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pseudopuberty, or exposure to exogenous estrogens, and careful follow-up with
the primary physician is required.
Juvenile Breast Hypertrophy
Juvenile breast hypertrophy is a rare disorder characterized by sudden, rapid,
massive breast enlargement at a time of intense endocrine stimulation, usually
between 8 and 16 years of age, after onset of menarche. It is believed to result
from end-organ hypersensitivity to estrogen. The hypertrophy is usually bilateral
and asymmetric and may progress at an alarming rate over 36 months. The
differential diagnosis of this lesion includes cystosarcoma phyllodes, juvenile
fibroadenoma, and precocious puberty; however, true endocrine or neoplastic
lesions are uncommon. In some cases, the hypertrophy regresses in 1 to 3 years,
but referral to a breast surgeon is always indicated; breast reduction or even total
ablation may become necessary. This disorder is often associated with extreme
emotional and psychosocial distress for patients and families.
Gynecomastia
Gynecomastia is a term commonly used to describe a broad spectrum of clinical
breast lesions in boys, including excess breast tissue, breast enlargement, and
masses of tissue below the nipple that are discrete and nonadherent to the chest
wall, and may occur unilaterally or bilaterally. Gynecomastia has been described
as the male equivalent of fibrocystic changes in the female breast, based on
histologic evidence. Typically, local breast tissue demonstrates evidence of mild
estrogen–testosterone hormone imbalance, resulting from physiologic changes
(neonatal, puberty, aging); exogenous medications; tumors of the testes, adrenal
glands, and lungs; metabolic conditions (cirrhosis, hyperthyroidism, renal
disease); or hypogonadism.
From a clinical perspective, gynecomastia occurs in about 50% of all boys
between the ages of 11 and 18 years and typically lasts about 2 years. It can be
associated with growth spurts and can also cause a significant degree of pain. The
glandular enlargement is about 4 cm and resembles the early stages of female
breast budding. More commonly, gynecomastia presents to the emergency
physician because of associated anxiety in adolescent boys. If the patient has

normal-sized genitalia and none of the predisposing conditions listed earlier,
reassurance is all that is required, though inquiry about both prescription and
illicit use of drugs should be sought. There is often particular concern about
gynecomastia in obese boys, since they may appear to have an overabundance of
fatty tissue in the breast region. Of note, the incidence of true gynecomastia is not