Interpretation of laboratory tests in the evaluation of unilateral or bilateral gynecomastia in phenotypically male children and adolescents

Initial tests					Additional evaluation/supportive findings	Potential cause(s)
hCG	Estradiol	Testosterone	LH	DHEAS
Increased	Normal or increased	Normal	Normal	Normal	Testicular US: Normal	Extragonadal germ-cell tumor or hCG-secreting nontrophoblastic neoplasm*
					Testicular US: Mass	Testicular germ cell tumor
Normal	Increased	Normal	Increased	Normal	Karyotype	Possible ovotesticular DSD^¶
Normal	Increased	Normal	Normal or decreased	Increased	Adrenal imaging: Adrenal mass	Adrenal neoplasm
					Adrenal imaging: Normal	Possible CAH^¶
Normal	Increased	Normal	Normal or decreased	Normal	Testicular US: Normal Adrenal imaging: Normal	Increased extraglandular aromatase activity (eg, aromatase excess syndrome)
					Testicular US: Mass	Sertoli-cell tumor
Normal	Increased	Increased	Normal or decreased	Normal	Testicular US: Mass	Leydig-cell tumor or Leydig-cell and Sertoli-cell tumor
Normal	Normal	Increased	Increased	Normal	TSH: Decreased Thyroxine: Increased	Hyperthyroidism
					TSH: Normal Thyroxine: Normal	Androgen resistance (eg, partial androgen insensitivity)
Normal	Normal	Decreased^Δ	Increased	Normal	Refer to UpToDate content on primary hypogonadism in males	Primary hypogonadism
Normal	Normal	Decreased^Δ	Normal or decreased^Δ	Normal	Serum prolactin: Normal	Secondary hypogonadism
					Serum prolactin: Elevated	Prolactin-secreting pituitary tumor^◊
Normal	Normal	Normal	Normal	Normal	NA	Pubertal or idiopathic gynecomastia

Our suggested initial laboratory evaluation for phenotypically male children and adolescents with unilateral or bilateral gynecomastia in whom a potential cause is not identified on history and physical examination includes measurement of early morning hCG, estradiol, LH, testosterone, and DHEAS. The reference range for hormones may vary by age, sexual maturity rating, and clinical laboratory. All patients may not fit into the categories in the table above.

hCG: human chorionic gonadotropin; LH: luteinizing hormone; DHEAS: dehydroepiandrosterone sulfate; US: ultrasonography; CT: computed tomography; MRI: magnetic resonance imaging; TSH: thyroid-stimulating hormone; NA: not applicable; DSD: difference of sex development; CAH: congenital adrenal hyperplasia.

* Further evaluation may include chest radiography and abdominal computed tomography.

¶ Referral to a pediatric endocrinologist is recommended. Refer to UpToDate content on atypical genitalia and congenital adrenal hyperplasia for more information.

Δ Decreased testosterone and decreased LH are normal findings in prepubertal-age males and not helpful in the evaluation of gynecomastia.

◊ Further evaluation may include magnetic resonance imaging of the head.

References:

Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med 2007; 357:1229.
Ma NS, Geffner ME. Gynecomastia in prepubertal and pubertal men. Curr Opin Pediatr 2008; 20:465.
Misra M, Sagar P, Friedmann AM, et al. Case records of the Massachusetts General Hospital. Case 12-2016. An 8-Year-Old Boy with an Enlarging Mass in the Right Breast. N Engl J Med 2016; 374:1565.

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خرید پکیج

Interpretation of laboratory tests in the evaluation of unilateral or bilateral gynecomastia in phenotypically male children and adolescents