Causes and diagnosis of breast swelling in adolescent boys. Breasts in boys: structure and disease As a consequence of various diseases

The mammary glands are needed by women to feed their offspring. Therefore, their development in adolescent girls is an important component of the difficult period of growing up of the body and preparation for future motherhood. The mammary glands of men do not carry such a functional load. But boys' breasts can also enlarge. In this case, they speak of gynecomastia. Despite the safety for life, such changes in the body cause not only physical but also psychological discomfort, especially if they occur in adolescence.

What is gynecomastia

Breast enlargement in newborns, children and adolescent boys is gynecomastia. The condition is hyperplasia (an increase in the number of cells) of the glandular tissue of the organ. Gynecomastia is not an independent disease, but a symptom of certain disorders in the child's body, most often endocrine disorders.

The development of the mammary glands, regardless of the sex of the unborn baby, begins at the beginning of the second month of the prenatal period. After birth and until puberty, the development of this organ occurs in both girls and boys in the same way. With the advent of puberty, the development of boy's glands normally stops, and they remain in their infancy.

The development and condition of the mammary glands is influenced by many hormones. These are mainly prolactin, estrogens and progesterone. Other steroids such as corticosteroids, insulin, and thyroid hormones also affect the glands. Androgens (male sex hormones) inhibit their development. Any violation of the hormonal balance entails various changes in the tissues of the organ. Most often, absolute or relative hyperestrogenism (an increased level of female steroids in the child's body) leads to gynecomastia.

Gynecomastia is an overgrowth of glandular tissue in the mammary glands

Classification of pathology

Gynecomastia can be of two types:

The true form involves the proliferation of glandular and stromal (connective) tissues.

Gynecomastia in a teenager can be physiological or pathological

Breast hyperplasia can be:

• diffuse;
• nodal;
• bilateral;
• one-sided.

Unilateral enlargement develops due to an increase in local sensitivity to female steroids, while left-sided gynecomastia is more common.

Gynecomastia has a complex classification and can occur for a variety of reasons.

Clinical classification implies the distribution of pathology by degrees:

• 1 degree - minimal changes;
• 2 degree - the compaction in the gland is less than the size of the areola;
• 3 degree - the size of the compacted area is equal to the circumference of the pigmented area;
• 4 degree - the enlarged area exceeds the diameter of the areola.

Depending on the size, gynecomastia is also divided into moderate, moderate and severe.

Video: what is children's gynecomastia

Causes of the phenomenon

Pathology can occur for various reasons. If the false one is in no way connected with hormonal disorders and changes in the glandular tissue of the organ, then the true - both physiological and pathological forms - is due to hormonal disorders. In addition, pathological hyperplasia can be associated not only with endocrine pathologies, but also with other internal diseases.

Most experts believe that the development of gynecomastia is based on a disorder in the ratio of male and female steroids or a pathological change in the sensitivity of hormonal receptors.

Physiological gynecomastia of newborns

In about half of boys, after birth (approximately in the first month of life), an increase in mammary glands is observed. In this case, the phenomenon goes away on its own over the next several weeks or months.

The mechanism for the development of such hyperplasia is associated with an increase in the level of pituitary hormones in the child's blood. By 3-4 months, the concentration of steroids drops. Other experts argue that the temporary increase in glands in babies is associated with the ingestion of maternal estrogens in their bodies with milk.

Physiological gynecomastia of newborns does not require specific treatment and goes away by itself

Physiological adolescent gynecomastia

In most adolescents, breast hyperplasia occurs at 12-14 years of age and is a common sign of puberty. Symmetrical enlargement of the glands is more often observed, less often it is noticeable on one side.

During puberty, the production of pituitary hormones, estrogens and androgens is triggered, while the production of estrogen grows faster than testosterone, and this is associated with a temporary imbalance with the predominance of female sex hormones. This is most likely due to the enhanced activity of aromatase, an enzyme that converts androgens into estrogens.

Physiological gynecomastia of adolescents occurs against the background of hormonal changes in the body, it requires medical intervention in extremely rare cases

These physiological processes, as a rule, do not require any intervention, since after a couple of years the symptoms of pubertal breast augmentation spontaneously regress.

