A 14-year-old boy comes to the office because his breasts have recently become tender and slightly swollen...

A 14-year-old boy comes to the office because his breasts have recently become tender and slightly
swollen. He is worried that he is undergoing feminization and will grow up to become a “freak.” Upon examination a tender, 2-cm mass is found to be palpable in the subareolar region of both breasts. Which of the following describes the best course of action?
(A) Excise the masses by performing a subcutaneous mastectomy.
(B) Incise and drain the masses.
(C) Treat the masses with topical steroids.
(D) Aspirate the masses for culture and cytology.
(E) Leave the masses alone.

Answer:
(E) Leave the masses alone.

Discussion: The patient has gynecomastia, the development of breast tissue in males, which is normal in the neonate, pubertal boy, and elderly male.
Increased estrogen stimulation (hyperestrinism) of breast tissue is the common factor in all cases of gynecomastia.
Adolescent gynecomastia is usually bilateral, and the tissue averages 2 to 3 cm in diameter. The breast enlargement is transient and most often subsides within 1 year; as a consequence the gynecomastic breast usually should be left alone (choice E). The boy should be reassured that he is normal and does not have to worry about developing breasts.

However, if the mass is greater than 5 cm or does not regress by 16 to 17 years of age, a subcutaneous mastectomy should be performed (choice A).
Incision (choice B), aspiration (choice D), and topical steroids (choice C) are not indicated under any circumstances.

Gynecomastia in a postpubertal, adult male younger than 70 to 80 years is not normal and hyperestrinism should be suspected. Hyperestrinism in an adult male is most commonly due to decreased catabolism of estrogen due to liver cirrhosis, most often induced by alcoholism.
However, hyperestrinism also can be due to increased synthesis secondary to an adrenal or testicular
tumor; increased human chorionic gonadotropin (HCG) from a testicular tumor; the hyperplastic Leydig’s cells in Klinefelter syndrome; decreased androgen activity, which leaves estrogen unopposed (e.g., caused by hypothalamic or pituitary disorders); and by several drugs.