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What is small breast: When the size of breast in girls is less than 36” which is considered ideal, is termed as small breast.( also known as micro-mastia).
How Normal Breast develops: All girls have same size of breast tissue in childhood. At the time of puberty i.e. beginning of genital development female hormone estradiol, adrenal hormone androstenidione, 17-oh Progesterone, DHEAS, Growth hormone, LH, FSH, increases & SHBG decreases, Thyroid Hormone also plays the role. These hormones changes lead to increased concentration of Free Testosterone, DHT & some more hormones. These hormones then act on the various sensors (called receptors) in the breast tissue. After the interaction of hormones & receptors certain changes occurs in the functioning of cells of breast tissue so that breast cells starts growing in thickness & size & more & more fat starts depositing in the breast . thus breast size gradually starts increasing. Simultaneously it also increases the blood supply to breast tissue leading to more availability of growth factors to the breast tissue resulting in faster growth of breast tissue. These hormones & growth factors are in high concentration during peak of secondary genital characters development i. e. puberty leading to persistent stimulation of breast tissue for next two to three years i. e. up to completion of genital development. Thus in normal girls in two to three years full breast develop.
Causes of Small Breast: In girls the small breast can be due to following causes:
1) Female genital hormones deficiency i.e. estradiol in body due to many of the below mentioned causes as leading to absence of estrogen production (hypogonadotropic hypogonadism). Craniopharyngioma, Germinoma, Hamartoma, Hand Schuller Christan disease, Teratoma, Endodermal, sinus tumors, metastatic carcinoma, Infection and other disorders : Tuberculosis, Syphilis, Encephalitis/meningitis, sarcoidosis, kallmann syndrome, idiopathic hypogonadotropic hypogonadism, Chronic debilitating disease, Pituitary other hormone-screening pituitary tumors (ACTH, thyrotropin-stimulating hormone, growth hormone), non-functional tumors (craniophyaryngioma), Metastatic carinoma, Space-occupying lesions : Empty sella syndrome, Arterial aneuysm, Necrosis : Sheehan syndrome, Panhypopituitarism, Inflammatory /infiltrative : Sarcoidosis, Hemachoromatosis. Gonadal agenesis, Gonadal dysgenesis, Turner syndrome 45, X, Mosaicism, Pure gonadal dysgenesis, 46, XX, 46,XX (Swyer syndrome), Ovarian enzymatic deficiency as 17a-Hydroxylase deficiency, 17, 20-Lyase deficiency, Premature Ovarian failure : Idiopathic – premature menopause, injury, mumps oophoritis, radiation, chemotherapy, Resistant ovary (Savage syndrome), Autoimmune disease, Galactosemia.
2) Second cause for small breast is resistance of breast tissue to normal level of female hormone in the body. So that even though female hormone is normal in the body, but the breast tissue of these girls do not have sufficient receptors for female hormone leading to insufficient estrogen action meaning that female hormone is unable to work & breast do not grow well. But when female hormone level is further increased by female hormone replacement treatment & certain more medicines are given so that female hormones becomes more effective on breast, then breast tissue starts growing. Breast size then fully normalizes in six months to one-year time.
3) Growth factor deficiency
4) Zinc Deficiency
5) Estrogen biosynthetic defects
6) Congenital adrenal hyperplasia
7) Congenital absence of breast bud
8) Lipoatrophy generalized
9) Ninth Cause is resistance of hair roots to normal level of male
hormones, in this disorder male hormone is normal in blood even then hair root do not grow because in hair root there is less male hormone receptor (i.e. sensor of male hormone) so that male hormone is unable to work & hair do not grow well. But when male hormone level is further increased by male hormone replacement treatment & certain more medicines are given so that male hormones becomes more effective on hair roots, then hair roots starts growing. Beard & moustaches then fully normalizes in six months to one-year time.
10) Absence of estrogen receptors in breast tissue
12) Growth hormone deficiency due to hypopituiarism, pituitary disorders
13) Progeria
12) DRUGS: Cytotoxic Agents, Cyclophoamide, Vincristine,Ionising radiation, Azathioprine
13) Overmastectomy
14) Structural Defects Of body fat cell so that they do not grow
15) Generalized hypoplastic syndrome
16) Dysmorphic Syndrome
Investigations
& Diagnosis:
For
diagnosis of cause of absent or small breast we do following tests.
