Gynecomastia in prepubertal and pubertal men

Surgical Technique Selection in the Management of Pediatric Gynecomastia

INTRODUCTION

Although the majority of pubertal onset gynecomastia is self-resolving in nature, persistent deformity may require surgical intervention. This study aims to identify patient factors associated with surgical technique selection and proposes an algorithm for the surgical management of pediatric gynecomastia.

METHODS

A retrospective analysis was performed of all surgically managed pediatric gynecomastia patients operated on at a single institution from 2012 to 2022. Charts and patient photos were analyzed for patient and operative demographics, endocrinologic comorbidities, complications, and outcomes. Data were analyzed using bivariate and logistic regression analysis.

RESULTS

Fifty-six surgically managed gynecomastia patients less than 18 years of age were included. The average age at surgery was 16.1 years old, with a mean BMI of 26.9. Most patients were overweight or obese (54.8%) and had Simon grade IIb or greater gynecomastia (55.4%) at presentation. All patients underwent 1 of 4 mastectomy techniques with or without liposuction: inferior periareolar (n=25, 44.6%), circumareolar (n=13, 23.1%), transverse with pedicled nipple (n=4, 7.1%), or free nipple graft (n=14, 25.0%). Bivariate and logistic regression analysis revealed significant differences in sternal notch-to-nipple distance, nipple-to-inframammary fold distance, breast resection weight, and gynecomastia grade between the 4 surgical techniques used in this study. An algorithm incorporating these factors was devised to guide surgical decision-making.

CONCLUSIONS

The proposed algorithm guides surgical technique selection for pediatric gynecomastia and is contingent upon the degree of ptosis and skin excess, anticipated resection weight, and skin quality.

Drug-Induced Gynecomastia: Data Mining and Analysis of the FDA Adverse Event Reporting System Database

Purpose

Drug-induced gynecomastia significantly affects patient health and quality of life. This study aimed to perform an exploratory analysis of gynecomastia reports and the most commonly associated medications within the FAERS database.

Patients and Methods

A comprehensive analysis of the FAERS from January 2004 to December 2023 was conducted. Disproportionality analysis and subsequent sensitivity analysis were performed to identify drugs potentially associated with gynecomastia, utilizing the reported odds ratio (ROR). Logistic regression analysis was employed to assess potential risk factors. The Weibull shape parameter (WSP) test was used to assess the time-to-onset characteristics of the top drugs associated with gynecomastia.

Results

The study identified 30,265 cases of gynecomastia, primarily associated with nervous system drugs, accounting for 85.50% of cases. Notably, risperidone accounted for 80.81% of the total cases. Among the 165 agents with ≥ 5 cases of gynecomastia, the strongest signals were exhibited by risperidone (ROR 602.38, 95% CI 585.07-620.20), dutasteride (ROR 17.18, 95% CI 15.55-18.89), spironolactone (ROR 15.8, 95% CI 13.99-17.83), and paliperidone (ROR 7.16, 95% CI 6.55-7.84). In the sensitivity analysis of disproportionality, unexpected associations were observed, such as montelukast (n = 21, ROR 1.94, 95% CI 1.26-2.98). The logistic regression analysis indicated that the risk of risperidone-induced gynecomastia was significantly lower in adults compared to pediatric patients (OR 0.12, 95% CI 0.09-0.15) and in patients with higher body weight than in those with lower body weight (OR 5.24, 95% CI 3.62-7.76). The WSP test showed that gynecomastia induced by most of the top 10 common agents tends to occur in an early failure mode.

Conclusion

The rankings and signal strengths of drugs associated with gynecomastia were extracted from the FAERS. The age distribution and time-to-onset distribution of the top 10 drugs linked to gynecomastia were investigated, which can facilitate accurate clinical recognition of drug-induced gynecomastia.

Gynecomastia in adolescent males: current understanding of its etiology, pathophysiology, diagnosis, and treatment

Gynecomastia (GM) is a common and continuously evolving condition that commonly occurs during adolescence. It is the source of significant embarrassment and psychological stress in adolescent males. GM is characterized by enlargement of the male breast due to the proliferation of glandular ducts and stromal components. The main cause of GM during adolescence is physiological or pubertal GM, which is primarily attributed to an imbalance between estrogen and androgen activity. Physiological GM is typically transient and resolves within several months, although it may take several years to resolve. GM may also be caused by other pathological conditions and could be indicative of an endocrine disease. It is crucial to understand the pathogenesis of GM to distinguish it from normal developmental variants due to pathological causes. The aim of this review is to highlight the significance of GM during adolescence in terms of potential etiologies, clinical and laboratory diagnoses, and current management.

Pubertal gynecomastia incidence among 530,000 boys: a cross sectional population based study

Background

Adolescent gynecomastia, a benign proliferation of male breast tissue, can lead to psychological issues during adolescence. The prevalence varies widely (4%-69%). The incidence peaks are during neonatal, pubertal, and senescent periods. Its affect on emotional well-being necessitates understanding and occasional intervention. This study aimed to determine the incidence of gynecomastia among male adolescents aged 12-15 years.

Methods

A retrospective cross-sectional study utilized the Clalit Health Care Services database (2008-2021) with a population of approximately 4.5 million. Participants aged 12-15 years were included if diagnosed with gynecomastia (International classification of diseases-9 code 611.1) and having a body mass index (BMI) measurement and no obesity diagnosis (ICD9 code 278.0). Data analysis included incidence rates and associations with ethnicity, age, BMI, and socioeconomic status.

Results

531,686 participants included with an incidence of 1.08%. Of all participants, 478,140 had a BMI ≤ 25 with an incidence of 0.7%, and 0.25%-0.35% yearly, and 70% of gynecomastia patients were aged 13-14 years. The prevalence of gynecomastia differed between Jews (1.28%) and Arabs (0.67%), but the disparity diminished when socioeconomic status was considered.

Conclusions

This unprecedented Population study establishes a definitive rate of true pubertal gynecomastia, revealing a lower yearly incidence as compared to previous reports. The higher observed prevalence among Jewish adolescents, may be caused due to complex interactions between different influencing factors. Understanding these dynamics can aid in formulating more targeted interventions and policy strategies to address gynecomastia's affect on adolescent well-being.

