Doctor, my boy has breasts!

Although obesity is a risk factor for gynaecomastia, it can also mimic the condition when excess adipose tissue and fatty infiltration of the breasts makes it look like the affected boys are developing actual breasts. — AFP

Puberty brings many physical changes with it, most of them expected, whether in boys or girls.

However, one physical change that can catch parents of boys offguard is pubertal gynaecomastia.

Gynaecomastia is when males of any age develop breasts.

Pubertal gynaecomastia refers specifically to the physiological enlargement of breast tissue that occurs in some boys during puberty.

It’s quite common, with some studies reporting it in more than half of male adolescents, although the exact percentage varies due to different study methods.

Many people are not aware that oestrogen – the sex hormone associated with females that causes breast development – is also found in males.

In males, testosterone is converted to a small amount of oestrogen via an enzyme known as aromatase.

The higher levels of testosterone in adult men inhibit the actions of oestrogen.

However, in boys, the hormonal imbalances between testosterone and oestrogen during puberty can cause breast enlargement when the balance tilts in favour of oestrogen.

This enlargement usually peaks around the middle stage of puberty, typically between the ages of 12 and 14, when most boys’ testes are around eight to 10 millilitres in size.

Boys with gynaecomastia might complain of a lump directly behind their nipple – this is the breast tissue.

While it might be tender initially, the tenderness usually goes away as the tissue changes.

Fortunately, pubertal gynaecomastia will go away on its own most of the time.

Around 70% of cases get better within a year; for the rest, it might take up to three years.

However, if the breasts are more than four centimetres each, persist for more than one to two years, or persist after the age of 17 years, the condition might not go away on its own.

When to worry

Do see a doctor promptly if your son’s gynaecomastia:

• Occurs outside of puberty
• Grows really fast
• Gets much bigger than expected
• Is very painful
• Is not in the centre of the breast
• Occurs along with other concerns about their testes, or
• Causes a lot of worry.

Other causes need to be evaluated when the clinical picture is not typical of pubertal gynaecomastia.

These include medical conditions that cause low testosterone or excess oestrogen, Klinefelter syndrome, or tumours of the testes, pituitary or adrenal glands.

Obesity, as well as liver, kidney and thyroid diseases, are also risk factors for gynaecomastia.

Gynaecomastia is also linked to certain drugs or substances, e.g. specific medications for stomach ulcers, vomiting, mental illnesses and heart conditions; antiretroviral therapy; anabolic steroids; illicit drugs; and even lavender and tea-tree oil.

In these cases, the amount and duration of exposure needs to be taken into account.

It’s important to differentiate gynaecomastia from other conditions.

For example, in overweight or obese adolescent boys, excess adipose tissue and fatty infiltration of the breast may mimic gynaecomastia.

And while breast cancer in males is rare, any localised lump or skin changes in the area should be evaluated promptly.

Address the cause

If gynaecomastia is linked to medication, a substance or herbal therapy, stopping the agent at an early stage may lead to improvement within a month.

Addressing any underlying cause must be done before considering other treatments.

In most cases of pubertal gynaecomastia, it tends to go away on its own within a year.

However, teenagers may face distress and teasing due to their condition.

Many can be comforted with regular medical follow-ups every few months.

For those struggling, talking to a therapist can help deal with issues like bullying or low self-esteem.

Medical or hormonal treatment is not routinely recommended as there is lack of evidence of its effectiveness in pubertal gynaecomastia.

It might be considered for a selected few patients, e.g. those with physiological gynaecomastia that enlarges rapidly; is more than 4cm, which is less likely to regress; and that causes significant embarrassment.

Surgical intervention might be considered if the condition is causing a lot of distress, has failed medical therapy, is significantly large, persists for two or more years, or occurs after the age of 16.

Doctors will typically assess the patient’s history and examine them, focusing on medication, supplements and cream use; puberty stage; family history; and associated symptoms.

They may also do blood tests and imaging to rule out other possible causes of the gynaecomastia.

Be aware

In conclusion, physiological gynaecomastia is a common occurrence in pubertal boys and usually resolves on its own.

However, certain symptoms warrant prompt medical evaluation.

These include gynaecomastia that appears before puberty, has rapid or significant growth, or causes severe pain or substantial worry.

Additionally, if a lump is not centrally located in the breast or if there are concerns regarding the testes, seeking immediate medical advice is important.

Healthcare professionals and parents should also be aware of the types of medications, herbal remedies and substances, including fragrances and oils, that may cause gynaecomastia.

Dr Jeanne Wong Sze Lyn is a consultant paediatrician and paediatric endocrinologist. For more information, email [e-mail]. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.