Gynaecomastia in adolescents: prevention, diagnosis and when to see a doctor

When an adolescent boy’s breasts enlarge, parents often do not know whom to turn to, and the adolescent himself is ashamed to talk about it. Meanwhile, the correct approach is mostly simple: examination, observation and only sometimes — tests and treatment. The editorial team explains what can realistically be done for prevention, how diagnosis proceeds and at what signs one must go to the doctor without delay.

What can be done for prevention

Pubertal gynaecomastia caused by natural hormonal changes cannot be fully prevented — it is part of normal puberty in many boys. However, it is possible to reduce the influence of factors that intensify it or make it persistent.

The first such factor is excess weight. Adipose tissue contains the aromatase enzyme, which converts androgens into oestrogens, and besides, fat in the chest area creates pseudogynaecomastia. A balanced diet and regular physical activity help maintain a healthy weight without harsh diets, which are undesirable in adolescence.

The second is avoiding hormonal drugs and dubious supplements. Anabolic steroids, prohormones and “test boosters” of unknown composition can cause gynaecomastia that no longer disappears on its own, and can also disrupt growth and sexual development. Sports nutrition for adolescents should be limited to tested products such as protein, and only when the diet really requires it.

The third is caution with drugs and cosmetics. If an adolescent constantly takes drugs that can affect breast tissue, it is worth discussing this with a doctor. In rare cases a link with the topical use of products with lavender and tea tree oil has been described; in case of doubt they are worth discontinuing.

• Maintain a healthy weight through nutrition and activity, without fasting.
• Do not use steroids, prohormones or “test boosters”.
• Choose sports supplements only from tested manufacturers and only when needed.
• Tell the doctor about all drugs the adolescent takes.

How the examination at the doctor proceeds

The first specialist is usually a paediatrician or family doctor, and if needed — a paediatric endocrinologist. The doctor finds out when the enlargement appeared, whether there is pain, whether it is growing quickly, which drugs and supplements the adolescent takes, and whether there were similar problems or endocrine diseases in the family.

During the examination the doctor palpates the mammary glands to distinguish firm glandular tissue from fatty tissue, assesses the size and symmetry, and the condition of the nipple and skin. The testicles are examined without fail: their size and the presence of any lumps, since a testicular tumour is one of the rare but important causes of gynaecomastia.

The doctor also assesses the stage of puberty by Tanner, height, weight and body proportions. For example, small-volume testicles against the background of tall stature may suggest Klinefelter syndrome.

In most adolescents with a typical picture — a symmetrical small enlargement in mid-puberty, normal testicles, no drugs or supplements — laboratory tests are not needed. The doctor recommends observation with a repeat examination in a few months.

Tests and instrumental examinations

If the picture is atypical, the doctor orders hormonal tests. The guidelines of the European Academy of Andrology (EAA, 2019) and endocrinology reviews usually include testosterone, oestradiol, LH, FSH, chorionic gonadotropin (hCG), prolactin, TSH, as well as indicators of liver and kidney function.

Each of the tests looks for a specific cause: raised hCG may indicate a tumour producing it; high oestradiol — a source of oestrogens; low testosterone with high LH and FSH — primary testicular failure. They must be interpreted taking into account the stage of puberty, because “adult” norms do not apply here.

Ultrasound of the mammary glands helps to distinguish glandular tissue from fatty tissue and to rule out other masses. Ultrasound of the testicles is ordered if a lump is suspected or if tests point to a hormonally active tumour.

Breast cancer in adolescent boys is extremely rare, yet a firm, immobile, one-sided mass, skin changes or discharge from the nipple require a full examination. Such signs are not characteristic of ordinary pubertal gynaecomastia.

When to see a doctor urgently

Ordinary pubertal gynaecomastia is not an emergency, but it is worth showing the adolescent to a doctor in any case — if only to make sure the picture is typical and to relieve anxiety. This is especially important if the enlargement causes pain or psychological discomfort.

The following require prompt attention: enlargement before the start of puberty or at a very early age; rapid progression; a size of more than a few centimetres; a firm, immobile or one-sided mass; discharge from the nipple, skin changes; enlarged lymph nodes in the armpits.

Any lump or enlargement of a testicle, asymmetry of the testicles or signs of incomplete sexual development (absence of hair growth, small testicles at a late stage of puberty) are a reason for an examination within the next few days.

Separately — gynaecomastia that appeared against the background of the use of steroids, prohormones or suspicious supplements. Parents should know that an adolescent may hide this. In such a situation, not only an assessment of the breasts but also an examination of the hormonal system, liver and lipids, and a consultation with an endocrinologist are needed.

Treatment: from observation to surgery

For most adolescents the main approach is observation. Since pubertal gynaecomastia usually regresses over 6 months – 2 years, the doctor schedules repeat examinations, and the parents and adolescent are given an explanation that the condition is temporary.

Drug treatment in adolescents is considered only in individual cases — with marked pain or persistent enlargement — and only as prescribed by a doctor. The literature describes the use of selective oestrogen receptor modulators, in particular tamoxifen, but the evidence base for adolescents is limited, and such drugs have side effects. Taking “anti-oestrogens” bought through sports forums on one’s own is unacceptable.

If gynaecomastia persists after the completion of puberty and the glandular tissue has turned fibrous, surgical correction becomes an effective method. It is usually planned after development has stabilised in order to avoid recurrence; the decision is made by a plastic surgeon together with an endocrinologist (Lemaine et al., 2013).

When gynaecomastia is caused by drugs or disease, the cause is treated first. Gynaecomastia caused by anabolic steroids is treated with the involvement of an endocrinologist, and with persistent fibrosis — surgically.

Editorial conclusions

Pubertal gynaecomastia cannot be fully prevented, but a healthy weight and avoiding hormonal drugs and dubious supplements reduce the risk of its intensification and persistence.

Diagnosis begins with an examination of the breasts and testicles; tests and ultrasound are needed with an atypical picture. A firm one-sided mass, rapid growth, changes in the testicles or signs of a disorder of sexual development require prompt attention.

The main approach is observation, while drug and surgical treatment are used for clear indications and only at the doctor’s decision.

We also recommend reading our materials on the causes of gynaecomastia in adolescent athletes, on the risks of anabolic steroids at a young age and on hormonal tests for men.

References

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3. Narula HS, Carlson HE. Gynaecomastia—pathophysiology, diagnosis and treatment. Nat Rev Endocrinol. 2014;10(11):684–698.
4. Lemaine V, Cayci C, Simmons PS, Petty P. Gynecomastia in adolescent males. Semin Plast Surg. 2013;27(1):56–61.
5. Henley DV, Lipson N, Korach KS, Bloch CA. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med. 2007;356(5):479–485.
6. Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341–375.