[Prepubertal gynecomastia at the debut of hereditary tumors predisposition syndrome (clinical case reports)]

Peutz-Jeghers Syndrome (Peutz-Jeghers Syndrome, PJS) refers to syndromes of hereditary tumor predisposition and is caused by pathological variants of the STK11 gene, leading to a defect in the synthesis of serine/threonine kinase 11 protein, which acts as a tumor suppressor.Clinical symptoms of the syndrome are combination of hamartomatous polyposis of the gastrointestinal tract and specific skin-mucosal hyperpigmentation. Also, this disease is characterized by a high risk of developing gastrointestinal and extra-intestinal tumors, including benign or malignant tumors of the reproductive system.One of the first signs of the disease in male patients may be prepubertal gynecomastia associated with large-cell calcifying Sertoli cells tumors expressing aromatase. In contrast to from pubertal gynecomastia, prepubertal is extremely rare, and it is often based on pathological causes. Early diagnosis of patients with pre-pubertal gynecomastia, including Peitz-Jaegers syndrome, defines the tactics of gynecomastia management and protocols for monitoring the development of other components of the disease in the future.This article describes two patients with pre-pubertal gynecomastia and Peitz-Jaegers syndrome with different molecular genetic defects: in one case associated with duplication of the STK11 gene site, in the other - with microdeletion of the short arm of chromosome 19 containing this gene.

Pediatric endoscopic subcutaneous mastectomy (pesma) with liposuction in adolescents with gynecomastia

BACKGROUND

Surgical techniques for treatment of gynecomastia are increasingly less invasive. We described technical standardization of pediatric endoscopic subcutaneous mastectomy (PESMA) with liposuction.

METHODS

All adolescents with primary gynecomastia, operated using PESMA with liposuction over the period June 2014-July 2021, were included. The video recording of procedures was analyzed to standardize the operative technique. After patient installation, 3 trocars were placed on the mid-axillary line. The technique included 5 steps: (1) subcutaneous injection of lipolysis solution and liposuction; (2) creation of working space using an inflated balloon; (3) gland dissection using 5-mm sealing device; (4) specimen extraction through the largest trocar orifice; and (5) placement of suction drainage tube.

RESULTS

Twenty-four male adolescents, operated for Simon's grade 2B and 3 gynecomastia using PESMA with liposuction over the study period, were included. Mean patient age was 16 years (range 15-18). Gynecomastia was bilateral in 19/24 (79.2%) and unilateral in 5/24 (20.8%). One (4.1%) conversion to open was reported. The mean operative time was 87 min (range 98-160) for unilateral and 160 min (range 140-250) for bilateral procedure. The mean length of stay was 2.2 days (range 1-4). Patients wore a thoracic belt for 15 up to 30 days postoperatively. Post-operative complications occurred in 5/24 (20.8%): 2- or 3 mm second-degree burns in 4 (16.7%) and subcutaneous seroma in 1 (4.1%). All complications were Clavien 2 grade and did not require further treatment. Aesthetic outcomes were very good in 21/24 (87.5%). Three (12.5%) boys had persistent minimal breast asymmetry but did never perceive it negatively.

CONCLUSION

PESMA combined with liposuction was feasible and safe for surgical treatment of gynecomastia in this selected cohort of patients. Although challenging, this procedure provided good aesthetic results, with no scars on the anterior thoracic wall. Standardization of the operative technique was a key point for successful outcome.

Efficacy of aromatase inhibitor therapy in a case with large cell calcifying Sertoli cell tumour-associated prepubertal gynaecomastia

OBJECTIVES

Large cell calcifying Sertoli cell tumours (LCCSCTs) are one of the infrequent causes of prepubertal gynaecomastia. Most of these tumours are in the content of Peutz-Jeghers syndrome (PJS) or other familial syndromes (Carney complex).

CASE PRESENTATION

Here, we report a long-term follow-up of an 8.5-year-old prepubertal boy with a diagnosis of PJS, who presented with bilateral gynaecomastia, advanced bone age and accelerated growth velocity, and were found to have bilateral multifocal testicular microcalcifications. As the findings were compatible with LCCSCT, anastrozole was initiated. Gynaecomastia completely regressed and growth velocity and pubertal development were appropriate for age during follow-up. Testicular lesions slightly increased in size. After four years of medication, anastrozole was discontinued but was restarted due to the recurrence of gynaecomastia after six months.

CONCLUSIONS

Testicular tumour should be investigated in a patient with PJS who presents with prepubertal gynaecomastia. When findings are consistent with LCCSCT, aromatase inhibitors may be preferred in the treatment.

Prevalence of endocrine disorders among children exposed to Lavender Essential Oil and Tea Tree Essential Oils

Background

Lavender essential oil and tea tree essential oil have become popular ingredients in personal care and household products in recent decades. Questions regarding the safety of these oils in pediatric populations have been raised, proposing a link between these essential oils and endocrine disruption in children, specifically prepubertal gynecomastia. To date, no epidemiological studies have been conducted to evaluate this proposed link.

Methods

This is a cross sectional study conducted among parents of children in the United States to identify the prevalence of endocrine disruption in children aged 2-15 years old. This study also evaluates the potential for a relationship between the exposure of lavender essential oil and tea tree essential oil products and endocrine disrupting outcomes.

Results

In 556 children with a mean age of 6.33 (SD = 3.92), prevalence of endocrine disruption was .016 (SD = 0.13). No cases of prepubertal gynecomastia were identified in either group, and prevalence of precocious puberty, delayed puberty, growth hormone deficiency, and hypothyroidism were all consistent with population norms. Total risk of endocrine disorders among those exposed (0.0194) did not differ from the risk of those unexposed (0.0069). The risk ratio was 2.796 (95% CI: 0.352, 22.163, P = .458).

Conclusion

Children who were regularly exposed to lavender or tea tree essential oils experienced the same risk of endocrine disorders as those who were not exposed.

The prevalence of incidental finding of gynecomastia on thoracic computed tomography in the pediatric age group

OBJECTIVES

This study aimed to determine the prevalence rate of gynecomastia, determine mean glandular breast tissue sizes, and evaluate whether there is any difference in the prevalence rate of gynecomastia according to age using three different reference values of glandular breast tissue size (≥5, ≥10, ≥20 mm) in the pediatric age group.