Complete hormone profile:
LH, FSH, total testosterone, Prolactin, Androstenidione, SHBG, 17 HYDROXYPROGESTERONE, DHEAS, Estradiol, Progesterone
Suppression & Stimulation Tests,Karyotype
Genetic testing
Choromosome analysis
Pro. Challenge test
High Resolution Ultrasound
Mammography
E2 CHALLENGE TEST
Diagnostic Therapeutic Response Test
Treatment
Options for Breast Enlargement
Before starting treatment for enlargement
of breast all above causes are investigated and proper diagnosis is made.
Then we test whether breast enlargement is possible or not.
First We Test Whether Breast Enlargement Is Possible Or Not
After above investigation we make the
decision about whether breast enlargement possible or not. We prescribe
the hormone treatment only if the above investigations suggest for the
scope of further breast enlargement.
Diagnostic
Therapeutic Response Test
This procedure is required in some
patient, if above test still does not clarifies of the possibility of
breast enlargement. For this hormone & other treatment is given for
three month in the form of female hormone tablet, local hormone
application at breast skiin, or vaginal gels & additional other
therapy. If breast enlarges in size i.e. it grows in size by more than 2
cm in these three months, it means breast of that patient has potential
for further growth. Once it is decided by above test that breast has
potential for further growth, in such patient further courses of hormone
therapy is given. By few courses of hormone treatment breast enlarges to
normal size in approximately one year time. By this therapy breast size as
well its consistency in firmness also increases. Thus breast becomes large
in size, more attractive & develops firm protruding look. This breast
enlargement treatment is very effective in those patient’s in whom
investigations & physical examination shows significant abnormality.
Thus most patients achieve fully normal breast. As breast size increases
in size patient's confidence increases and feeling of well-being is
achieved.
How this treatment works:-When
we give below-mentioned hormones by any of the below-mentioned routes. The
concentration of these hormones in blood circulation rises. This leads to
binding of more hormones on estrogen receptors of breast. After binding
with receptors these hormones leads to certain changes in the breast
tissue. This leads to multiplication of breast tissue leading to further
growth. This continued multiplication of breast tissue leads to further
breast growth. This continued multiplication of breast tissue under the
effect of above mentioned hormone treatment continues till breast size
normalizes. Usually in one-year time breast size as well as texture i.e.
firmness normalizes. Unluckily most doctors have less knowledge about
hormone treatment for this problem & also they think the problem of
small breast as more of cosmetic problem so that they neither investigate
the patient nor give hormone or other medical therapy for breast growth.
Various therapeutic options of breast
enlargement are available as:
This treatment can be either:
a. Hormone & Other Medicine Therapy: available
as pills, hormonal skiin patches or vaginal creams & other adjuvant
drugs are prescribed
OR
b. Surgical therapy: Breast
enlargement surgeries
Hormone & Medicine Treatment of Small Breast
We start medical treatment only when above tests shows that breast has capacity to enlarge. It is given in the form replacement of female hormones & other hormone as growth hormone & growth factor replacement. These hormones can be given in the form of oral tablets, skiin patches, ointments, gel or creams.
As this treatment has no side effects, is economical and easy to take either as oral tablets, skiin patches, or as gel, thus it is most preferred form of breast enlargement therapy.
The various Treatment options are:
Treatment of specific disease: Once the cause for absent or small breast is found by above tests then treatment started. Abnormalities of the pituitary and abnormalities in the adrenal glands can be treated by appropriate medicines. Normally patient starts getting improvement in breast size in three to six months.
The various drugs which are required are as follows:
1) Female hormones replacement: The replacement of female hormones is one of the common treatments for breast enlargement. The various female hormones are as follows:
a) Estradiol
b) Conjugated equine estrogen
c) Estriol
d) Natural estrogens
e) Prohormones
f) Estrogen skiin patches
g) Estrogen vaginal creams
h) Medroxyprogesterone
i) Oral E & P Combination Pill
j) Desgestro
k) Megestrol
L) Norethisterone
N) Hydroxyprogesterone
2) Growths Hormones Therapy: Growth hormone is given when somatotropin deficiency is found & that was cause of small breast..
