Paediatrics: Gynaecomastia

Gynaecomastia

This is a condition affecting boys in which there is hyperplasia of the glan-dular 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 hypersentivity to oestrogens, or a decrease in the produc-tion, or action of free androgen levels may induce gynaecomastia.

Aetiology

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

Pubertal gynaecomastia

This is most common cause of gynaecomastia in children and adolescents. The exact cause remains unclear. Proposed mechanisms include altera-tions 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 eth-nicity and nutritional status. 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 gynaecomastia 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 gynae-comastia 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 inves-tigations should be considered:

·US abdomen/testis;

·MRI abdomen/testis;

·serum BhCG levels.

Management

Reassurance and explanation are usually sufficient for pubertal gynaeco-mastia. In severe cases where pubertal gynaecomastia is causing significant pyschological distress or where gynaecomastia 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.