METHODS

Glandular breast tissue sizes were measured retrospectively from thoracic computed tomography (CT) images taken for other reasons in 961 boys aged 1-18 years.

RESULTS

When each breast was evaluated separately (1,922 breasts), gynecomastia was observed in 1,001 (52.1%), 719 (37.4%), and 216 (11.2%) breasts with ≥5, ≥10, and ≥20 mm considered as reference values, respectively. A significant difference was found in terms of gynecomastia (p<0.001) and mean glandular breast tissue size (p<0.001) with respect to age.

CONCLUSIONS

New studies are currently needed to determine the glandular breast tissue size and the prevalence rate of gynecomastia in boys, and thoracic CT images can be used for this purpose.

Minimal Incision Technique for Gynecomastia

Background:

Gynecomastia or enlargement of the male breasts affects a large proportion of males, with most patients requiring surgical intervention as only a few lesions are actually resolved with medical management alone. Surgery cures the patients of their problems, albeit, at the cost of scarring and other cosmetic problems in some patients. Therefore, refinements in the surgical process are still ongoing so as to provide the best results with minimal scarring.

Aims and Objectives:

To find out the feasibility of a minimal incision technique for glandular excision after liposuction in patients with gynecomastia so as to decrease the final visible scars in these patients.

Materials and Methods:

From July 2018 to September 2018, eight patients were subjected to gynecomastia surgery employing liposuction and gland removal through a single transverse 5–7 mm incision in the nipple. All the patients subjected to this technique had Grade IIa gynecomastia as per Simon’s scale. The Global Aesthetic Improvement Scale, comprising a 5-point Likert scale, was employed to find out the satisfaction level of the patients 12 months after surgery; this level was compared with that of a similar population of patients being operated on by employing liposuction and subcutaneous mastectomy by the periareolar technique.

Results:

The mean operating time was 110 min, and there was minimal bleeding during the procedure. Complications were also negligible, and all patients achieved an excellent chest contour with restoration of protective nipple sensation when evaluated 12 months after surgery. The difference in mean between the 2 patient groups was 0.125 with a p-value of 0.64.

Conclusions:

Glandular excision through a single transverse incision made through the nipple is a safe approach in selected patients and it produces excellent cosmetic outcomes. However, it requires patience on the part of the surgeon to achieve the desired goals of the surgery.

Imaging in gynecomastia

BACKGROUND

Gynecomastia (GM) is the benign proliferation of glandular tissue in the male breast. It is a common condition, which may occur physiologically and shows three age peaks during a male's lifespan: infancy, puberty, and senescence. An underlying pathology may be revealed in 45%-50% of adult men with GM, such as aggravating medications, systemic diseases, obesity, endocrinopathies, or malignancy.

OBJECTIVE

To discuss the role of imaging in the evaluation of GM and its contribution to therapeutic decision-making.

MATERIALS/METHODS

The current literature was reviewed through PubMed, Scopus, and CENTRAL electronic databases to identify the best available evidence concerning imaging modalities in patients with GM.

RESULTS

Most male breast lesions can be diagnosed on clinical grounds; however, in certain cases, when physical examination is inconclusive, imaging may be helpful.

DISCUSSION

The main purpose of evaluating a patient with GM is to establish the diagnosis and differentiate true GM from pseudogynecomastia, exclude breast cancer, and detect the possible cause. GM is seen in mammography as a subareolar opacity and three mammographic patterns of GM are described: nodular, dendritic, and diffuse, corresponding to florid GM of early onset, fibrous persistent GM, and GM due to exogenous estrogen administration, respectively. In ultrasound (US), florid GM is depicted as a disk-shaped, hypoechoic area underlying the areola, whereas echogenicity of the lesions increases as fibrosis develops. Data on the use of MRI in the evaluation of the male breast and GM are still limited. Imaging findings can be classified according to the BIRADS (breast imaging reporting and data system) based on their malignant potential.

CONCLUSION

Both mammography and US are sensitive and specific to diagnose GM and distinguish it from breast cancer. When clinical findings are suggestive of malignancy or imaging findings are inconclusive, a histological confirmation should be sought.

Biochemical features of eugonadal patients with idiopathic gynaecomastia: A retrospective cross-sectional study

Patients with idiopathic gynaecomastia have greater BMI and an unfavourable lipid profile compared with age-matched controls. Twenty-five adult eugonadal patients with idiopathic gynaecomastia and 50 age- and BMI-matched controls were selected. Clinical and biochemical parameters and ultrasound testis volume were reviewed retrospectively. Patients and controls differed for no biochemical parameter, except for LH levels, which were 31% higher in patients (p = 0.019), although within the normal range. Compared with controls, patients had a threefold greater rate of elevated LDL-c (p = 0.025). Patients ≥ 25 years had higher levels of serum LDL-c compared with either patients < 25 years (p = 0.006) or controls ≥ 25 years (p = 0.012). In patients, both at bivariate analysis and at linear regression, age correlated positively with total cholesterol and LDL-c, the latter correlated inversely with total testosterone. Negative interactions were found for age and total testosterone with LDL-c, for LH and estradiol to testosterone ratio (E2:T) with LDL-c, and for age and E2:T with total cholesterol. Our data suggest inadequate local androgen action in patients with idiopathic gynaecomastia. This partial androgen resistance might blunt the beneficial effects of testosterone on lipid metabolism. Further studies are needed to verify whether this metabolic derangement impacts the cardiovascular health of these patients.

Marked Increase in Incident Gynecomastia: A 20-Year National Registry Study, 1998 to 2017

CONTEXT

Gynecomastia, the proliferation of mammary glandular tissue in the male, is a frequent but little-studied condition. Available prevalence data are based on selected patient populations or autopsy cases with their inherent bias.

OBJECTIVE

The objective of this work is to evaluate the age-related incidence and secular trends in gynecomastia in the general population.

DESIGN

An observational, 20-year national registry study was conducted.

SETTING

This population-based study used nationwide registry data.

PARTICIPANTS

Participants included all Danish males (age 0-80 years) with a first-time diagnosis of gynecomastia.

