Breast distress

CONCERNS regarding breast development are very common among both male and female teenagers.

Adolescent boys may be alarmed by the temporary gynaecomastia they commonly experience, while adolescent girls worry about the size, shape and symmetry of the developing breast.

Many teenagers may be extremely reluctant to disclose their concern to their doctor, but they may be relieved by the opportunity to discuss common breast problems if raised during the consultation.

This becomes an excellent opportunity to establish trust and provide reassurance to adolescent patients that can extend into other areas of their health, such as weight management, exercise and self-harming behaviours. While the majority of concerns are benign, there are some that may require further examination and investigation.

Gynaecomastia, characterised by increased palpable subareolar breast tissue in males, can be seen in up to 70% of teenage boys and is usually physiological, peaking around 14 years and caused by a relative imbalance between oestrogen and androgen.

The significant pathological causes to be excluded, particularly if galactorrhoea is present, relate to drugs (antipsychotics, tricyclics, omeprazole, substance abuse, such as marijuana and heroin, and other drugs like gabapentin) as well as hormone-producing tumours and other endocrine disorders such as Klinefelter’s syndrome.

Further investigation and referral for specialist assessment is recommended. Physical examination will reveal the difference between gynaecomastia and the pseudogynaecomastia from fatty adipose tissue seen in the overweight teenager.

Physiological gynaecomastia will often resolve within 6-12 months; however, in some cases, if it persists for more than two years and is of significant size, surgery may be required.

Breast pain is a common complaint among teenage girls, and it is important to clarify an underlying cause related to breast masses, inflammation, drug use (usually noncyclic) and physiological (usually cyclic).

A careful history and examination is the first step. Fibrocystic changes of the breast are the physiological responses to cyclical hormone changes. Mild cyclical breast pain prior to the period is normal, requiring only reassurance and symptomatic management; however, if severe, the oral contraceptive Pill relieves symptoms in 70%-90% of patients and may lessen the incidence of breast cysts.

Breast cysts are the most common cause of painful breast lumps. Characteristically, the lump regresses after menstruation and half will completely resolve within two to three cycles.

An ultrasound will differentiate between a cyst, an abscess, fibrocystic changes and a fibroadenoma. Fibroadenomas are typically painless, slow growing, rubbery and mobile, with characteristic ultrasound findings. If the mass is over three centimetres, symptomatic, enlarging or suspicious of malignancy, referral for further assessment and biopsy is required.

Breast asymmetry is often seen in early puberty with the majority achieving catch-up growth and symmetry. However, in about 25% of young girls, asymmetry may persist and it is important to exclude congenital anomalies such as hypomastia, amastia, hypermastia or a giant fibroadenoma.

Breast atrophy of both the fatty and glandular elements can be seen with weight loss and raise the possibility of chronic illness or an eating disorder.

Both hypomastia and macromastia can be familial; however, macromastia is also related to obesity and can certainly be associated with significant physical symptoms (intertrigo, back pain, etc) and psychological distress. Weight loss will help in this situation and any surgical intervention in the adolescent age group needs careful evaluation.

There are many other breast disorders or concerns that can emerge during the adolescent years and an awareness of appropriate assessment, investigation and when to offer referral is most important.

Reference

Donald E. Greydanus, Dilip R. Patel, Helen D. Pratt, Essential Adolescent Medicine; McGraw-Hill Companies Inc, 2005.

Dr Susan Towns, FRACP, is head of adolescent medicine at The Children’s Hospital at Westmead, NSW.