Gynecomastia in Elderly Males

Diagnosis and Evaluation

The American Urological Association recommends measuring serum estradiol in all men presenting with gynecomastia, and those with elevated baseline estradiol must be referred to an endocrinologist to determine the underlying hormonal cause 1
Measure both testosterone AND estradiol levels in all testosterone-deficient patients who present with breast symptoms or gynecomastia before starting any therapy 1
Perform testicular examination to assess for masses, size, consistency, and varicoceles that might indicate estrogen-secreting tumors 1
Calculate BMI and assess body habitus to differentiate true gynecomastia from pseudogynecomastia (fatty tissue deposition) 1
If testosterone is low, measure LH levels to differentiate primary from secondary hypogonadism 1
If LH is low or low-normal with low testosterone, measure prolactin to evaluate for pituitary pathology 1
If estradiol is elevated, mandatory endocrinology referral to identify the source (testicular tumor, adrenal tumor, increased peripheral aromatization, exogenous sources) 1

Men who develop gynecomastia on testosterone therapy should undergo monitoring as symptoms sometimes resolve spontaneously 1
Selective estrogen receptor modulators may be considered in testosterone-deficient patients with low or low-normal LH levels 1
Observation is appropriate initially, as noncyclical breast pain resolves spontaneously in up to 50% of patients 1
Gynecomastia is a recognized potential risk of testosterone replacement therapy, listed alongside other adverse effects 2, 3