MAIN OUTCOME MEASURES

All Danish males (age 0-80 years) were followed up for incident diagnosis of gynecomastia in the Danish National Patient Registry from 1998 to 2017 using the International Codes of Diseases, 10th revision, and the Danish Health Care Classification System. Age-specific incidence rates were estimated. The hypothesis tested in this study was formulated prior to data collection.

RESULTS

Overall, a total 17 601 males (age 0-80 years) were registered with an incident diagnosis of gynecomastia within the 20-year study period, corresponding to 880 new cases per year and an average 20-year incidence of 3.4 per 10 000 men (age 0-80 years). The average annual incidence was 6.5/10 000 in postpubertal males age 16 to 20 years and 4.6/10 000 in males age 61 to 80 years, with a respective 5- and 11-fold overall increase in these 2 age groups over the 20-year period.

CONCLUSIONS

The incidence of gynecomastia has dramatically increased over the last 20 years, implying that the endogenous or exogenous sex-steroid environment has changed, which is associated with other adverse health consequences in men such as an increased risk of prostate cancer, metabolic syndrome, type 2 diabetes, or cardiovascular disorders.

PREPUBERTAL GYNECOMASTIA: A RARE MANIFESTATION OF MYOTONIC DYSTROPHY TYPE 1

OBJECTIVE

To present a case of bilateral gynecomastia in a prepubertal boy with autism spectrum disorder, diagnosed with myotonic dystrophy type 1.

CASE DESCRIPTION

A 12-year-old boy with autism spectrum disorder presented at a follow-up visit with bilateral breast growth. There was a family history of gynecomastia, cataracts at a young age, puberty delay, and myotonic dystrophy type 1. The physical examination showed that he had bilateral gynecomastia with external genitalia Tanner stage 1. Neurologic examination was regular, without demonstrable myotonia. The analytical study revealed increased estradiol levels and estradiol/testosterone ratio. After excluding endocrine diseases, the molecular study of the dystrophia myotonica protein kinase gene confirmed the diagnosis of myotonic dystrophy type 1.

COMMENTS

A diagnosis of prepubertal gynecomastia should include an investigation for possible underlying diseases. This case report highlights the importance of considering the diagnosis of myotonic dystrophy type 1 in the presence of endocrine and neurodevelopmental manifestations.

Combined surgical and medical treatment in an adolescent with severe gynecomastia due to excessive estradiol secretion: a case report

Background

Gynecomastia develops due to the reversed estradiol-to-Testosterone ratio in adolescence, and symptoms typically improve within 2 years. The causes vary widely, including estrogen excess and tumors, and surgical treatment is usually given in late adolescence because postoperative symptoms may recur in adolescents. This study reports a case of a pediatric patient with severe gynecomastia due to excessive estradiol secretion who showed a positive outcome after receiving surgical treatment combined with aromatase inhibitor administration.

Case presentation

A 9-year old boy visited to the Department of Pediatric Endocrinology for breast budding. At that time, the patient showed breasts at Tanner stage II and no abnormality on hormone tests. During a follow-up, both gynecomastia had progressed to Tanner stage III–IV at age 13. Tamoxifen 10 mg bid was administered; however, the condition rapidly progressed to Tanner stage V at 13.5 years. The evaluation of pathologic gynecomastia showed an increase of estradiol to 296 pg/mL with normal range 10 ~ 36 pg/mL and microlithiasis in both testes. As the condition worsened, total mastectomy was performed at the age of 13.5 years. Based on the assessment that elevated aromatase activity had induced breast budding, we changed the medication to anastrozole (Arimidex) 1 mg once a day, after which the estradiol level improved to 38.5 pg/mL and was maintained well in the two-year postoperative follow-up.

Conclusions

This case report shows a combined plastic surgery and appropriate medical management bring a positive outcome in severe gynecomastia patient.

Partial androgen insensitivity syndrome presenting as pubertal gynecomastia: clinical and hormonal findings and a novel mutation in the androgen receptor gene

Pubertal gynecomastia is common, can be seen in 65% of the adolescent boys and is considered physiological. It is thought to be due to transient imbalance between the ratio of testosterone and estradiol in the early stages of puberty. It resolves in 1-2 years and requires no treatment. However, more persistent and severe pubertal gynecomastia is less common and can be associated with pathological disorders. These can be due to diminished androgen production, increased estrogen production or androgen resistance. We report a case of persistent pubertal gynecomastia due to partial androgen insensitivity syndrome (PAIS), classical hormone findings and a novel mutation in the androgen receptor (AR) gene. Learning points: Laboratory testing of follicle-stimulating hormone (FSH), leutinizing hormone (LH) and testosterone for pubertal gynecomastia is most helpful in the setting of undervirization. The hormonal finding of very high testosterone, elevated LH and estradiol and relatively normal FSH are classical findings of PAIS. Gynecomastia due to PAIS will not resolve and surgery for breast reduction should be recommended.

The Effect of Surgical Treatment for Gynecomastia on Quality of Life in Adolescents

PURPOSE

Despite the psychosocial deficits associated with gynecomastia, surgical treatment of adolescent gynecomastia remains controversial. This longitudinal cohort study measures changes in health-related quality of life following surgical treatment of gynecomastia in adolescents.

METHODS

The following surveys were administered to adolescents with gynecomastia and male controls, aged 12-21 years: Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), and Eating-Attitudes Test-26. Subjects completed surveys at baseline and postoperatively/at follow-up at 6 months, 1 year, 3 years, and 5 years.

RESULTS

From 2008 to 2017, 44 patients undergoing surgical treatment of gynecomastia and 64 unaffected male controls participated in our study. At baseline, gynecomastia patients scored significantly worse than controls on the RSES and in five SF-36 domains: general health, vitality, social functioning, role-emotional, and mental health. Scores significantly improved postoperatively on the RSES, and in four SF-36 domains: physical functioning, role-physical, bodily pain, and social functioning. Postoperatively, gynecomastia subjects scored similarly to controls in all SF-36 domains and the RSES. Young and overweight/obese patients and those with severe gynecomastia had the greatest postoperative improvement across survey measures.

CONCLUSIONS

Surgical treatment of gynecomastia significantly improves the quality of life of adolescents, with measurable improvements in physical and psychosocial functioning. Postoperatively, gynecomastia patients performed comparably to unaffected controls. Surgical treatment of gynecomastia in adolescents and young men has the potential to significantly improve quality of life, particularly in younger and overweight/obese patients and those with moderate to severe gynecomastia. Concerns regarding patient age and body mass index alone should not contraindicate surgery.

