Paediatrics: Gynaecomastia

2021-04-15 03:46 PM

This is a condition affecting boys in which there is hyperplasia of the glandular tissue of the breast resulting in enlargement of one or both breasts.

Gynaecomastia

 

This is a condition affecting boys in which there is hyperplasia of the glandular tissue of the breast resulting in enlargement of one or both breasts. It is a common condition with 3 well-defined time periods of occurrence:

  • neonatal;
  •  puberty;
  •  during older adult life.

It is due to either an imbalance in the normal systemic or local oestrogen/ androgen ratio. An absolute or relative increase in oestrogen levels, local breast tissue hypersensitivity to oestrogens, or a decrease in the production, or action of free androgen levels may induce gynecomastia.

Aetiology

A number of diverse causes are recognized. Gynaecomastia must be differentiated from pseudo gynecomastia, which is breast enlargement due to fat accumulation.

 

Pubertal gynecomastia

This is the most common cause of gynecomastia in children and adolescents. The exact cause remains unclear. Proposed mechanisms include alterations in the rate of change in oestrogen and androgen production during puberty and/or hypersensitivity of breast tissue to oestrogen.

May affect 40–50% of children to some degree. It also depends on ethnicity and nutritional status. The usual age of onset of development is just before puberty (ages 10–12yrs), peaking during puberty (age 13–14yrs). In the majority of children, the gynecomastia usually involutes after 1–2yrs and is generally resolved by end of puberty (age 16–17yrs).

 

The diagnosis is established by excluding other possible causes of gynecomastia by taking a detailed clinical and family history, and examination.

Investigations should include:

  • serum oestrogen, testosterone, LH, FSH;
  •  serum prolactin;
  •  LFT; thyroid function tests;
  •  karyotype.

Where testicular/adrenal/hepatic tumour is suspected the following investigations should be considered:

  • US abdomen/testis;
  •  MRI abdomen/testis;
  •  serum BhCG levels.

 Management

Reassurance and explanation are usually sufficient for pubertal gynecomastia. In severe cases where pubertal gynecomastia is causing significant psychological distress or where gynecomastia persists beyond puberty, surgical resection of excess glandular breast tissue is warranted. The role of medical therapy with aromatase inhibitors or with selective oestrogen receptor blocking agents (e.g. tamoxifen) is currently unclear.