Gynaecomastia History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you today about the swelling you have noticed in your chest area. I will ask you some questions to try to determine what might be causing the problem. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presenting, for example: “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’, and can offer valuable information about why the patient has sought medical attention, as well as cues surrounding their ideas, concerns, and expectations (ICE), to pick up on later in the consultation.

History of Presenting Complaint

Next, you need to gather more specific information about the patient’s presenting complaint in order to establish the differential diagnosis. You can use a mixture of open and closed questions. 

Examples of open questions here would be: “Could you describe the changes you have noticed?” or “Have you noticed any other symptoms alongside the swelling?” Examples of closed questions include: “Is the swelling on both sides of your chest?” or “Have you found any testicular lumps?”

When taking a history of gynaecomastia, it may be useful to think about the following structure for your questions, as well as what useful information the patient’s answers give you about the likely diagnosis:

• Site – is the swelling unilateral or bilateral? Most causes of gynaecomastia will present with bilateral swelling, as most causes are systemic. Physiological gynaecomastia may be asymmetrical. Unilateral swelling with any red flags, e.g., lumps, nipple changes, skin changes requires urgent assessment to rule out malignancy.
• Onset – when did the swelling start? Is there a physiological process occurring which may explain the symptoms, e.g., puberty? Does the onset coincide with starting a new prescribed medication or an increase in substance use?  
• Character – how would the patient describe the swelling? Is it entirely soft, (e.g., adipose tissue in pseudogynaecomastia)? Or, is there a firm swelling (developing breast tissue) extending out from behind the nipple, which is more likely to represent true gynaecomastia?
• Associated symptoms – has the patient experienced any other symptoms alongside the swelling? You will ask  closed questions about breast-specific and system-specific symptoms later, but this is an opportunity for the patient to answer an open question and inform you of anything else they have noticed.
• Impact – many patients may find gynaecomastia an embarrassing or worrying symptom, and it is important to find out if their daily activities or quality of life have been affected. 

System-specific History

After obtaining further details of the presenting complaint, you need to gather any relevant system-specific information. In this case, the system in question is the breast. 

Consider breast-specific symptoms that may occur alongside gynaecomastia, and ask about these specifically. 

It is important not only to ask about these symptoms, but also to consider why their presence or absence is significant in narrowing the differential diagnosis. 

Symptoms related to the breast to enquire about include, but are not limited to:

• Breast lumps – it is very important to determine whether the patient has noticed any lumps on self-examination, and to examine all patients presenting with gynaecomastia. The presence of a breast lump alongside gynaecomastia warrants urgent referral for further investigation to rule out malignancy.
• Skin changes – puckering, tethering, thickening, dimpling, or a peau d’orange appearance are all concerning for malignancy and warrant further assessment.
• Nipple changes – has the patient (or anyone else) noticed any nipple changes, e.g., inversion that is new for them? Nipple retraction or inversion are also concerning symptoms for malignancy and warrant urgent referral to breast services. 
• Mastalgia – is the swelling associated with any tenderness? True gynaecomastia will often be tender due to the presence of developing breast tissue. Pseudogynaecomastia (excess fat around the breast area) is less likely to be tender. A non-tender lump in the breast is a red flag for malignancy and should always be investigated. 

Red Flags

It is important to ask about symptoms that may lead you to consider more sinister causes of gynaecomastia in the differential diagnosis, which may require more urgent investigation and management, e.g., malignancy. 

Some of these symptoms have been covered in the sections above but are listed below for clarity.

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information, as they might find the symptoms worrying or may lack the same insight into the significance as you do. 

Red flag symptoms to screen for which would prompt an urgent referral to rule out male breast cancer include:

• Breast lump
• Nipple retraction or inversion
• Nipple discharge
• Skin changes

Relevant Systems Review

A systems review is a useful tool to ensure no key information from the history has been missed. However, it is important to consider which systems are relevant to review so that your questions remain pertinent to the presenting complaint.

Relevant systems to review when taking a history of nipple discharge include the following:

• Endocrine – does the patient have obesity (defined as BMI ≥ 30)? Are there any associated symptoms to suggest hyperthyroidism, e.g., tremor, sweating, goitre, heat intolerance, signs of thyroid eye disease?
• Urological – a key question to ask all patients presenting with gynaecomastia is whether they have noticed any testicular lumps, pain or swelling. Patients should be offered a testicular examination to look for lumps, (testicular Leydig cell tumours) or inflammation (orchitis).
• Gastrointestinal – are there any associated symptoms of liver cirrhosis (e.g., ascites, palmar erythema, jaundice, testicular atrophy, spider naevi)?

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern, and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you. Some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing this swelling?”
• Concerns – “Is there anything that is worrying you about this?” “Have you read or Googled anything about your symptoms that has made you anxious?”
• Expectations – “Was there anything specific you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of the presenting complaint of gynaecomastia. For example, a patient who is known to have non-alcoholic fatty liver disease presenting with gynaecomastia may indicate that their disease has progressed to liver cirrhosis.

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer, e.g., over-the-counter medications, herbal or alternative remedies, contraception, HRT, or injections such as B12. Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis. For example, consider a patient who presents with gynaecomastia and has recently started spironolactone for their uncontrolled high blood pressure.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, other than their presenting complaint. Consider asking the following:

• Who do they live with? Do they have a social support network they could depend on if they were to receive a life-changing or life-limiting diagnosis, e.g., malignancy?
• Do they work? Is the patient going to require time off work to attend appointments, investigations, or treatment? 
• Do they drive? Does their condition affect their ability to drive or to attend appointments?
• Do they smoke? Smoking is associated with increased risk of malignancy.
• Do they drink alcohol? Alcohol-related liver disease is a significant cause of liver cirrhosis, which in turn can cause gynaecomastia due to changes in oestrogen levels.
• Do they use recreational drugs? Several recreational substances are associated with gynaecomastia, including opiates and cannabis. Patients may not think about anabolic steroids as a recreational drug or substance misuse, so it is important to ask patients presenting with gynaecomastia about steroid use. 

Family History

Does anyone in the family have any breast conditions, e.g., breast cancer? Patients may ask whether they are at increased risk of breast cancer due to a positive family history. It is worth familiarising yourself with the criteria that define increased risk of familial breast cancer, which may prompt discussion about referral for genetic counselling.

Do any other health conditions run in the family which may be important when thinking about causes of gynaecomastia, e.g., hyperthyroidism?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests, or further investigation and imaging.

Last updated June 2025

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