Gynecomastia Surgery-Impact on Life Quality: A Prospective Case-Control Study

OBJECTIVE

To evaluate the results of surgical treatment of gynecomastia in the context of quality of life and satisfaction after the surgery.

METHODS

Fifty male patients (mean age, 25.1 years [SD = 8 years]) who underwent surgery for gynecomastia and completed both (preoperative and postoperative) stages of the study were included in the analysis. The quality-of-life evaluation instrument was The Short Form-36 Health Survey Questionnaire. Additionally, we used a short questionnaire including 2 questions about patient satisfaction with gynecomastia surgery.

RESULTS

The overall change in life satisfaction after gynecomastia surgery was 1 point on Likert scale (sign test, P < 0.0001). Participants after gynecomastia surgery scored significantly higher than before the procedure in all Short Form-36 Health Survey Questionnaire domains as well as in 2 main scales Psychical and Physical Health. The changes were especially visible for the domain social functioning and a scale Psychical Health (P < 0.0001).

CONCLUSIONS

Gynecomastia surgery significantly improved men's life quality in all aspects and especially in the social aspect and psychical health. This indicates that adult men with gynecomastia are a specific group of patients, in which surgery may result in life quality improvement even over the average scores.

Management of Adolescent Gynecomastia: An Update

Gynecomastia refers to an enlargement of the male breast caused by benign proliferation of the glands ducts and stromal components including fat. It is the most common form of breast swelling seen in adolescent males. During pubertal development, gynecomastia can develop as a result of transient relative imbalances between androgens and estrogens. Pubertal gynecomastia is self-limited in 75 to 90% of adolescents and regresses over 1 to 3 years. However it may cause significant psychological stress and depression in adolescents. For boys with persistent gynecomastia that is causing substantial tenderness or embarrassment a tailored approach of close follow-up and use of anti-estrogen drugs may be recommended. These drugs block the effects of estrogens in the body and can reduce the size of the breasts somewhat. It appears that pharmacological therapy of persistent adolescent gynecomastia is reasonable effective if given early in the course of the disease and more successful in cases with small or moderate breast enlargement. However, neither of these drugs is universally approved for the treatment of gynecomastia because the risks and benefits have not been studied completely. Surgical approach may be needed under special conditions for cosmetic reasons. In this update, we review the different published trials for managing adolescent gynecomastia. (www.actabiomedica.it)

Surgical management of gynecomastia: experience of a general surgery center

AIM

Gynecomastia is a common finding in male population of all ages. The aim of our study was to present our experience and goals in surgical treatment of gynecomastia.

PATIENTS AND METHODS

Clinical records of patients affected by gynecomastia referred to our Department of Surgery between September 2008 and January 2015 were analyzed. 50 patients were included in this study.

RESULTS

Gynecomastia was monolateral in 12 patients (24%) and bilateral in 38 (76%); idiopathic in 41 patients (82%) and secondary in 9 (18%). 39 patients (78%) underwent surgical operation under general anaesthesia, 11 (22%) under local anaesthesia. 3 patients (6%) presented recurrent disease. Webster technique was performed in 28 patients (56%), Davidson technique in 16 patients (32%); in 2 patients (4%) Pitanguy technique was performed and in 4 patients (8%) a mixed surgical technique was performed. Mean surgical time was 80.72±35.14 minutes, median postoperative stay was 1.46±0.88 days. 2 patients (4%) operated using Davidson technique developed a hematoma, 1 patient (2%) operated with the same technique developed hypertrophic scar.

CONCLUSIONS

Several surgical techniques are described for surgical correction of gynecomastia. If performed by skilled general surgeons surgical treatment of gynecomastia is safe and permits to reach satisfactory aesthetic results.

Long-Term Follow-up of Recurrence and Patient Satisfaction After Surgical Treatment of Gynecomastia

BACKGROUND

"Gynecomastia" is an enlargement of the male breast. Our study aims to assess patient satisfaction as well as evaluate differences in recurrence rates in lipomatous and glandular gynecomastia 10-19 years postoperatively.

METHODS

Forty-one gynecomastia patients undergoing surgical treatment from 1997 to 2005 were invited for a follow-up examination 10-19 years postoperatively. Of these, 16 patients presented for a clinical examination. Patient satisfaction was measured with a validated questionnaire [consultation satisfaction questionnaire (CSQ)-9]. Furthermore, photo-material and patient charts were evaluated concerning preoperative macroscopical type of gynecomastia, BMI, and operative technique.

RESULTS

Mean follow-up time was 13.8 years (range: 10.5-19 years). Eight patients (50%) had presented with lipomatous and eight patients (50%) with glandular gynecomastia prior to surgery. One of the patients with glandular gynecomastia (12.5%) presented with recurrence at the time of follow-up, while five of the eight patients showing lipomatous gynecomastia (62.5%) presented with recurrence. Interestingly, younger patient groups tend to be more satisfied with the operative treatment of gynecomastia than older patient groups, especially regarding the improvement of self-esteem.

CONCLUSIONS

Long-term follow-up results showed that recurrence rates are significantly higher in patients with lipomatous gynecomastia than in patients with glandular gynecomastia, with BMI increase in patients with glandular and lipomatous gynecomastia showing no statistically significant differences. Furthermore, general patient satisfaction and improvement of self-esteem was higher in younger patient groups than older patient groups.

LEVEL OF EVIDENCE IV

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CLINICAL TRIAL REGISTRATION NUMBER

DRKS00009630.

Evaluation of Serum Vitamin D Levels in Adolescents with Pubertal Gynecomastia

BACKGROUND

Since vitamin D has an inhibitory function on ductal morphogenesis of the pubertal mammary gland, it may have a role in the development of gynecomastia. The aim of this study was to determine the effect of vitamin D deficiency on the development of pubertal gynecomastia.

METHODS

Serum 25-hydroxyvitamin D (25D) levels in 50 adolescents with pubertal gynecomastia and 54 healthy controls between the ages of 11 and 17 years were compared.

