Evaluation of Boys with Marked Breast Development at Puberty
ABSTRACT & COMMENTARY
Synopsis: About 12% of adolescent boys referred to a pediatric endocrinology clinic because of gynecomastia had an underlying endocrine disorder. The rest were mostly idiopathic, tall, and heavy for age.
Source: Sher ES, et al. Evaluation of boys with marked breast development at puberty. Clin Pediatr 1998;37:367-372.
Sixty boys, younger than 9 years of age, were evaluated in a pediatric endocrine clinic over a 10-year period because of significant breast enlargement (> 4 cm in diameter during puberty). An endocrine abnormality was documented in seven boys. Pathology included Kleinfelter syndrome; 46, XX maleness; primary testicular failure; partial androgen insensitivity; hepatocarcinoma; and increased aromatase activity. Eight of the remaining 53 boys had underlying medical disorders including five with neurological disorders. The remaining 45 boys were considered to have idiopathic gynecomastia, or macromastia. These boys were, on the average, taller and heavier for their age. Although pathologic causes of pubertal breast enlargement are unusual (12% in this series) Sher and associates believe that an endocrinological evaluation is indicated in such patients.
COMMENT BY MYRON GENEL, MD, FAAP
Breast development occurs frequently enough in adolescent males, perhaps in a majority, that it is often considered part of the normal pubertal process. In some boys, however, gynecomastia is sufficiently pronounced or prolonged, and considerable emotional distress ensues and prompts endocrine evaluation. A series from a pediatric endocrine referral center will, thus, be a relatively skewed sample, and finding endocrine pathology in 12% does not reflect the incidence in the general population, as noted by Sher et al. Of the remaining patients, a large number were significantly overweight and it is likely that adiposity exaggerated the breast development, in part accounting for the referral. Many boys with pathological gynecomastia can be detected because of abnormalities discernable on careful examination. Patients with Klinefelter's syndrome frequently will have small testes discordant for their stage of sexual development. Patients who are clearly obese should be encouraged to exercise and reduce caloric intake, often something easier to prescribe than to accomplish. The gynecomastia may provide motivation, since in my experience, most surgeons will not operate in the presence of significant obesity.
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