Pubertal gynecomastia is the temporary enlargement of the glandular structure in the breast in men without an endocrine pathology. While breast enlargement can be unilateral or bilateral and painful, it is important that these adolescents do not have a history of chronic disease or drug use. Physiological gynecomastia is most common in three periods throughout life; neonatal period, pubertal period and late period of life.
Transient pubertal gynecomastia is the most common type of gynecomastia and is more common in men aged 10-16 years. It peaks especially between the ages of 13-14. The exact cause of pubertal gynecomastia is unknown. Often, an underlying chronic disease, endocrinopathy, and a history of drug use cannot be determined. Under normal conditions, there is a balance between estrogen and androgen in the body. Disruption of the balance between estrogen and androgen is very important in the development of gynecomastia. For example, increased free estrogen concentration as a result of decreased sex hormone binding globulin (SHBG) level in overweight children contributes to the development of gynecomastia. With the progression of puberty, testosterone is released from the testicles day and night, and gynecomastia regresses by keeping the testosterone levels high during the day. Most of the gynecomastia seen in the pubertal period has a good prognosis. In the first 3 years, most of the cases resolve spontaneously, while there is no improvement in 10% of the cases.
Pubertal gynecomastia is usually detected incidentally by the patient himself or his parents. Swelling in the breast often does not cause any complaints, but in some cases, pain and tenderness may occur with or without touching. Depending on the volume and growth rate of the glandular tissue in the breast, the sensitivity, pain and size may not be symmetrical. Generally, the glandular tissue is often less than 4 cm. It can show unilateral onset as well as bilateral initiation. The onset is bilateral in 25-75% of cases. Macrogynecomastia is the glandular tissue diameter of 5 cm or more, and this condition often does not regress spontaneously.
In most of the cases, breast development regresses spontaneously within the first 6 months, while 75% recover within two years and 90% within three years. In cases of pubertal gynecomastia in whom no hormonal pathology is detected, resection can be considered in cases of severe gynecomastia or its long-term persistence (10%). may be the subject.
Lipomastia, which is more common nowadays with increasing obesity problems, can be diagnosed with a careful physical examination. It should be kept in mind that gynecomastia may be seen more frequently in overweight men due to the high body fat mass. In overweight men, the inability to feel the subareolar disc and glandular tissue when the breast tissue is palpated is considered as lipomastia (pseudogynecomastia).
Unilateral or bilateral breast enlargement that develops in the absence of pubertal findings in men is called prepubertal gynecomastia. The risk of being pathological is high, so it is very important to approach these cases carefully and with care. In the evaluation of these patients, congenital adrenal hyperplasia (11-beta hydroxylase defect), increased aromatase enzyme activity, drugs (digitals, cimetidine, reserpine, etc.), adrenal and testicular tumors, animal foods treated with estrogen, estrogen-containing creams and products used for hair, Reasons such as growth hormone therapy should not go unnoticed. Today, more than 300 drugs are known to cause gynecomastia. In the presence of a detectable condition, the cause must be eliminated.
Pubertal gynecomastia treatment; There are three approaches: follow-up, drug therapy and surgical treatment.
Follow-up: In cases with pubertal gynecomastia without an underlying cause, observation is the basis of treatment. Considering that nearly 90% of pubertal gynecomastia can regress spontaneously in an average of 3 years, it is recommended that cases with pubertal gynecomastia be followed up at 3-6 month intervals. Because the pathology in most of the cases regresses spontaneously without medical or surgical approach.
Medical Treatment: its aim is to change the estrogen/androgen ratios and the increase in estrogen sensitivity that constitute the gynecomastia physiopathology. Medical treatment is recommended for patients who have pain and tenderness in the breast area within the first year after pubertal gynecomastia starts, and the condition causes psychological trauma in terms of cosmetic. However, there is still no drug approved for the treatment of pubertal gynecomastia until now.
Surgical Treatment: Surgical treatment should be preferred in cases with macrogynecomastia, since fibrosis has developed more than 4 years since the onset.