RESULTS

Mean 25D level was 14.03 ± 6.38 (5.0-32.5) ng/ml in the pubertal gynecomastia group and 15.19 ± 6.49 (5.0-33.2) ng/ml in the control group (p = 0.361). According to the vitamin D status classification of the American Academy of Pediatrics, 66% of the pubertal gynecomastia group was found to be deficient and 14% were insufficient. In the control group these values were 53.7% and 29.6%, respectively (p = 0.158).

CONCLUSION

From our results we hypothesize that, rather than low serum levels of 25D, a dysregulation of the vitamin D signal pathway, vitamin D metabolism or vitamin D storage within the mammary tissue might be the contributing factors to the development of gynecomastia.

Skin steroidogenesis in health and disease

The skin is an important extra-gonadal steroidogenic organ, capable of metabolizing various hormones from their precursors, as well as of synthesizing de novo a broad palette of sex steroids and glucocorticoids from cholesterol. In this manuscript, we review the major steroidogenic properties of human skin and we suggest steroidogenesis' impairment as a cardinal factor for various pathological conditions such as acne, rosacea, atopic dermatitis, and androgenic alopecia.

The effect of tamoxifen on pubertal bone development in adolescents with pubertal gynecomastia

During puberty, estrogen has a biphasic effect on epiphyses; at low levels, it leads to an increase in height and bone mass, whereas at high levels, it leads to closure of the epiphysis. Tamoxifen is a selective estrogen receptor modulator that has been used in the treatment of pubertal gynecomastia. Although it has not been approved for this indication, studies have shown it to be both successful and safe. In males, the peak of pubertal bone development occurs during Tanner stage 3-4, which is also when pubertal gynecomastia reaches its highest prevalence. Thus tamoxifen treatment could potentially effect pubertal bone development. The aim of this study was to assess the effects of tamoxifen on bone mineral density (BMD) and skeletal maturation when used for pubertal gynecomastia. We evaluated 20 boys with pubertal gynecomastia receiving tamoxifen for at least 4 months. BMD was measured with dual-energy X-ray absorptiometry. Z-score and absolute BMD (g/cm(2)) was determined at baseline and 2 months after completing tamoxifen treatment. Bone age and height was evaluated before treatment and again one year later. Using absolute BMD (g/cm(2)), the mean difference from baseline was significant between the two groups both at spine (p=0.002) and femur (p=0.001), but not with the Z-score. This result was attributed to the expected increase during puberty according to sex and age. No significant effect on skeletal maturation was found (p=1.112). We conclude that when pubertal bone development is concerned, tamoxifen is safe for the treatment of pubertal gynecomastia as neither bone mineralization nor growth potential was affected.

Unilateral gynaecomastia in a 16-month-old boy with neurofibromatosis type 1 - case report and brief review of the literature

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease that shows high penetrance with a wide variability in the phenotype. Prepubertal enlargement of the breast in male subjects affected by this condition is well known, but rarely reported. The present case report describes diagnosis and therapy of unilateral gynaecomastia in a toddler showing integumental stigmata of NF1. Furthermore, the report provides a brief review of the literature concerning this finding in NF1. According to this review, the present case appears to be one of the youngest NF1-affected males affected by gynaecomastia that has been reported.

Can digit ratio (2D:4D) studies be helpful in explaining the aetiology of idiopathic gynecomastia?

BACKGROUND

Aetiology of idiopathic form of gynecomastia is unknown and it has not been established if it is related to factors present at the prenatal period or if it is caused by yet unidentified environmental conditions.

OBJECTIVE

The aim of this study is to compare digit ratio (2D:4D) in men with idiopathic gynecomastia and unaffected male and female controls from the general population.

METHODS

The study involved 250 subjects (50 men with idiopathic gynecomastia, 100 control men and 100 control women). Eight measurements were taken: body height, waist and hip circumferences, II and IV digits' lengths (right and left), and body weight, and 4 indices were calculated: BMI, WHR, and 2D:4D for the right and left hand.

RESULTS

2D:4D in men with gynecomastia ([median (I-III quartiles)]: 1.03 (1.01-1.04) for right hand and 1.03 (1.01-1.03) for left hand) was significantly different than the ratio in control men [0.97 (0.95-0.99)] for right and left hand) (p<0.0001) and similar to the ratio found in control women [1.02 (1-1.03)] for right and left hand) (p=1). Men with gynecomastia were characterized with higher values of the following variables: weight, waist and hip circumferences, BMI and WHR. Their body height was significantly greater than in women (p<0.0001) but similar to the values observed in control men (p=0.2687).

CONCLUSION

The findings presented in this study may influence the aetiology-related classification of gynecomastia and justify introducing the new group: "gynecomastia related to the prenatal sex hormones disturbances".

Tamoxifen treatment for pubertal gynecomastia in two siblings with partial androgen insensitivity syndrome

BACKGROUND

Although tamoxifen has been shown to be fairly safe and effective for idiopathic pubertal gynecomastia, it remains unknown whether it is also beneficial for gynecomastia associated with endocrine disorders. Here, we report the effect of tamoxifen on pubertal gynecomastia in 2 siblings with partial androgen insensitivity syndrome (PAIS).

CASE REPORTS

Cases 1 and 2 presented with persistent pubertal gynecomastia at 13 and 16 years of age, respectively. Physical examinations revealed breast of Tanner stage 3 and normal male-type external genitalia in both cases. Clinical features such as female-type pubic hair and borderline small testis indicated mildly impaired masculinization.

RESULTS

Molecular analysis identified a previously reported p.Arg789Ser mutation in the androgen receptor gene (AR) in the 2 cases. Two months of oral administration of tamoxifen ameliorated gynecomastia to Tanner stage 2 with no adverse events. Additional treatment with testosterone enanthate showed negligible effects on body hair and penile length. Hormone values of the 2 cases during tamoxifen treatment remained similar to those in previously reported untreated patients with PAIS.

CONCLUSION

The results indicate that tamoxifen was effective in treating pubertal gynecomastia in these 2 patients with PAIS and may be considered as a therapeutic option in this situation pending further studies.

