A BOY WITH BREASTS

Anthony has pubertal gynaecomastia. All males have small amounts of oestrogen, just as all females have small amounts of adrenal androgens (which, in females, leads to the development of pubic and axillary hair). Gynaecomastia is common in pubertal males and is due to a decreased ratio of testosterone to oestrogen in puberty. Klinefelter’s syndrome (XXY) can be associated with gynaecomastia and learning difficulties. These patients also have small testes and this makes that diagnosis unlikely in our patient. Gynaecomastia is occasionally familial. Very rarely, oestrogen-secreting tumours can lead to gynaecomastia, e.g. a feminizing adrenal tumour or a Leydig cell tumour of the testis. The absence of abdominal signs, of a unilaterally enlarged testis and the normality of the oestradiol level make these diagnoses very unlikely. Drugs such as oestrogen and spironolactone and drugs of abuse, such as marijuana, can also cause gynaecomastia. Prolactinomas are not usually accompanied by gynaecomastia and the absence of galactorrhoea makes this diagnosis unlikely. Breast cancer would be exceptionally rare in puberty. Mild-to-moderate cases of pubertal gynaecomastia need no investigation. The condition is transient and usually lasts for several months to 2 years. Anthony is somewhat overweight and a proportion of the breast enlargement could be accounted for by adipose rather than breast tissue. Advice on weight loss could therefore be helpful. In mild-tomoderate cases, reassurance usually suffices. If the gynaecomastia is severe, or is leading to psychosocial problems, e.g. severe teasing, plastic surgery is indicated. Mammary reduction by either liposuction or a subareolar incision with removal of the excess tissue can be performed.

KEY POINTS

• Gynaecomastia is common in pubertal boys.

• Reassurance usually suffices, but occasionally plastic surgery is indicated.