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Gynecomastia (Breast Enlargement in Boys)

 

What is Gynecomastia?
Why Breast Enlargement Occurs?
Causes of Gynecomastia
Investigations & Diagnosis
Medicine & Hormone Therapy
Surgery for Breast Enlargement
Liposuction Therapy
Response of treatment

 

What is Gynecomastia? Breast enlargement in boys called gynecomastia (also known as gynecomazia). It may start any time from childhood to 35 years of age.  It may start as small breast nodule then grow further to large size. It causes lot of embarrassment to boys. It leads to inferiority complex & lack of concentration in study or work.  Sometimes breast enlargement may be associated with decreased development of secondary genital characters like less beard & moustache, less body hair, soft skiin as found in girls, soft voice like females, less muscular development i.e. less manly body. Due to all this patient may have decreased confidence on himself & may even sometimes may have nervousness in talking to others. The body energy may also become less so that patient feels tired all the time. There memory also may be less. Sometimes all above disorders can lead to severe anxiety & even frank depression may occur.

Why Breast Enlargement Occurs? All boys have very little undetectable breast tissue in childhood. In some boys due to any of below mentioned causes either male hormones decreases or female hormone as estradiol & other hormone either increase in amount or their effect increases in the body. These hormones changes lead to increased concentration of female hormones in the breast tissue. 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 become particularly 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 leading to further breast enlargement. In some boys breast size keeps on increasing for many years where as in other growth stops after few years.  

Causes of Gynecomastia:  Breast enlargement in male can occur due to any of the following causes as:

1) Deficiency of male hormones: It can be due to decreased production of male hormone (Testosterone & other male hormones) from testis either due to defect in testis or due to deficiency of trophic hormones from the pituitary gland.   

 a) Primary Testicular Disorder: Viral orchits, trauma, castration, granulomatous disease, varicocele, Congenital anorchia, Klinefelter syndrome, Noonan syndrome, Viral orchitis, Mumps Orchitis, Leprotic Orchits, other Testicular disorders, primary leydig cell dysfunction, XX male gonadal dysgenesis 

b) Deficiency of Trophic Hormones: Hypothalamic Ė pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome , Hypothalmic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, tuberculosis, fugal infection, hemochromatosis), Autoimmune hypophysitis, Isolated gonadotropic deficiency with or without anosmia, Fertile eunuch syndrone, Idiopathic hypopituitarism, CNS disorders  : tumors, infections, pituitary agenesis or hypoplasia, hydrocephalus, Septooptic dysplasia, CNS radiation for leukemia or brain tumor, Prader-Willi and Laurence-Moon-Biedly Syndrome, Thalassemia major

c)      Defects in androgen synthesis.

2) Excess female hormone production from Adrenal Glands: Increased female hormone estrogen in body due to excess production from testis, HCG-producing tumor , testicular tumor, True hermaphorditism, Estrogen-producing adrenal tumor, Increased production of female hormone in other body parts as in Adrenal disease, liver disease , thyrotoxicosis.

3) Excess female hormone production from testis: due to many disorders ovaries start producing more female hormones. This may occur due to Alcoholic Liver Disease, Hyperthyroidism, Obesity, Androgen-Insensitivity syndrome ,Familal aromatase excess  

4) Idiopathic Gynecomastia: In this disorder breast tissue is more sensitive  to even small amount of female hormone in the body . It can also due to abnormally increased sensitivity of breast tissue to tiny levels of female hormones so that they over-react & grow large.

5) Drug  Induced: There are many drugs which when used wrongly may lead to enlargement of breast as  phenothiazine, methyldopa, reserpine, trycyclic antidepressant, metochlopramide, estradiol, diethylstilbestrol, digitalis, HCG, clomiphene,  ketoconazole, alkylating agents, spironolactone, cimetidine, aminoglutethimide, flutamide, cypoterone. Others : amiodarone, busulfan, captropril, ethionamide, isoniazid, D-penicillamine, phenytoin, diazepam, marijuana, heroin, omeprazole, rantidine, enalapril, niledipine, verapamil, Cytotxic drugs

6) Androgen Receptor defects: Defects in the structure or function of androgen receptors, Complete testicular feminization syndrome, Partial androgen insensitivity syndrome(Reifenstein syndrome)

7) Genetic i.e. hereditary causes

8) Postreceptor transduction abnormalities

9)    Increase in peripheral aromatase activity

10)  Physiological Pubertal Gynecomastia

Investigations & Diagnosis: We take detail history to pinpoint the possible causes of this problem. After this we do certain of below mentioned tests to diagnose the possible cause of breast enlargement in that particular patient. At our diabetes & thyroid center we have most advance state of the art laboratory with all the modern facility for all above tests. After these tests we reach the final diagnosis.