In a small part of young men, the glands remain enlarged after the end of puberty (longer than 3-4 years). At the same time, it is not always possible to establish the reason, since the ratio of female and male steroids remains normal. In this case, we are talking about persistent (persistent, stubborn, chronic) gynecomastia. This phenomenon already requires medical attention.

Pathological form

Pathological changes in the mammary glands in children of different ages can be the result of diseases accompanied by androgenic insufficiency, increased synthesis of estrogens, a violation of the conversion of male sex hormones into female ones. Gynecomastia occurs in children with congenital malformations of sexual differentiation.

Against the background of genetic pathologies, mixed gynecomastia can be observed

Table: diseases accompanied by gynecomastia

Obviously, there are many reasons for the development of mammary gland hyperplasia in children, so the condition requires careful examination to choose the right treatment tactics.

Disease symptoms

The reason for the visit to the doctor is a persistent enlargement of the boy's mammary glands. When examining a child, the doctor visually determines the swelling of the chest, when palpating - compaction, heterogeneity, and sometimes soreness. Increased sensitivity to palpation indicates a rapid growth of glandular tissue. There are various discharge from the nipples - serous secretion or colostrum.

In newborns, engorgement of the glands may be accompanied by redness.

In adolescents, bilateral enlargement usually occurs, but unilateral gland hyperplasia also occurs, and it can be very pronounced.

Changes in the mammary gland can be unilateral

In adolescent boys, the pathology causes severe psychoemotional disorders, becomes the cause of social adaptation disorders, and the development of depression. Young men are shy of their peers, become withdrawn, sometimes aggressive. The physician must show maximum tact to find an approach to such patients.

Persistent gynecomastia, which remains after puberty, is pathological, leads to tissue fibrosis, does not respond well to medication and often requires surgical removal. The doctor must convey this fact to the patient's parents and adjust them to such treatment.

It is important to remember that breast cancer develops with gynecomastia. Therefore, changes in the skin of the mammary glands, induration, ulceration, bloody discharge from the nipple, an increase in nearby lymph nodes may speak in favor of such a diagnosis.

Clinically persistent glandular hyperplasia in adolescents can occur with various abnormalities of sexual development, with several types of gynecomastia being distinguished:

• normopubertal - with a normal physique (the shoulders are wider than the pelvic girdle), the consistent development of the gonads;
• feminipubertal - with obesity, a sharp delay in the development of the testicles and penis, an effeminate figure and female hair type;
• hypopubertal - with a eunuchoid type, reduced weight, delayed development of the gonads, while there is a testosterone deficiency;
• hyperpubertal (hyperprolactinemic) - with short stature, overweight, premature puberty, high levels of prolactin and testosterone in the blood.

Development stages

In its development, gynecomastia goes through 3 stages:

• proliferation, when the growth of the gland structures begins;
• intermediate development - accompanied by the maturation of the glandular tissue;
• fibrosis, in which the formation and growth of connective and adipose tissue occurs in the mammary gland.

Gynecomastia can be different - from subtle changes to very pronounced

Diagnostic methods

With the problem of enlarged glands, worried parents most often come to consult a pediatrician. The doctor must refer them to an endocrinologist.

Examining the patient, the specialist first of all determines whether false or true gynecomastia takes place. The early age of a child - from two to 12 years old - makes it possible to suspect a pathological form. The doctor should find out if there are symptoms of underdevelopment of the gonads, accompanying signs characteristic of hereditary syndromes. Since true hyperplasia in boys after a year is an infrequent phenomenon, one can think of a serious endocrine disorder or a hormone-producing tumor.

From laboratory tests used:

• a blood test for the level of hormones (in dynamics) - testosterone, estradiol, gonadotropins, thyroid hormones;
• biochemical blood test, in which attention is paid to creatinine, liver enzymes;
• if genetic abnormalities are suspected, karyotyping is performed - a study of the child's chromosome set.

Instrumental techniques include:

Gynecomastia treatment

Since hyperplasia of the mammary glands can accompany various pathologies, treatment is aimed at eliminating the cause of the increased estrogen content in the child's body. Physiological processes in babies and adolescents do not require medical intervention. Parents are encouraged to follow up and re-consult a doctor in case of prolonged gynecomastia.