Clinical and surgical management of unilateral prepubertal gynecomastia

INTRODUCTION

Gynecomastia is the benign proliferation of the glandular tissue in the male breast. This condition is thought to be caused by the imbalance between estrogen action relative to androgen action at the breast tissue level. Bilateral gynecomastia is frequently found in the neonatal period, early in puberty, and with increasing age. Prepubertal unilateral gynecomastia in the absence of endocrine abnormalities is extremely rare, with only a few cases in literature.

PRESENTATION OF CASE

We present an otherwise healthy boy of 12 years old with unilateral breast masses. No abnormalities were found on ultrasonography and on all endocrine parameters. Treatment consisted in a new "modified" Webster technique.

DISCUSSION

The results confirmed validity of this technique in terms of esthetic and functional results, and patient satisfaction. Atypical presentations of gynecomastia are often not recognized. The main pathophysiology of gynecomastia is alteration in the balance between the stimulatory effect of estrogen and the inhibitory effects of androgens on the development of the breast. If there is no causal treatment, surgical resection is the therapy of first choice.

CONCLUSION

The exact mechanism of unilateral gynecomastia formation in our case is unclear. The evaluation of unilateral gynecomastia can therefore be complex. In conclusion, the surgical treatment of unilateral gynecomastia requires an individual approach, based on an appropriate diagnostic algorithm.

Prepubertal unilateral gynecomastia in the absence of endocrine abnormalities

Gynecomastia is defined as the excessive development of breast tissue in males, which can occur as unilateral or bilateral. Although the overall prevalence of gynecomastia is 40%-65%, the prepubertal unilateral gynecomastia in the absence of endocrine abnormalities is unusual, with only a few case reports in literature. Idiopathic gynecomastia in prepuberty is benign but a diagnosis of exclusion. We here report two cases of healthy prepubertal boys aged 8.8 and 9.6 years old, respectively, presented with painful palpable mass in their unilateral breast. Breast tissue with glandular proliferation was confirmed on ultrasonography. Serum levels of estradiol, testosterone, and other laboratory findings were within normal range. They seem to have the prepubertal idiopathic gynecomastia but further follow-up to see their progression is needed.

Gynecomastia in adolescent males

Gynecomastia is defined as an enlargement of the male breast. It is often benign, and can be the source of significant embarrassment and psychological distress. A general medical history and careful physical examination are essential to distinguish normal developmental variants from pathological causes. Treatment is geared toward the specific etiology when identified. In the majority of cases of pubertal gynecomastia, observation and reassurance are the mainstays of therapy as the condition usually resolves naturally. Pharmacological treatment and surgery are recommended only in selected cases.

Hormonal, anthropometric and lipid factors associated with idiopathic pubertal gynecomastia

BACKGROUND AND OBJECTIVES

To determine factors associated with pubertal gynecomastia.

DESIGN AND SETTINGS

A cross-sectional study among healthy male school children and adolescents in Riyadh, Saudi Arabia.

METHODS

Subjects were selected from diverse socioeconomic backgrounds. Tanner stage, height, weight, blood hormonal levels (leutilizing hormone [LH], follicle-stimulating hormone [FSH], total testosterone, and estradiol), and anthropometric and lipid parameters (body mass index [BMI], triglycerides, high-density lipoprotein [HDL], and low-density lipoprotein [LDL]), were collected and compared in children with and without gynecomastia.

RESULTS

The study included 542 children and adolescents. Median (interquartile range) age in the whole group was 11(8-13) years. The prevalence of gynecomastia was 185/542 (34%), with a peak at age 14. The 2 groups compared had nonsignificant difference in cholesterol (P=.331), LH (P=.215) and FSH (P=.571) levels. Those with gynecomastia were significantly older, had lower gonad stage, had higher anthropometric (height, weight, and BMI), and lipid (triglycerides, HDL, and LDL) values. In multivariate regression analysis, factors significantly associated with gynecomastia were BMI (odds ratio [OR]=1.05; 95%CI 1.00-1.10; P=.013), HDL (OR=0.42; 95%CI 0.19-0.92; P=.03), and gonad (Stage II OR=2.23; 95%CI 1.27-3.92; P=.005, Stage III OR=6.40; 95%CI 2.70-15.0; P < .0001, Stage IV OR=3.24; 95%CI 1.32-7.95; P=.01, Stage V OR=1.37; 95%CI 0.52-3.56; P=.53, compared with stage I).

CONCLUSION

Pubertal gynecomastia tends to increase in mid-puberty. In our setting, BMI, HDL, and gonad stage were the major factors associated with the development of pubertal gynecomastia.

Management of prepubertal gynecomastia in two monozygotic twins with Peutz-Jeghers syndrome: from aromatase inhibitors to subcutaneous mastectomy

BACKGROUND

Prepubertal gynecomastia is characterized by the presence of palpable uni- or bilateral breast tissue in boys without other signs of sexual maturation. It may be the endocrine expression of rare syndromes such as Peutz-Jeghers syndrome (PJS). This study aimed to evaluate the effectiveness of anastrozole and to describe an innovative surgical approach.

METHODS

This report presents twins with PJS, bilateral prepubertal gynecomastia, and testicular multifocal calcifications. Both twins were treated with anastrozole for 2 years. After finishing treatment, both were followed before subcutaneous mastectomy was performed by the "modified" Webster technique.

RESULTS

Growth velocity decreased and gynecomastia diminished during anastrozole treatment. After discontinuation of therapy due to a sharp reduction in growth velocity, both twins showed regrowth of gynecomastia, with painful and strained breasts. A significant reduction in breast volume with glandular removal was achieved.

CONCLUSIONS

The findings of this study showed a multidisciplinary approach to prepubertal gynecomastia due to the synergy of pediatricians, radiologists, and plastic surgeons. The follow-up evaluation after the anastrozole treatment showed it to be an efficacious medical treatment, as an alternative to orchidectomy, to control the effects of circulating estrogens. Moreover, the results observed in the patients confirmed the validity and feasibility of the "modified" Webster technique in terms of aesthetic and functional results, patient satisfaction, and absence of complications.

