissue due to gynaecomastia is often asymmetrical. A soft, well-defined lump away from the breast tissue is likely to be a lipoma and may not require further investigation, especially if other lipomas are present. A specific lump within the breast tissue (rather than generalised breast swelling) or other features of concern (such as nipple inversion, nipple discharge or distortion) requires referral to the breast unit.

History

Should be taken for causes of gynaecomastia, including drugs (prescribed or otherwise), alcohol, protein supplements, liver disease, testicular issues and obesity (see Systemic conditions associated with gynaecomastia). In those going through puberty or the very old, gynaecomastia is likely to be due to normal, age-related hormonal changes. Drugs causing gynaecomastia include antioestrogens, spironolactone, calcium channel blockers, proton pump inhibitors, cimetidine, allopurinol, digoxin, opioids, anabolic steroids and cannabis. The use of protein supplements also appears to be associated. Testicular examination should be performed for atrophy, absence or lump. If any predisposing cause is identified this should be addressed. Gynaecomastia is likely to persist or recur after treatment if the underlying cause is still present. Pubertal gynaecomastia will usually resolve spontaneously but can take many months.

Blood tests

In the absence of a predisposing cause, consider blood tests for urea and electrolytes, liver function tests, Luteinizing hormone, Follicle Stimulating Hormone testosterone, prolactin, beta human chorionic gonadotropin- and alpha-fetoprotein and thyroid function tests and address any abnormalities.

Medical treatment

Consider medical treatment for persisting pubertal gynaecomastia or where there is no obvious predisposing cause or abnormality of blood tests. This is an unlicensed indication. It is most useful for recent onset gynaecomastia and usually improves breast sensitivity. If prescription of a medication out with it's licensed indication is being considered discussion with secondary care colleagues is an option should this be felt necessary for the small number of patients who may benefit.

• Tamoxifen 10mg once daily for 3-9 months
• Anastrozole 1mg daily for 3 months

Surgical excision

For cosmesis is considered through the exceptional aesthetic referral pathway.

• Those with a breast lump (not just generalised breast swelling) should undergo triple assessment. Those with a clinically obvious lipoma may not need further investigation.

• Investigation and treatment pathways are otherwise as noted above for primary care.

• When an obvious cause of gynecomastia is present, further investigation is not necessary.

• Consider mammography in those over 40. Ultrasound scanning is not required unless a specific breast lump (not just generalised breast swelling or a lipoma) is present.

• Testicular failure
• Liver disease
• Obesity
• Renal failure
• Adrenal disease
• Hyperthyroidism
• Testicular cancer
• Lung cancer
• Klinefelter’s syndrome

1. Association of Breast Surgery (2021) Investigation and management of gynaecomastia in primary and secondary care Last accessed 22 August 2023
2. Royal College or Radiologists (2019) Guidance on screening and symptomatic breast imaging, Fourth edition Last accessed 22 August 2023
3. Thiruchelvam P, Churchill W, Walker JN, Rose K, Lewis J, Al-Mufti R. Gynaecomastia. BMJ 016;354:i4833 https://doi.org/10.1136/bmj.i4833
4. Niewoehner, CB. Gynaecomastia. BMJ Best Practice. Oct 2022. https://bestpractice.bmj.com/topics/en-gb/869 Last accessed 22 August 2023

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