The general principle of treatment for pathological gynecomastia is to reduce the level of female steroids. Along with drugs, physiotherapy is used, it is advised to adjust nutrition, temper and play sports - swimming, outdoor sports games. Daily outdoor walks and jogging are helpful.

Medication

Antiestrogens (Tamoxifen) and blockers of aromatase activity (Testolactone) are used to treat idiopathic (with an unexplained cause) gynecomastia in adolescents that persists for more than 3 years.

Pathological proliferation of glandular tissue is treated taking into account its shape:

• With hyperprolactinemia, Bromocriptine or its substitutes are prescribed.
• With a normal prolactin level and sufficient testosterone production, adolescents are prescribed:
  • aromatase suppressants - Thiamine chloride;
  • antiestrogens - Tamoxifen, Danazol, Clomiphene;
  • Aevit and vitamin B1.
• The hypopubertal variant requires an increase in testosterone production. For this purpose, anabolic steroids (Andriol, Sustanon) are prescribed in combination with Galidor, which enhances the androgenic effect. Also shown are zinc preparations that stimulate the secretion of androgens.
• In the hyperpubertal form, vitamin B6 is shown to increase the activity of dopamine receptors, or Bromocriptine is prescribed.
• The feminipubertal type is treated with drugs that increase the secretion of gonadotropins. A low-calorie diet is also indicated. Apply:
  • amino acids - Glycine, Piracetam, glutamic acid;
  • means for improving blood circulation in the brain - Cavinton, Actovegin;
  • vitamin B6, ATP.

The most effective treatment for normopubertal gynecomastia, the most difficult to cure is the hypopubertal form. The effectiveness of therapy increases if it is started before the age of 15.

Photo gallery: drugs for the treatment of gynecomastia

Bromocriptine is prescribed for gynecomastia caused by hyperprolactinemic syndrome Tamoxifen is an antiestrogenic drug, it is prescribed for gynecomastia caused by high estrogen levels in adolescents Aevit is a combined drug prescribed for metabolic and hormonal disorders Andriol is prescribed to adolescents with hypopubertal form of gynecomastia caused by testosterone deficiency Galidor is a drug that enhances the androgenic effect of testosterone preparations Vitamin B6 (pyridoxine) is prescribed for the fiminipubertal form of gynecomastia to regulate metabolic processes Glycine is an amino acid prescribed to improve brain metabolism Actovegin - a drug that affects metabolic processes in the brain, is prescribed for gynecomastia associated with disruption of the hypothalamic-pituitary system
Teslac is a drug that inhibits aromatase, an enzyme that affects the conversion of testosterone to estrogen
Vitamin B1 (thiamine) has the ability to inhibit the conversion of testosterone to estrogen

Physiotherapy

To reduce the secretion of prolactin, pubertal gynecomastia is treated by means of transorbital electrophoresis with gamma-hydroxybutyric acid, electrophoresis with potassium iodide (also transorbital) is used to affect the pituitary gland, bitemporal inductothermy - the use of a high-frequency magnetic field.

For the treatment of gynecomastia, inductothermy is used - the effect on the pituitary gland by a high-frequency electromagnetic field

For the treatment of false and true forms in combination with obesity, balneotherapy and hydrotherapy are used - carbon dioxide, hydrogen sulfide, iodine-bromine baths, mud therapy - mud applications on the collar zone, the projection area of \u200b\u200bthe adrenal glands.

Folk remedies

Pathological enlargement of the mammary glands cannot be cured with folk remedies. Such methods can be used as an addition to the traditional ones.

It is quite possible to use herbal medicine for physiological gynecomastia in adolescents, but you should first consult with your doctor. In this case, it is necessary to select herbs with a fortifying, normalizing metabolic processes, sedative and anti-inflammatory effect.

Thyme decoction is used as a sedative, anti-inflammatory agent:

1. Dry raw materials (2 tablespoons) pour 600 ml of water, bring to a boil and boil over low heat for 7 minutes.
2. Cool and drain.
3. Take 1/3 cup three times a day 20 minutes before meals.

