A soft well-defined lump away from breast tissue is likely to be a lipoma, particularly if other lipomas are present, and may not require further investigation.

A specific lump within the breast tissue or other features of concern (nipple inversion, discharge/distortion) requires referral to the breast clinic.

Physiological gynaecomastia occurs in the newborn period, during puberty, and with ageing and obesity.

History should explore potential causes:

• drugs - prescribed or otherwise
  • anti-androgen drugs
  • spironolactone
  • calcium channel blockers
  • proton pump inhibitors
  • cimetidine
  • allopurinol
  • digoxin
  • opioids
  • anabolic steroids
  • cannabis
• alcohol
• protein supplements
• liver disease
• testicular issues
• obesity

Testicular examination should be carried out to identify atrophy, absence or lump

When an obvious cause is identified, no further investigation is needed. If cause is not identified from the history consider bloods for:

• U&E, LFT, TFT
• LH, FSH, prolactin, beta HCG, AFP, testosterone

Address any identified underlying cause. Symptoms should start to resolve after around a month but gynaecomastia is unlikely to reverse if present for more than 12 months.

Most cases require no specific treatment.

Pubertal gynaecomastia will usually resolve spontaneously but may take many months.

Consider medical treatment for persistent pubertal gynaecomastia or where there is no obvious cause or abnormality of blood tests.

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

This is an unlicensed indication. They are most effective in gynaecomastia of recent onset and often help relieve pain.

Gynaecomastia is likely to persist or recur after treatment if the underlying cause is still present.

Refer specific lumps, nipple inversion nipple discharge or distortion.

Referral for surgery needs to be done via the exceptional aesthetic pathway.

Advice request can be used to discuss medical treatment.