3) IGF-1 therapy: is given when somatomedin-c deficiency is the cause.
4) Gonadotropin therapy is also very effective in breast enlargement in many patient.
5) Gonadotropin releasing hormone therapy is effective in many cases of under developed breast.
6) Medicine to increase the fat in breast tissue & body.
But unluckily many doctors do not take the problem seriously leading to patient not given proper treatment. Thus many patients remain having small size of breast & associated lifelong inferiority complex.
Response of Medical Treatment:
In properly selected patient, when any of above treatment is started the response is very good & has no side effects. In many scientific studies when the above treatment started breast size increases from previous size of hardly visible breast to as big as 36 inches & in some even larger size of 38 or 40 inches. Thus the trial of treatment should be given to all patients with small breast before asking them to go for surgery. It has no side effects if given in proper disease and in-patients when it is really indicated.
Breast Enlargement Surgery
Surgical Treatment is required when medicine are not effective then there are various surgical procedures which can lead long lasting good size firm breast. Our Cosmetic surgeon performs all breast increasing surgery.
Female Hormone Deficiency
Female Hormone Deficiency (Hypogonadism) is called when female hormone estradiol is less in body. The symptoms of female hormone deficiency are: menstrual irregularity, small breast, decreased desire for genital, dryness of vagina or pain during intercourse.
Cause of female hormone deficiency are hypothalamic disease, pituitary failure, L.H., F.S.H deficiency, prolactin excess, functional, hypothalamic amenorrhoea, defective egg formation or no egg formation at all or ovarian failure due to many of the causes. (hypogonadotropic hypogonadism). Craniopharyngioma, Germinoma, Hamartoma, Hand Schuller Christan disease, Teratoma, Endodermal, sinus tumors, metastatic carcinoma, Infection and other disorders : Tuberculosis, Syphilis, Encephalitis/meningitis, sarcoidosis, kallmann syndrome, idiopathic hypogonadotropic hypogonadism, Chronic debilitating disease, Pituitary other hormone-screening pituitary tumors (ACTH, thyrotropin-stimulating hormone, growth hormone), non-functional tumors (craniophyaryngioma), Metastatic carinoma, Space-occupying lesions : Empty sella syndrome, Arterial aneuysm, Necrosis : Sheehan syndrome, Panhypopituitarism, Inflammatory /infiltrative : Sarcoidosis, Hemachoromatosis. Gonadal agenesis, Gonadal dysgenesis, Turner syndrome 45, X, Mosaicism, Pure gonadal dysgenesis, 46, XX, 46,XX (Swyer syndrome), Ovarian enzymatic deficiency as 17a-Hydroxylase deficiency, 17, 20-Lyase deficiency, Premature Ovarian failure : Idiopathic – premature menopause, injury, mumps oophoritis, radiation, chemotherapy, Resistant ovary (Savage syndrome), Autoimmune disease,
Galactosemia.
Investigation: For diagnosis of cause of absent or small breast we do following tests.
Complete hormone profile: LH, FSH, total testosterone, Prolactin, Androstenidione, SHBG, 17 HYDROXYPROGESTERONE, DHEAS, Estradiol, Progesterone
Suppression & Stimulation Tests,
Karyotype
Genetic testing
Choromosome analysis
Pro. Challenge test
High Resolution Ultrasound
Mammography
E2 CHALLENGE TEST
Diagnostic Therapeutic Response Test
Treatment: After finding out the cause various hormone defects are corrected. Some short cause of female hormone is given. After treatment of approximately six months body starts forming hormone itself in many cases. Breast development starts uterus starts growing. In next three one year complete development of female genital character develops & menstrual period starts.
1) Female hormones replacement: The replacement of female hormones is one of the common treatments for breast enlargement. The various female hormones are as follows:
a) Estradiol
b) Conjugated equine estrogen
c) Estriol
d) Natural estrogens
e) Prohormones
f) Estrogen skiin patches
g) Estrogen vaginal creams
h) Medroxyprogesterone
a) Desgestrol
b) Megestrol
c) Norethisterone
d) Hydroxyprogesterone
e) Oral E & P Combination Pill
2) Gonadotropin therapy is also very effective in breast enlargement in many patient.