Thyme - a medicinal plant with anti-inflammatory, tonic, sedative properties

Fortifying herbal tea with ginseng:

1. Take in equal parts the roots of licorice, ginseng and eleutherococcus, add the same amount of raspberry leaves, mix.
2. Take a tablespoon of raw materials, pour 400 ml of boiling water.
3. Insist in a thermos for at least 2 hours.
4. Strain and take 2 tablespoons 4 times daily before meals.

Ginseng root has long been famous for its tonic properties

A decoction of lovage to normalize metabolism and hormonal levels:

1. Dry raw materials (1 large spoonful of chopped roots) need to be poured with a glass of water, boiled under a lid for 20 minutes.
2. Cool, drain, top up with boiled water to the original volume.
3. Take a tablespoon 20 minutes before meals three times a day.

Lovage is a proven remedy for various hormonal imbalances

Nutrition correction

Diet food is especially important for mixed forms of pathology. It is impossible to get rid of breast hyperplasia against the background of hormonal disorders by changing dietary habits. But good nutrition for any type of gynecomastia will definitely benefit.

When the glands of newborns are engorged, do not give up breastfeeding and transfer the baby to the formula.

The diet of an older child should consist of an optimal amount of protein products (meat, dairy products, eggs), fresh fruits and vegetables, vegetable side dishes, and a variety of cereals. The child should receive a sufficient amount of fresh water, juices, compotes. It is necessary to exclude fast food, sugary soda, foods with food additives and an excessive amount of sweets (cakes, pastries, fatty desserts). The baby's nutrition should be varied, fortified and as natural as possible.

The diet of adolescents can be additionally enriched with foods rich in zinc:

• meat (veal, rabbit, turkey);
• beef liver;
• citrus fruits;
• seafood;
• dates, figs;
• brown rice;
• wheat bran;
• nuts and mushrooms.

Green tea, rosehip drink, fruit drinks are useful.

The nutrition of a teenager with gynecomastia should be complete, natural, rich in vitamins and microelements

Surgical intervention

A pronounced enlargement of the mammary glands, especially at the stage of fibrosis, is practically not amenable to conservative therapy, so one has to resort to surgery - removal of glandular tissue.

New techniques allow avoiding the consequences of surgical intervention in the form of rough keloid scars on the chest. Removal of glandular tissue is performed through incisions made as close as possible to the areola (subareolar approach) or in the armpit area.

Persistent gynecomastia is the reason for breast surgery

The recovery period does not take long. After the operation, drains are applied and removed the next morning. In the next 2-3 days, elastic bandaging and wearing compression underwear is recommended for 1-1.5 months to contract the skin and form the correct muscle contour. The stitches are usually removed on the 9-10th day. Exercise can be done after 2 weeks, but this implies a reduced load on the shoulder girdle and chest muscles.

Video: surgical treatment of juvenile gynecomastia

Prognosis and complications

Gynecomastia can be complicated by inflammation - bacteria sink into the gland through ducts or microcracks in the nipples. In this case, mastitis develops, requiring appropriate therapy.

Experts say that 10% of all cases of persistent gynecomastia can lead to the development of a tumor, therefore, plastic surgery is recommended for children with a fibrous stage of the pathology, which is not only aesthetic, but also preventive in medicine.

Gynecomastia in young men can lead to certain inconveniences, cause the development of complexes and depressive disorders, and significantly reduce the quality of life.

The prognosis of treatment depends on the form of the pathology and the initial disease. Medicinal gynecomastia is the most favorable prognostically, while the treatment caused by hereditary diseases is much more difficult. The stage of fibrosis of the glands makes conservative therapy ineffective, which forces one to resort to surgical methods.

Prevention

Preventive measures are reduced to:

• timely examination and identification of diseases that can lead to gynecomastia;
• maintaining a healthy lifestyle;
• rational nutrition;
• the use of drugs strictly according to medical prescriptions.

The unpleasant phenomena of gynecomastia can be successfully treated in the early stages. Therefore, parents should not delay a visit to the doctor, even if the boy's breast enlargement is not accompanied by other symptoms. An attentive attitude to the health of the child is the guarantee of his future happy life.

