A 24-year-old man comes to the office for evaluation of progressive enlargement of the breasts for 2 years. He reports normal early morning erections and has had no headaches, breast pain or discharge, or fatigue. The patient does not use alcohol or recreational drugs. Blood pressure is 110/70 mm Hg and pulse is 88/min. BMI is 35 kg/m². Examination of the breast shows soft tissue enlargement without clearly defined, palpable borders or nodules. There is no tenderness, discharge, nipple retraction, or skin dimpling. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?

Question

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This patient has diffuse enlargement of the breasts without pain, tenderness, nodules, or skin dimpling. In light of the chronicity, underlying obesity, and lack of hypogonadal (eg, loss of erections) and pituitary (eg, headache) symptoms, this most likely represents pseudogynecomastia (also called lipomastia). Pseudogynecomastia is characterized by excessive deposition of fat in the breast, which commonly extends into the axilla and skin folds without a distinct margin. In contrast, in true gynecomastia (ie, enlargement of the glandular breast tissue), the margin of firm glandular tissue is often palpable and the breast may be tender. The diagnosis is usually apparent on clinical findings (ie, body habitus, palpation). Management includes weight loss, which is usually adequate. Liposuction or surgical reduction can be considered, but risks include scarring, asymmetry, and poor cosmetic results. (Choice A) Breast imaging (eg, mammogram, ultrasound) should be considered to exclude malignancy in patients with eccentric, asymmetric, or nodular breast findings. This patient has no signs of malignancy and imaging is not needed. (Choice B) Hormonal testing (eg, testosterone, estradiol, LH, hCG, prolactin) is indicated for evaluation of patients with true gynecomastia who do not have a known underlying cause (eg, cirrhosis). Biochemical testing is not needed for those with pseudogynecomastia. (Choice C) Testicular ultrasound to evaluate for gonadal malignancy is indicated for patients with a palpable scrotal mass or elevated beta-hCG level. In general, endocrinologic imaging studies are done only when the biochemical evaluation has detected a significant abnormality. (Choice D) Tamoxifen is a selective estrogen receptor modulator that is used to treat gynecomastia and is also sometimes used for prevention of gynecomastia in patients receiving antiandrogen therapy for prostate cancer. It is not beneficial in pseudogynecomastia. Educational objective: Pseudogynecomastia is characterized by chronic, excessive deposition of fat in the breast without a distinct margin, typically in patients with obesity. In true gynecomastia (ie, enlargement of the glandular breast tissue), the margin of firm glandular tissue is often palpable and the breast may be tender. The diagnosis is based on clinical findings. Management includes weight loss. References: Gynecomastia. (http://www.ncbi.nlm.nih.gov/pubmed/22534349)

A 24-Year-Old Man Comes to the Office for Evaluation of Progressive