3) Gonadotropin releasing hormone therapy is effective in many cases of under developed breast.
Response of Treatment: After treatment of approximately six months body starts forming hormone itself in many cases. Breast development starts uterus starts growing. In next three one year complete development of female genital character develops & menstrual period starts.
Breast development at early age (Precocious Puberty)
Precocious Puberty :Breast development alone or additional genital development may occur at early age early age (termed as Precocious Puberty).
Causes:
If puberty occurs early then there is risk that her height may remain short & some psychological problem may occur. Sometimes threr may be risk of genital exploitation by others as child is still innocent even with good genital development.
After hormone testing the particular hormone defect is corrected leading to disappearance of breast & pubic hair. Later breast development & menstrual period comes at right time. So In all such cases one should try to find out exact cause of hormone disorder & then treatment should be started there are many suppressant hormone i.e. GnRH analogues which when given to girls then breast & of pubic hair regresses back.
Causes of Precocious Puberty
This can be due to increase in female hormone at very young age due to:
Ovarian cause, or due to pituitary-hypothalmic disorder as hypothalmic harmartoma, ovarian tumors, congenital adrenal hyperplasia & adrenal tumour & other CNS disorder. It can be due to idiopathic central precocious puberty (i.e. true) or pseudo precocious puberty. Other causes are premature thelarche, & premature
pubarche.
Central (GnRH) driven : Idiopathic (sporadic or familial), Central nervous system abnormalities,Acquired (Abscess, chemotherapy, granulomas, hypothalamic hamartomas, sept-optic dysplasia, suprasellar cyst.Tumor (LH-secreting adenoma, astrocytoma, slioma (may be associated with neurofibromatosis), crainpharyngiomas, ependymomas.
Secondary to chronic exposure to genital steroid (causes of peripheral puberty, CVAH, GIP, tumors) Reversible forms : space-occupying or pressure-associated lesions (Abscess, hydrocephalus) Peripheral (GnRH independent) : Genetic disorders (mutations) , Congenial virlizing adrenal hyperplasia (CVAH), males, Gonadotropin-independent puberty (GIP), males, McCune-Albright syndrome.
Tumors : Adrenal genital steroid secreting (adenoma, carcinoma), gonadotropin-producing (choriocarcinoma, chorioepithelioma, dysgerminoma, hepatoblastoma, hepatoma, teratoma) Ovarian (granulose cell, may be associated with Peutz-Jeghers syndrome); granulose, theca cell Testicular (Leydig Cell)
Limited or reversible forms : Chronic, primary hypothyroidism, CVAH, Exogenous genital steroid or gonadotropins, Ovarian cysts.
Variants of normal development : Premature pubarche (Secondary to premature adrenarche), Premature
thelarche.
Investigations & Diagnosis:
For diagnosis of cause of absent or small breast we do following tests.
Complete hormone profile: LH, FSH, total testosterone, Prolactin, Androstenidione, SHBG, 17 HYDROXYPROGESTERONE, DHEAS, Estradiol, Progesterone
Suppression & Stimulation Tests,
GnRH Stimulation test
Pro. Challenge test
High Resolution Ultrasound
Mammography
Diagnostic Therapeutic Response Test
MRI
Treatment Options for Early Puberty
Treatment of specific disease: Once the cause for early genital development is found by above tests then treatment started. Abnormalities of the pituitary and abnormalities in the adrenal glands can be treated by appropriate medicines. Normally patient starts getting decrease in breast size in three to six months.
The various drugs which are required are as follows:
1) Female hormones suppressant: GnRH analogues as triptorelin’ ,naferelin, Gonadorelin, testolactone, MEdroxy progesterone
Some times surgery may also be required
Response of treatment: Normally in three month breast size starts decreasing including pubic hair regresses. This treatment may be continued till the child puberty needs to be deferred. The moment we stop the treatment normal pubertal & genital development resumes.
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