This is a harmless pathology that creates both physical and psychological discomfort. It occurs in both boys and girls, at any age. As a rule, the enlargement of the mammary glands (see photo) quickly passes.

Gynecomastia in adolescents 12-15 years old

Urgent treatment is especially important for adolescents: gynecomastia occurs at 12, 13, 14, 15, 16 and 17 years old - that is, during a period of self-doubt. Enlargement of the mammary glands can occur in young children (for example, girls at 1 year old), in prepubertal age - gynecomastia occurs at 7 and 8 years old.

Distinguish:

Physiological gynecomastia - due to mother's hormones (in babies) or hormonal disruptions (in adolescents).

Pathological - due to drugs, tumors, organ dysfunction, dystrophies, excess or lack of hormones.

Ideopathic - with an unknown cause.

Adolescent gynecomastia - diagnosis

It is carried out with the participation of an endocrinologist and an oncologist. It is possible to accurately indicate that the pathology is gynecomastia after a blood test for the content of luteinizing and follicle-stimulating hormones, prolactin and steroid hormones and hCG. An ultrasound of the mammary glands will also be needed.

How to treat gynecomastia in adolescents

The indication for treatment is the duration of gynecomastia in combination with the inability to establish its cause. For drug treatment, androstanol or testolactone aromatase inhibitors are used (a method under development). Surgical method - removal of breast tissue.

Gynecomastia in boys

Most often, pubertal (in boys) and juvenile (in newborns) gynecomastia is physiological. She quickly passes, and the problems from her are only psychological. Nevertheless, diagnostics is the best solution for both children and adolescents.

Swelling of the mammary glands in boys can occur in infancy and older age. In newborn babies, breast swelling is due to the presence of mother's hormones in the baby's body. If you find such a phenomenon, do not worry, as this is not dangerous and the swelling will pass on its own in a few weeks. Younger men who are overweight may look enlarged at an older age, but this may actually be due to increased body fat in the upper body.

Male breast enlargement at an older age can be triggered by puberty.

The boy's body produces male and female sex hormones. Swelling of the mammary glands occurs when the female hormones estrogen are released. In most cases, there is only swelling of the areola, but significant growth of the entire breast is also possible. In the course of the boy's sexual development, in most cases, the production of male sex hormones increases and the swelling of the breast passes.

One of the most serious reasons due to which swelling of the glands can occur can be the development of an endocrine disease. In the process of the disease, the growth of glandular tissue occurs.

Swelling of the mammary glands in boys is called gynecomastia.

Gynecomastia caused by endocrine disease is a pathological form of the course of the disease. It can be symmetrical or asymmetrical.

Boy and mom

This disease is quite common. The main reasons for its occurrence are an imbalance in the ratio between male and female hormones, an increase in the level of the hormone prolactin, taking drugs that provoke the development of male breasts and the use of narcotic drugs.

The increase occurs on average by 4 cm, but can reach 10 cm. In adolescents, the disease begins to manifest itself as a characteristic itching and the appearance of a seal in the gland. In addition to the appearance of itching, the areolas of the nipple acquire pigment, and discharge may appear from it. The mammary glands may not have pain, but most often their hypersensitivity is observed. A feeling of squeezing may appear. Gynecomastia is physically uncomfortable, and the changes in the body also cause psychological difficulties in boys.

When a disease is diagnosed in the initial stages, when the mammary gland has just begun to change, it can be treated with the correct prescribed treatment. As the disease progresses, the glandular matures and the connective tissue increases. When lymph nodes appear in the armpits, discoloration of the nipples or the release of fluid from them with blood, there is a risk of developing cancer of the gland. If you find such symptoms, you should immediately see a doctor.

Swelling of the mammary glands can be triggered by some drugs, and if they are canceled, the ratio between male and female hormones may normalize. In such cases, the size of the mammary glands is reduced without prescribing additional drugs. In other cases, hormone therapy is prescribed to increase male hormones in the boy's body.

In cases where drug treatment does not give results, the only option is to perform an operation. During the surgical procedure, part of the adipose tissue and glandular cells is removed. For some time after the operation, medications with an analgesic effect are prescribed to relieve pain. In the following days, it is not recommended to raise your hands, make sudden movements, or play sports.

