I entered the cramped examining room in the Hommocks nurse’s office where I was doing pre-season sports physicals for those who hadn’t been able to see their own physicians in time for the clearance deadline. The thirteen-year-old boy was standing uncomfortably in his boxers and sweatshirt waiting for this dreaded but necessary checkup. I asked him to take off the sweatshirt. He obliged but stood with his arms crossed over his chest. Usually the thirteen-year-old boys stand with their arms stiff and their hands covering their “privates.” So right away I had a clue.
Gynecomastia — or the enlargement of a male’s breasts — is a rarely discussed but exceedingly common problem. It was recently featured in the New York Times (October 31, 2008) in a story about a plastic surgeon who has developed a specialty in surgical correction of abnormally enlarged breasts in men.
Dr. Elliot W. Jacobs explained that his zeal to help men with gynecomastia grew from his personal experience. He recalled being made fun of as a thirteen-year-old boy. “One time I went to the gym and one of my friends had hung a bra on the locker door. I can empathize with what these kids go through.” He goes on to describe operating on a 14-year-old boy who told the surgeon: “You gave me back my life.”
I was a pudgy middle schooler and I too can empathize with being made fun of. But I also know that as an adolescent medicine physician my arsenal for healing is much more complicated and sophisticated than a scalpel. The fact is that the American Academy of Pediatrics estimates over 40% of healthy boys experience gynecomastia and it almost always resolves within two years.
Pubertal gynecomastia is distinct from breast enlargement in older boys or men, where it may be due to a number of medical causes including medications, tumors, toxins, or endocrine disorders. Interestingly, excessive marijuana smoking can lead to breast enlargement in boys and men. Benign, pubertal gynecomastia peaks at around age 13 and is thought to be due to a temporary imbalance in the ratio of testosterone to estrogen. Surgical intervention is almost never recommended unless it fails to resolve within two years as normal puberty progresses.
So how do we help a lad like my middle school patient survive those two years? A week can seem like an eternity, but two years is unimaginable for a boy who questions whether he is “turning into a gir.l” Because I am aware of this issue, I have made it my practice to address it directly with every pubertal boy I see who has swollen breast tissue. I simply examine the breasts during the course of listening to his heart or palpating his abdomen and say something like this:
“I’m sure you‘ve noticed that your breast tissue is a little swollen. Most guys get a little embarrassed or even freaked out about this. But did you know that almost a third of all guys have this?” An instant look of relief will flood his face at this moment.
“Yeah,” I say. “Most guys try to hide this in the locker room so you don’t’ even realize it. But, did you know that it is a totally NORMAL part of puberty and it will go away in about two years?.
“You just have to be patient and don’t touch it or squeeze it because that can irritate it and even make them temporarily bigger.”
I usually make a pal after this conversation. It doesn’t take much time; there is no pain, no surgery, and no expense involved in healing this problem. Again and again, I am reminded that a solid knowledge base and careful talking to patients is the best medicine.
Whereas I was tempted a few weeks ago to write an uppity “shame on you” letter to the editor about Dr. Jacobs’ practice, I opted instead for the gratitude on my patient’s face.