Overview
Definition:
Gynecomastia is defined as the enlargement of glandular breast tissue in males
In adolescents, it is typically a physiological, transient condition associated with pubertal hormonal fluctuations, distinct from pseudogynecomastia (fat accumulation).
Epidemiology:
Physiological gynecomastia affects 30-60% of adolescent males, most commonly appearing between ages 12 and 17
It usually resolves spontaneously within 6 months to 2 years.
Clinical Significance:
While often benign, identifying true gynecomastia is crucial to rule out underlying pathological causes, reassure the adolescent and family, and manage potential psychological distress associated with body image concerns
Accurate evaluation aids in appropriate management and prevents unnecessary investigations or treatments.
Clinical Presentation
Symptoms:
A palpable, firm, rubbery or disc-like mass beneath the areola
May be unilateral or bilateral
Sometimes associated with mild tenderness or sensitivity
Absence of galactorrhea or nipple discharge
No significant systemic symptoms.
Signs:
Bilateral, symmetrical breast enlargement of glandular tissue, measuring at least 0.5 cm in diameter
Usually a firm, mobile mass under the areola
Normal penile and testicular size for pubertal stage
No other physical stigmata of endocrine disorders or malignancy.
Diagnostic Criteria:
Diagnosis is primarily clinical
Key features include: presence of palpable glandular tissue, absence of significant adipose tissue, onset during puberty, and absence of red flags suggestive of underlying pathology
WHO/Endocrine Society guidelines emphasize careful physical examination.
Diagnostic Approach
History Taking:
Detailed history of pubertal development (tanner staging of genitalia and pubic hair)
Onset, duration, and progression of breast enlargement
Presence of tenderness or pain
Family history of endocrine disorders or breast cancer
Medication history (e.g., anabolic steroids, spironolactone, cimetidine, ketoconazole)
History of exposure to estrogenic compounds
Recent weight changes
Symptoms of other endocrine diseases (e.g., hypothyroidism, hyperthyroidism, liver disease).
Physical Examination:
Thorough pubertal assessment (Tanner staging for secondary sexual characteristics)
Palpation of breast tissue to differentiate glandular hypertrophy from adipose tissue
Assess for tenderness and size
Examine for testicular size and consistency
Check for abdominal masses or hepatomegaly
Assess for any chromosomal abnormalities stigmata
Examine for signs of liver disease or malnutrition
Evaluate for any skin lesions or signs of malignancy.
Investigations:
In most cases of typical adolescent gynecomastia, investigations are not required
If history or physical exam raises suspicion for pathology: Serum testosterone, LH, FSH (to assess gonadal function)
Estradiol levels
Prolactin levels (to rule out pituitary adenoma or hyperprolactinemia)
Beta-hCG (if testicular tumor suspected)
Liver function tests (LFTs) and renal function tests (RFTs) if systemic illness suspected
Karyotype analysis (if Klinefelter syndrome suspected, i.e., small testes, hypogonadism)
Thyroid function tests (TFTs) if hyperthyroidism is suspected
Imaging like ultrasound of testes may be considered if testicular mass is palpable.
Differential Diagnosis:
Pseudogynecomastia (lipomastia) due to obesity, which is diffuse fatty infiltration without glandular enlargement
Malignancy (rare in adolescents but should be considered in cases of unilateral, irregular, painless mass with skin changes or nipple retraction)
Prepubertal or pubertal breast buds (usually smaller and transient)
Accessory breast tissue
Fat deposition
Klinefelter syndrome (XXY) characterized by hypogonadism, small testes, and gynecomastia.
Management
Initial Management:
Reassurance is the cornerstone of management for physiological adolescent gynecomastia
Educate the adolescent and parents about the benign nature of the condition, its transient course, and normal hormonal fluctuations during puberty
Advise on maintaining a healthy lifestyle and avoiding medications or substances known to cause gynecomastia.
Medical Management:
Medical treatment is generally not indicated for physiological adolescent gynecomastia as it usually resolves spontaneously
Medications like tamoxifen or aromatase inhibitors are typically reserved for persistent or severe cases that cause significant psychological distress, and are often managed by specialists.
Surgical Management:
Surgery is considered only for persistent gynecomastia (lasting >2-3 years), severe psychological distress, or when there is a suspicion of malignancy after thorough evaluation
Surgical options include liposuction for fat reduction or mastectomy for glandular tissue removal
This is usually performed in late adolescence or adulthood.
Supportive Care:
Psychological support and counseling for adolescents experiencing significant body image issues or social anxiety due to gynecomastia
Encouraging open communication between the adolescent and parents
Regular follow-up to monitor regression of breast tissue and address any persistent concerns.
Complications
Early Complications:
Psychological distress, anxiety, depression, and social isolation related to body image concerns
Mild tenderness or discomfort.
Late Complications:
Persistent gynecomastia requiring surgical intervention
Long-term psychological impact if not adequately addressed
Rarely, undetected malignancy.
Prevention Strategies:
Avoiding exposure to exogenous estrogens or substances that can induce gynecomastia
Maintaining a healthy weight to prevent pseudogynecomastia
Early identification and reassurance of physiological gynecomastia to prevent undue anxiety.
Prognosis
Factors Affecting Prognosis:
The majority of adolescent gynecomastia cases resolve spontaneously within 1-2 years
Factors influencing prognosis include the duration of the condition, pubertal stage, and absence of underlying pathological causes.
Outcomes:
Excellent prognosis for spontaneous resolution in most cases
Psychological outcomes are significantly improved with appropriate reassurance and support
Surgical intervention offers good cosmetic results for persistent cases.
Follow Up:
Follow-up is primarily to monitor regression of breast tissue and provide ongoing reassurance
If the condition persists beyond 2-3 years or causes significant distress, referral to an endocrinologist or plastic surgeon may be considered
Routine follow-up is not necessary for typical physiological gynecomastia once reassurance has been provided.
Key Points
Exam Focus:
Differentiate physiological gynecomastia from pseudogynecomastia
Recognize red flags for pathological causes
Understand the typical pubertal timing and spontaneous resolution
Know which investigations are indicated and when.
Clinical Pearls:
Always perform a thorough pubertal assessment
Palpate for firm glandular tissue under the areola, not just diffuse fat
Reassurance is often the most potent treatment
Avoid unnecessary investigations in typical cases to prevent iatrogenic anxiety.
Common Mistakes:
Over-investigating benign physiological gynecomastia
Misdiagnosing pseudogynecomastia as true gynecomastia
Failing to reassure adolescents and families, leading to unnecessary anxiety
Delaying referral for persistent or concerning cases.