Juvenile gynecomastia is an enlargement of the mammary glands in boys.

It can be caused by a pathological process, hormonal changes, or a physiological phenomenon.

In all cases, there is a change in the appearance of the mammary glands upward.

In contact with

Classification

is divided into three main types:

1. True - glandular cells develop in the tissues of the mammary glands, which subsequently replace the natural component.
2. is characterized not by glandular formations, but by deposits of its own fat cells due to weight gain and subsequent obesity.
3. Physiological - this type of gynecomastia is characterized by congenital features of the body to fullness or is caused by hereditary factors.

The ICD-10 code for gynecomastia in adolescents does not exist separately and is included in the underlying disease, which is designated No. 62.

Causes

The main reasons for the development of pathology are hormonal changes in the body.

They can be present as at the birth of a person, when they are caused by hereditary factors, and also develop already in the process of rebuilding the body. In boys, it is 12-15 years old when puberty occurs.

Being overweight is also a hormonal cause, especially when the process of obesity begins to develop rapidly. This is the first indicator that the hormonal background has changed dramatically.

In addition to the main reason, there are several additional, but no less important:

• excess of female hormones and a decrease in the level of male hormones in the body;
• pathology of the adrenal glands, renal failure, dysfunctions of the endocrine system;
• pathology of the scrotum and testicles;
• the presence of tumors of various etiologies in the body.

Diagnostics

Gynecomastia in children is diagnosed at different ages and depends on its form.

In some cases, gynecomastia in adolescents can be diagnosed at 17-18 years old, when the draft age comes. In such cases, a thorough examination is carried out to clarify the history and the time of the disease development.

Take note: in obesity, unlike true gynecomastia, a military ID may not be issued, instead providing a certain period for a deferral. You should not use this by refusing treatment and measures for losing weight.

When diagnosed with gynecomastia, the teenager is exempt from military service. This applies to both true and false forms, since in the first case, a disease is meant that is spelled out in the list of pathologies for which exemption from service is issued. In the second case, the disease implies grade 4 obesity, in which a military ID is also issued.

Treatment

Therapy for the treatment of gynecomastia is provided only for the true form of the disease, when a direct effect on the cause of the disease is required. For this, the following actions are carried out:

1. Appointment of hormonal drugs with full confidence that this is the reason.
2. Treatment of causative diseases - renal and endocrine systems.
3. Diet - restriction of "junk" food (fried, smoked, fatty, as well as rich in carbohydrates and carcinogens).
4. Constant control of body weight.

For the treatment of false gynecomastia, only diet and the maximum range of exercise are used. Constant weight control and striving for weight loss.

Gynecomastia - This is a benign increase (hypertrophy) of both ductal and connective tissue components of the mammary glands in men, which is sometimes accompanied by lactation.

In 1963, Williams showed that gynecomastia is much more common than previously thought: histological findings at autopsy of 447 men found gynecomastia in 40% of cases. In recent clinical trials, Nuttal and Carlson independently confirmed the high incidence of gynecomastia (36% and 32%, respectively) on the material of preventive examinations of healthy adult men.

Normal mammary gland in menis an underdeveloped organ consisting of a nipple, short ducts and fatty tissue. With gynecomastiapalpation is determined by discrete compaction of hard subareolar tissue of the breast more than 2 cm in diameter or as a diffuse accumulation of fibroadipous tissue. In an objective study, it is possible to differentiate fibroadipous tissue from simple fat by pinching the adipose tissue of the anterior axillary fold and comparing its density and consistency with the breast tissue. There is a tendency for bilateral lesions, but more often it is asymmetric. Unilateral gynecomastia is observed in 5-25% of patients.