Efavirenz-induced gynecomastia in a prepubertal girl with human immunodeficiency virus infection: a case report

BACKGROUND

Prepubertal gynecomastia is a rare condition and most frequently classified as idiopathic. In HIV-infected adults gynecomastia is a recognised but infrequent side-effect of antiretroviral treatment (ART) and mostly attributed to efavirenz use. Gynecomastia should be distinguished from pseudogynecomastia as part of the lipodystrophy syndrome caused by Nucleoside Reverse Transcriptase Inhibitors (NRTIs) to avoid incorrect substitution of drugs. In the medical literature only five cases of prepubertal gynecomastia in children taking ART are described and underlying pathogenesis was unknown. The occurrence of adverse effects of ART may interfere with therapy adherence and long-term prognosis and for that reason requires attention. We report the first case of prepubertal gynecomastia in a young girl attributed to efavirenz use.

CASE PRESENTATION

A seven-year-old African girl presented with true gynecomastia four months after initiation on ART (abacavir, lamivudine, efavirenz). History, physical examination and laboratory tests excluded known causes of gynecomastia and efavirenz was considered as the most likely cause. Six weeks after withdrawal of efavirenz the breast enlargement had completely resolved.

CONCLUSIONS

Efavirenz-induced gynecomastia may occur in children as well as in adults. With the increasing access to ART, the possibility of efavirenz-exposure and the potential occurrence of its associated side-effects may be high. In resource-poor settings, empirical change from efavirenz to nevirapine may be considered, providing no other known or alarming cause is identified, as efavirenz-induced gynecomastia can resolve quickly after withdrawal of the drug. Timely recognition of gynecomastia as a side-effect of efavirenz is important in order to intervene while the condition may still be reversible, to sustain adherence to ART and to maintain the sociopsychological health of the child.

Differential expression of estrogen receptor α and β transcripts in tissues and in primary culture cells from pubertal gynecomastia

BACKGROUND

Pubertal gynecomastia is a common problem occurring in up to 65% of adolescent boys. Gynecomastia comes at a time when self-image awareness is at its greatest and psychologically could be a psychologically disabling condition. Surgery is considered the mainstay of treatment for severe or persistent cases. A medical management aimed at altering the effective androgen/estrogen ratio has been suggested with inconstant results. Some promising results have been obtained by using anti-estrogens. Surprisingly there are no data on the estrogen receptor (ER) α and β RNA expression in gynecomastia.

AIM

We studied ER RNA subtypes in pubertal gynecomastia.

METHODS

ERα and β RNA were determined by real time RT-PCR in 50 mammary samples from pubertal boys with idiopathic gynecomastia subjected to reductive mammoplasty. To study ERα and β pattern of expression, epithelial and stromal primary cell cultures were set up from fresh tissues.

RESULTS

These analyses indicated that in all stromal cells ERβ was expressed at higher level than ERα and in epithelial cells both ERα and ERβ were barely detectable.

CONCLUSIONS

Our data suggest that also stromal cells are involved in the pathophysiology of pubertal gynecomastia. The high level of expression of ERβ seen in pubertal gynecomastia adds new insight on validation of ERβ as a target for candidate diseases and exploration of ERβ as a marker for clinical decision-making and treatment in pubertal gynecomastia. This could drive to search for new and selective anti-estrogen drugs for medical treatment of pubertal gynecomastia with a particular attention to the ERβ-selective ligand.

Aromatase inhibitors in pediatrics

Aromatase, an enzyme located in the endoplasmic reticulum of estrogen-producing cells, catalyzes the rate-limiting step in the conversion of androgens to estrogens in many tissues. The clinical features of patients with defects in CYP19A1, the gene encoding aromatase, have revealed a major role for this enzyme in epiphyseal plate closure, which has promoted interest in the use of inhibitors of aromatase to improve adult height. The availability of the selective aromatase inhibitors letrozole and anastrozole--currently approved as adjuvant therapy for breast cancer--have stimulated off-label use of aromatase inhibitors in pediatrics for the following conditions: hyperestrogenism, such as aromatase excess syndrome, Peutz-Jeghers syndrome, McCune-Albright syndrome and functional follicular ovarian cysts; hyperandrogenism, for example, testotoxicosis (also known as familial male-limited precocious puberty) and congenital adrenal hyperplasia; pubertal gynecomastia; and short stature and/or pubertal delay in boys. Current data suggest that aromatase inhibitors are probably effective in the treatment of patients with aromatase excess syndrome or testotoxicosis, partially effective in Peutz-Jeghers and McCune-Albright syndrome, but probably ineffective in gynecomastia. Insufficient data are available in patients with congenital adrenal hyperplasia or functional ovarian cysts. Although aromatase inhibitors appear effective in increasing adult height of boys with short stature and/or pubertal delay, safety concerns, including vertebral deformities, a decrease in serum HDL cholesterol levels and increase of erythrocytosis, are reasons for caution.

Consensus statement on diagnosis and clinical management of Klinefelter syndrome

Nearly 70 years after its description, Klinefelter syndrome (KS) remains a largely undiagnosed condition. As its clinical presentation may be subtle, many of those affected may be unaware or diagnosed only during evaluation for hypogonadism and/or infertility. In February 2010 an interdisciplinary panel of specialists met in Abano Terme (Padua, Italy) in a workshop on "Klinefelter Syndrome: diagnosis and clinical management". The main aim of this meeting was to discuss several aspects related to the epidemiology, pathogenesis, and evaluation of KS and to develop a consensus defining its early diagnosis and treatment. In the present consensus we have highlighted the features that may prompt the physicians to look after patients with KS both for the syndrome and correlated diseases. We have provided evidences that, during the different phases of life, there might be some advantages in establishing the diagnosis and starting proper follow-up and treatment. The workshop was carried out under the auspices of the Italian Society of andrology and Sexual Medicine (SIAMS).

Bilateral Pulmonary Emboli After Bilateral Mastectomy in a 15-Year-Old Boy with Hypogonadism: A Case Report

Pulmonary emboli are rare, yet serious, complications of body contouring surgery. When they occur, they more often follow as complications of long, invasive procedures in adults. The present report details a case of bilateral pulmonary emboli in an obese 15-year-old boy with hypogonadism undergoing bilateral mastectomy for gynecomastia. The diagnosis of bilateral pulmonary emboli was made on the basis of clinical presentation and positive ventilation/perfusion scan. The patient responded well to heparin anticoagulation treatment. The relevance of pediatric obesity, pediatric body contouring surgery and the risk of thromboembolic events in pediatric patients are discussed.