Billy is an eleven-year-old male who was brought to the office by his mom because of a common concern shared by many adolescent males. To Billy it is a real problem.
In our office, when a patient is put into one of the examining rooms, the nurse will write the patient’s name, age, temperature and chief complaint at the top of the chart. The chart then goes into a little rack outside the door for the doctor to peruse before entering the room. As I grabbed Billy’s chart I noticed that his name, age and temperature were recorded, but there was no chief complaint. I thought that the nurse had forgotten to write it down. So I shrugged my shoulders, picked up the chart, knocked on the door and walked into the room.
When I entered, I realized that I had just seen Billy about a month ago for his yearly physical. He was in perfect health, and quite an athlete who excelled in ice hockey and soccer.
His mom greeted me with a warm smile and said, “We’re back…Billy asked me to make this appointment.” My first thought was that 11 year olds don’t usually ASK to come to the doctor.
I looked at Billy who was sitting there with a somber look on his face. “Hi Billy…hey, how is your hockey season going?” I asked very upbeat to try to break the ice. All he muttered was, “All right, I guess” which was totally out of character for him.
My eyes then darted to mom who raised her eyebrows and said, “We’re here because Billy found a lump under his left breast…it is tender and it has him worried.” Billy didn’t budge an inch as mom related this to me. I realized that he was worried, and to help put his mind at ease I said, “Well, Billy, let’s talk about and have a look. I have a feeling that this is going to be much ado about nothing because I think this is going to be something that occurs in most adolescent males. In fact, you will be the second male that I have seen this week with the same complaint. It is funny how things seem to go that way.”
As I spoke, his eyes moved right to mine and he was fixated on every word. One could feel the anxiety start to lift, and he re-positioned himself in his chair making himself more comfortable.
I was able to learn from Billy that he first noticed this around two weeks ago when he bumped his chest against something. It was tender, and then he felt the lump. He checked it every day and it wouldn’t go away. His aunt had been diagnosed with breast cancer a month ago, and that was the topic of discussion around the house which warranted the escalation of his worries. I also learned that there was no redness or warmth around the breast. There was never any type of discharge from the nipple, and things had not changed over the two weeks since he first noticed it.
When I examined Billy, I found that there were no enlarged lymph nodes in his armpit, and both breasts looked to be symmetrical and normal. What I did find was a pea-sized mass beneath the left nipple that was freely moveable and not too tender.
Billy has gynecomastia which is the occurrence of breast/mammary tissue in the male. It is a common condition that is seen in about two-thirds of all males at mid-puberty. This “hyperplasia” of the breast tissue is due to an imbalance of the estrogen (female)/ androgen (male) hormones. It usually involves one breast more than another, but both may be equally involved. This may occur at different rates and degrees. Tenderness of the breast is common and this can wax and wane. It is rarely a problem. Gynecomastia typically self-resolves in a few months. However, in some cases it may last for a couple of years.
In rare and extreme cases the breast development may be significant and can mimic female breast development. This might NOT resolve on it’s own, and in selected cases surgery might be required for cosmetic purposes. This is really the exception.
One other situation of interest, where gynecomastia occurs is in the normal newborn male. Babies are exposed to very high levels of estrogens during the pregnancy, and, as a result, they can be born with significant breast development. In fact, in some cases the breasts can be so developed that milk can actually be expressed (the so-called “witches milk”). This all disappears completely within a couple of weeks.
When I told Billy of my findings, explained how this was normal in males his age, and related my own experiences with gynecomastia (…and MY fears at about his age, for I went through the very same thing) he was like a different person. His out-going self reemerged and a big grin replace the somber scowl that he had. His mom chuckled at the immediate transformation. “Hey doc, I scored two goals yesterday in our hockey game”, he proudly announced.
It was interesting how deeply worried and concerned Billy was over this. He stuffed it inside and was afraid to mention it to anyone, fearing the worse…as do many boys his age. I commended him for having the courage to bring this to his mom’s attention and following through to have it checked. I also had to confess to him that he did much better than I did when I was his age. It took me TWO MONTHS before I had the nerve to tell my parents about it, and my father was a doctor.