CLASSIFICATION OF GYNECOMASTY

I. PHYSIOLOGICAL gynecomastia:
- newborns - associated with the influence of maternal estrogens that cross the placenta; goes away after a few days / weeks;
- pubertal (more often unilateral, disappears on its own) - caused by increased secretion of gonadotropins during puberty in boys 12-15 years old; adolescent gynecomastia is considered a normal variant that does not require special treatment; in some adolescent boys, the proliferation of glandular tissue can be expressed to a large extent and create cosmetic and psychological problems in patients; in case of gynecomastia in a child or adolescent without other signs of puberty, endocrine disease, mainly a hormone-producing tumor, should be suspected;
- senile (after 65 years, almost always bilateral) - associated with a decrease in testosterone production;

II. TRUE gynecomastia: observed in various pathological conditions when the balance between testosterone and estrogen is disturbed:
- increased estrogen content:
their excessive production by tumors (testicles, liver, lungs, etc.);
insufficient metabolism of estrogen in the liver (cirrhosis, chronic hepatitis, other liver diseases);
the use of medicines containing estrogens or having an estrogen-like effect (digitalis, anabolic steroids, estrogens);
hyperthyroidism: the conversion of androgens into estrogens in tissues increases and the content of circulating globulin, which binds sex hormones, increases, which leads to the predominance of estrogens over androgens;
primary hypothyroidism: due to a significant increase in TSH concentration, a friendly increase in prolactin secretion is possible;
- androgen deficiency:
primary: with genetic abnormalities (Klinefelter syndrome, etc.);
secondary: with testicular injuries, orchitis, radiation;
drug-related: suppression of testosterone production by drugs (cimetidine, spironolactone, furosemide, diazepam, antineoplastic drugs, reserpine, verapamil, theophylline);

III. FALSE gynecomastia: an increase in the size of the mammary glands due to the excessive development of adipose tissue in the areola;

IV. Idiopathic gynecomastia: in some cases, the cause cannot be found out.

Forms of gynecomastia depending on the uniformity of tissue development:
diffuse gynecomastia;
nodular gynecomastia.

CLINICAL PICTURE

Gynecomastia has three stages of development:
STAGE I - DEVELOPING (proliferating) gynecomastia - the very initial stage, which lasts about 4 months, this stage is reversible, that is, when conservative therapy is prescribed, the enlarged mammary gland can return to its previous size;
II STAGE - INTERMEDIATE - last from 4 months to 1 year; during this period, the maturation of the breast tissue occurs; reverse development at this stage occurs very rarely;
III STAGE - FIBROSE - characterized by the appearance of mature connective tissue in the mammary gland, the deposition of adipose tissue around the glandular tissue; the mammary gland never undergoes reverse development at this stage.

With gynecomastia, there is an increase in the mammary glands (glands); their compaction is possible, less often - secretion, hyperemia of the skin over the gland. Gynecomastia can be painful. Pain or tenderness to palpation means recent and rapid growth of breast tissue. With a nodular form, against the background of hypertrophy of the gland tissue, a denser area with fuzzy contours is determined, as a rule, a single, eccentrically located areola. Gynecomastia pubertal appears at the age of 12-15 years. Usually looks like a small dense subareolar nodule that disappears within 1–2 years. Soreness and secretion from the ducts are possible. With gynecomastia caused by hypogonadism, symptoms of the underlying disease (for example, manifestations of Klinefelter, Wilson-Turner syndromes) and the actual manifestations of gynecomastia are revealed. It is possible to mention in the history of the previous period of fasting. In this case, gynecomastia is transient, lasting up to several months. Depending on the hormonal pathology that led to the development of gynecomastia, there are also signs of liver damage (more often alcoholic cirrhosis) or symptoms of thyroid disease (hyper- or hypothyroidism); manifestations of a malignant tumor secreting hormones (symptoms depend on the type of tumor), symptoms of kidney damage, requiring hemodialysis.

DIAGNOSTICS

ANAMNESIS COLLECTION AND PHYSICAL EXAMINATION : one of the important stages of clinical examination is to determine the general degree of virilization and identify symptoms indicating hypoandrogenism or estrogenization (weakening of libido, decreased potency, changes in the nature of hair growth); patients should be specifically asked about their use of pharmaceutical and illegal (narcotic) drugs, as well as alcohol consumption; a necessary part of the physical examination for gynecomastia should be palpation of the mammary glands, testicles; it is necessary to pay attention to signs of systemic diseases (liver, kidney, etc.).