Various tests needed are as follows:

Complete male hormone profile: This profile includes all the male hormone tests which controls all the male features & does not allows breast to enlarge.

Thyroid test

Serum testosterone is either below normal range or on the lower side of normal. Similarly free testosterone is either low or on lower side of normal.

SHBG

Adrenal Hormones

Female hormone tests

HCG

Mammography

USG breast

USG of testis or abdomen or for some other part

Chromosomal analysis is done to see the genetic structure of testis, because there are many chromosome disorders lead to hypogonadism.  
Capacity of generation of active testosterone i.e. DHT is tested. This DHT generation test is abnormal in some cases of hypogonadism.  

Molecular genetic studies done in some special cases.  
Serum estrogen increased whenever testicular function decreased.  
Serum DHT is low in some conditions when generation of dihydrotestosterone is decreased.  
Assessment of androgen receptor is due when needed, dynamic tests as HCG test, response to antiestrogen & gonadotropin releasing hormone tests.

Treatment: There are many drugs which cure gynecomazia in six months to one year time. All above drugs or procedures have no side effects.

A) Drug treatment: various treatments are:

1) Antiestrogens as tamoxifen& clomiphene is very effective. These drugs block the effect of female hormone on the breast cells. After few week of treatment breast size starts shrinking. In many cases few month of therapy may completely cure the gynecomastia leading to absolutely flat chest.  

2) Danazol also decreases the gynecomastia and is also very effective. The effects starts in three months & breast enlargement is cured in six months. 

3) DHT gel local application: Local application of D.H.T. gel is new preparation for male hormone replacement. By binding to breast cell receptors it leads to shrinking & finally disappearance of breast enlargement. It is   very effective for gynecomastia treatment & in most cases of cure of breast development in boys.

4)  Male Hormone Replacement: Treatment with male hormone testosterone is available as oral tablets,  skiin patch, skiin gels or injection is  given with very good results.

The various preparation of testosterone & route of administration are: 

a)     Oral preparation that is available in capsule form. It needs to be given one to three capsules daily. These have no side effects. 

b) Transdermal Testosterone given as testosterone gel preparations.  It need to be applied any part of skiin once a day. It is very effective & has no side effects. 

c). Transdermal Testosterone scrotal patch are also available which are very effective even if used in small doses.. It is very effective & has no side effects.

d)   Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & better effective.  It is used as one tablet daily to be kept under the tongue for few minutes. It has no side effect and it is very effective.

e)   Local application of D.H.T. gel available is a new preparation for male breast treatment. 

f)  Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given  every 10 to 14 days. 

g)   Long acting testosterone as testosterone bucilate given once in 4 months. 

h)   Testosterones implants are now available which once injected remain effective for up to six months. 

5) Liposuction: In this technique with the help of needle all fat & breast tissue. In this no admission required. It is painless. Patient need to stay at the centre just for few hours.

6) Localized fat dissolving devices

B) Surgical treatment:  is done by our surgeon. This procedure is called Reduction mammoplasty. This surgery is a minor surgery takes 15 to 30 minute under local anaesthesia.

Why doctors donít take this problem seriously: The problem of breast enlargement is psychologically very painful for the patient who is suffering with this problem.  It makes them feel less manly among the friends. This creates lot of mental stress in the patients. Unluckily majority of doctors do not take this problem seriously, because they think it to be more of cosmetic problem. Many patients come to our center from different cornerís of Indian cities including many from abroad too, all patient complained to us that majority doctors did not give much importance to their problem. Most doctors do not take this problem seriously, because they are not aware of the proper treatment of this case. At our center because we are specialize in exclusive treatment of breast  enlargement & other hormone disorders, we take this problem as seriously as any other hormone disease.

Response of treatment: At our center we have treated successfully thousands of patients breast enlargement from different states of India & other parts of world. After start of treatment breast size starts decreasing in approximately 3 months time. In next six to nine months almost all breast size disappears in most patients. 

Side effects of treatment: The treatment has no side effects.

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