Endocrine Department of Peking Union Medical College Hospital
Male breast hypertrophy, also known as male female type breast, refers to unilateral or bilateral breast hypertrophy in men at different stages and ages due to different reasons, with breast distention and pain, discoid nodules under the areola, and nipple retraction seen individuallyNipple dischargeSome of them are similar to the mammary glands of adolescent girls, so they are also clinically known as adolescent breast hypertrophy, middle-aged and elderly breast hypertrophy, idiopathic male breast hypertrophy, etc.
Male breast hypertrophy is a common disease. It is reported in foreign literature that the incidence of asymptomatic breast hypertrophy that can be felt in normal people ranges from 32% to 38%.It has been reported that the incidence of puberty can be as high as 67%, and the incidence of men over 50 years old can also be as high as 57%.The age of onset is almost any age, ranging from 7 to 85 years old. There is no significant difference in the incidence of left and right breasts, and bilateral breast hypertrophy is more common.
pathogeny
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（1） Primary male breast hypertrophy
It is mostly seen in children and adolescence. It is often caused by physiological imbalance of endocrine, the plasma estradiol content is higher than testosterone content, resulting in a temporary abnormal ratio of estrogen/androgen, or the sensitivity of breast tissue to estrogen is increased, which is also called physiological male breast hypertrophy.
（2） Secondary male breast hypertrophy
1. Endocrine diseases
(1) Testicular disease due to gonadal dysfunction, low androgen secretion, changes in the proportion of testosterone and estrogen in the blood, resulting in male breast hypertrophy ①Congenital testicular agenesis(Klinefelter syndrome); ②Complete testicular feminization; ③Kallmann syndrome; ④OrchitisSymptoms, trauma and tumor; ⑤Reifenstein syndrome.
(2) Adrenal diseases such as adrenal cortical hyperplasia, benign tumors, malignant tumors and hypofunction, such tumors can directly secrete estrogen or produce excessive estrogen precursors (such as androstanone), which can be transformed into effective estrogen in the tissue, and blood estradiol increases, causing breast hypertrophy.
（3）thyroid disease For example, hyperthyroidism, an increase in the concentration of plasma sex hormone binding globulin, an excess of bound androgens, an increase in free estradiol (unconjugated estradiol), and an increase in the ratio of estrogen to testosterone lead to hormone imbalance that stimulates breast tissue hyperplasia, leading to male breast hypertrophy.
2. Other non endocrine diseases
(1) Liver diseases such as hepatitiscirrhosis、liver cancerWhen accompanied by liver function decline, it often causes breast hypertrophy.
(2) ChronicinnutritionconvalescenceinnutritionGonadotropin secretion was decreased at the time of treatment.WheninnutritionAfter correction, there is a side note of the second puberty phenomenon, which is called "feeding increased breast hypertrophy".
(3) Bronchuslung cancerAnd chronic lung diseases such as oatmeal cell carcinomapulmonary tuberculosis、empyemaIt can cause breast hypertrophy due to local stimulation.
（4）Chronic renal failurecauseuremiaAfter detection, it was found that serum estrogen and prolactin concentration were relatively elevated in 30% of patients, which led to breast growth and hypertrophy.
(5) Nervous system diseases such as paraplegia caused by high spinal cord diseaseSyringomyelia. Hereditary dyskinesia may be accompanied by mammary gland hypertrophy.
(7) Lymphatic system diseaseslymphomaMalignant histiocytoma, myeloma and other reticuloendothelial system diseases are also rare in male breast development.
(8) Drug induced breast hypertrophy gonadotropin chlorpromazine, cimetidine, methyldopa, metoclopramide, metronidazole, isoniazid, reserpine, and thyroid extract can bind to estrogen receptors, causing endocrine dysfunction and male breast development,But most of the enlarged breasts after drug withdrawal can be recovered.
Male unilateral or bilateral mammary glands show female development, hyperplasia and hypertrophy, and the nipple and areola are well developed. The diameter of the disk like, hard and tough diffuse masses with clear edges that can be touched under the areola is mostly 2~3cm, and there is certain activity and no adhesion with the skin.A few patients have swelling pain or mild tenderness, and very few may haveNipple discharge。
Clinical classification
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According to the location and size of hyperplastic and hypertrophic breast, it can be divided into three types clinically.
1. Diffuse type
Hyperplasia mammary gland is diffuse, often located under the areola in a disc shape, does not form solitary nodules, and is characterized by slight pain and tenderness. It is medium in size.
The tumor is a solitary nodule with good activity and no adhesion. The surrounding boundary is clear and the volume is small. This type should be differentiated from male breast cancer.
3. Female
Bilateral mammary glands are symmetrically hypertrophic without obvious nodules, and white milk can be seen when pressing the nippleNipple dischargeIt is large in size and looks like the breasts of adolescent girls.
(4) Gonad function testEtwo, T, PRL, LH, FSH, β - HCG, etc.
(5) Genetic examinationOral mucosal chromatin, chromosome and karyotype examination.
(6) Histopathological examinationThe above examinations cannot confirm the primary diagnosisSTDWhen the tumor changes, fine needle aspiration cytology or biopsy can be used.
2. Auxiliary inspection
(1) Molybdenum target X-ray examinationThe breast appearance is normal.In addition to normal adipose tissue, hyperplastic glands can be seen.The area behind the areola is flocculent, fan-shaped or discoid dense shadows with uniform density.The edges of most glands are blurred, and the hair brush can be seen radiating around.The edges of the lumpy glands can be clearly seen
(2) MRI examination of sellar areaMRI examination of sellar region can be taken when hypothalamus pituitary disease or tumor is suspected.
(3) CT of adrenal gland and B-ultrasound of abdominal organsIf it is suspected to be adrenal disease or tumor, it can be examined by adrenal CT and abdominal organ B ultrasound.
(4) B-ultrasonic examination of thyroid or testisB ultrasonic examination of thyroid or testis is feasible if thyroid or testis function is suspected to be abnormal.
treatment
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1. Etiological treatment
The etiology of this disease is complex, so we can get a correct diagnosis and then treat it according to the etiology.Adolescent primary male breast hypertrophy often has a self-healing tendency and can return to normal within about 6 months.Adult and elderly primary male breast hypertrophy, some can self heal, some need medication.The secondary male breast hypertrophy needs to be diagnosed and treated according to its cause. When the primary lesion is cured, the enlarged breast can often gradually recover.
2. Drug treatment
(1) Selective estrogen receptor antagonistSuch as tamoxifen.
(2) Androgen therapyIt can reduce breast development in androgen deficient patients, but in patients with normal androgen levels, it is often not recommended to increase breast development because androgen is converted into estrogen in the body.
(3) Aromatase inhibitors such as testosteroneIt can inhibit the aromatization of androgen in the body, thereby reducing the production of estrogen.
3. Surgical treatment
In addition to etiological treatment and drug treatment, male breast hypertrophy can be treated surgically.
(1) Indications① The male breast diameter is more than 4 cm, which can not subside for a long time; ②Breast hypertrophy significantly affects beauty; ③Those who have no obvious curative effect after regular drug treatment; ④The patient is suspicious of malignant change and nervous.
(2) Surgical methods① Subcutaneous mastectomy (retaining nipple and areola), suitable for young patients; ②Simple mastectomy (without retaining nipple and areola) is mostly suitable for elderly patients.The specimens were resected surgically and sent to pathological biopsy for confirmation.