LABORATORY STUDY : testosterone, estradiol, LH, FSH, hCG, prolactin, globulin that binds sex hormones, hepatic transaminases.

Ultrasound mammary glands allows you to differentiate true and false gynecomastia, to identify a breast tumor; An ultrasound scan of the testicles is necessary to exclude their tumor.

OTHER STUDIES : according to indications, a study of thyroid function, chromosomal analysis, CT, mammography, fine-needle aspiration biopsy, etc.

When performing ultrasound and mammography, a clearer quantitative determination of the ratio of glandular and adipose tissue is possible. Both methods can help to suspect a tumor, mammography can reveal a stellate seal with an indistinct outline, ultrasound reveals a hypoechoic formation with irregular contours, possibly with hyperechoic inclusions, hypervascularization with color mapping of blood flow.

!!! if there is any doubt about the benign nature of the formation, it is necessary to perform a puncture biopsy, if its dubious or uninformative results, it is necessary to perform an excisional biopsy

Differential diagnosisgynecomastia is performed with male breast carcinoma, lipoma, neurofibromatosis, false gynecomastia.

!!! breast tumors in men are rare, but in order to avoid the severe clinical consequences of late diagnosis, they must be constantly remembered in the differential diagnosis of gynecomastia; unilateral enlargement of the mammary gland be a stage in the development of bilateral gynecomastia, but it may also be breast cancer ; any asymmetric painless and dense swelling in the area of \u200b\u200bthe halo should cause cancer alertness

TREATMENT

Efficiency therapeutic treatmentgynecomastia in patients without obvious endocrine disorders using hormonal agents (testosterone, dihydrotestosterone) as well as tamoxifen, danazol, testolactone, clomiphene should be considered unproven. Given the low incidence of side effects of the antiestrogen tamoxifen, it is used in a daily dose of 20 mg (for 2 doses) in patients with "idiopathic" gynecomastia. With timely initiation of treatment (before the development of fibrotic changes), there is a possibility of a decrease in gynecomastia. Usually, if there is no effect within 2 months, treatment is stopped.

Indications for surgical treatment of true gynecomastiaare cosmetic in nature. We must not forget that the psychological discomfort that occurs in this group of patients can be the cause of severe psychosomatic disorders and sexual maladjustment. Quite often in cases of slightly pronounced gynecomastia, or if the patient is not worried about a cosmetic defect, an explanatory conversation about the absence of a pathological effect on the body allows not to undertake any treatment. The same approach is used for physiological gynecomastia when spontaneous regression is likely.

If gynecomastia is a symptom of a serious medical condition, then treatment should be directed primarily to the underlying cause. So, if gynecomastia is associated with an increase in estrogen levels or testosterone deficiency, then the correction of these conditions may well lead to its disappearance. However, it must be borne in mind that even after the cure of the underlying disease, both proliferative processes and secondary fibrosis of the glandular tissue can be irreversible (or partially irreversible). In these observations, cosmetic indications for surgical treatment come to the fore.

Especially carefully it is necessary to approach the justification of mastectomy. in elderly patients... In addition to the need to diagnose the causes of gynecomastia, it is necessary to take into account the general state of health and the risk of surgery.

With false gynecomastiaassociated with breast lipomatosis, both the surgeon and the patient should be aware that the cosmetic effect of the operation may be more depressing than the preoperative appearance of the patient.

The most correct scope of surgical treatment for gynecomastia not associated with a tumor process is subcutaneous mastectomy. For the most natural cosmetic effect and a comfortable postoperative period, it is desirable to preserve the thoracic fascia and subcutaneous tissue. The choice of the incision is debatable; options for para-reolar and submammary approaches are considered. With large mammary glands, pronounced mastoptosis, the nipple-reolar complex is transferred upward on a de-epidermal fatty skin flap. The success of the operation depends on the absence of residual breast tissue and, to the greatest extent, on the experience of the surgeon.

additional Information

Article: Modern concepts of the epidemiology, etiology and pathogenesis of gynecomastia
Yu.N. Yashina, R.V. Rozhivanov, D.G. Kurbatov
(journal "Andrology and Genital Surgery" No. 3, 2014)