Gynecomastia, the benign enlargement of male glandular breast tissue,1 is a common occurrence during puberty, with a reported prevalence of 4 to 69 percent in adolescents.2 – 5 Given that adolescent gynecomastia may spontaneously resolve 1 to 3 years after onset (typically at 14 to 16 years of age), the preferential modality of treatment is that of “sympathetic reassurance” with observation and re-evaluation every few months until symptoms resolve.6 – 8 However, in a subset of patients (8 percent), gynecomastia will persist into adulthood.9 The physical and psychosocial impact of gynecomastia on younger patients is largely unknown.
Previous studies have acknowledged the physical impairment and psychological distress associated with gynecomastia in adult men10 using validated surveys,11 but few have quantified the effect of this condition on afflicted adolescents. Published work consists largely of single case reports using psychological assessments and retrospective chart reviews.12 – 16 These studies suggest a considerable impact on younger patients with gynecomastia, but prospective data will better inform patients, families, and providers when making treatment decisions. In the current study, we sought to evaluate the physical and psychological impact of gynecomastia on adolescent males using a prospective study design.
Eligible subjects included adolescent males aged 12 to 21 years who had been formally diagnosed with gynecomastia by a plastic surgeon using the patient's symptom profile and physical examination. Subjects were prospectively enrolled through the Adolescent Breast Clinic at the Department of Plastic and Oral Surgery at Boston Children's Hospital from October of 2008 through December of 2011.
Healthy male control subjects were also prospectively enrolled at clinics within the Department of Plastic and Oral Surgery and the Division of Adolescent/Young Adult Medicine (a nonsurgical clinic) at the same tertiary care center. Controls were within the same age range as case subjects and were deemed eligible if they or their clinical provider attested to a current state of good health with no significant past medical or surgical history. Potential control subjects were excluded if they had ever been diagnosed with a benign or malignant breast disorder, if they were being seen for a breast complaint, or if they had ever been treated for a breast condition.
Informed verbal consent was obtained from all subjects 18 years and older or from a parent or guardian if the participant was under the age of 18. This study was approved by the Boston Children's Hospital Committee on Clinical Investigation.
Demographics and Clinical Presentation
Height and weight were obtained from all subjects except for one gynecomastia patient and seven control subjects. Body mass index was calculated by dividing weight (kilograms) by height squared (meters squared). Using the Centers for Disease Control and Prevention Child and Teen Body Mass Index Calculator, body mass index–for–age percentiles were calculated for all participants aged 19 and younger, taking into account the patient's age and sex.17 Patients were deemed to be of normal weight if their body mass index was between the fifth and 84th percentiles for age and sex, underweight if it was less than the fifth percentile, overweight if it was between the 85th and 94th percentiles, and obese if it was in the 95th percentile or higher. For subjects 20 years of age or younger, body mass index classification was derived using the Centers for Disease Control and Prevention Adult Body Mass Index Calculator.18,15 For these older patients, the following weight categories were defined: normal weight, body mass index = 18.5 to 24.9 kg/m2; underweight, less than 18.5 kg/m2; overweight, 25 to 29.9 kg/m2; and obese, 30 kg/m2 or higher.
For case subjects, gynecomastia severity was graded by a board-certified plastic surgeon (B.I.L.). Grading criteria for gynecomastia followed those of Rohrich et al., with each patient given a grade between I and IV for each breast.19 Grade I gynecomastia is marked by minimal hypertrophy of the breast without the presence of ptosis, while grade II is defined as moderate hypertrophy without ptosis. Breasts denoted as grade III have severe hypertrophy with skin excess and mild ptosis. Grade IV breasts also have severe hypertrophy with marked skin excess and moderate or severe ptosis. In the event that the breasts were asymmetric, the higher grade was used for analysis.
All study subjects completed three self-administered surveys: the Short Form-36 Version 2.0, the Rosenberg Self-Esteem Scale, and the Eating Attitudes Test-26. These surveys were chosen because of their reliability and validity, and they have been used in other studies to assess the physical and emotional well-being of adolescents and adults with other breast conditions.20 Participants completed the surveys independently in the clinic or at home.
The Short Form-36 Version 2 is a 36-item questionnaire used frequently to measure health-related quality of life within several domains, including physical functioning (10 items), role-physical (four items), bodily pain (two items), general health (five items), vitality (four items), social functioning (two items), role-emotional (three items), and mental health (five items).21 The raw score for each domain is then transformed to a scaled score, ranging from 0 to 100. A higher health-related quality of life is associated with a higher Short Form-36 domain scaled score, while a lower health-related quality of life is associated with a lower score. We report transformed domain scores for case-control comparison and within-subjects tests.
The Rosenberg Self-Esteem Scale is a 10-item scale used to assess global self-esteem.22 The survey is designed as a four-point Likert scale in which participants answer “strongly agree,” “agree,” “disagree,” or “strongly disagree” to statements such as “On the whole, I am satisfied with myself.” Raw scores range from 10 to 40. A higher raw score on the Rosenberg Self-Esteem Scale is associated with higher levels of self-esteem.23
Disordered eating behaviors and attitudes were assessed using the Eating Attitudes Test-26 survey because of its prior use in adolescent patients and in those with benign breast disorders.20 Previous studies have found an association between gynecomastia and eating disorders9,16; the Eating Attitudes Test-26 was used in this study to assess such behaviors and thoughts. Participants report on the 26-item survey how often they agree or disagree with statements concerning eating and body image, such as “I am terrified about being overweight.” Raw scores of 20 and above are indicative of disordered eating.24 For analyses, we used mean Eating Attitudes Test-26 scores and dichotomized raw scores into those falling below or meeting the disordered eating threshold.
Control participants only also completed a short investigator-designed survey to determine whether they had gynecomastia or breast-related concerns that had not been addressed by a healthcare provider. The survey asked control participants the following questions: Are you worried that your chest looks too big (such as a woman's chest)? Have you ever been diagnosed with gynecomastia (enlarged breast tissue)? Do you feel uncomfortable taking your shirt off in front of others or participating in activities without a shirt? If you have enlarged breast tissue, does your chest feel tender?
Data Management and Statistical Methods
Survey and patient data were collected and organized using Research Electronic Data Capture, or REDCap. The electronic data capture tools are hosted by Boston Children's Hospital (with additional support through Harvard Catalyst). Research Electronic Data Capture is a secure, Web-based application designed to support data capture for research studies. It provides (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.25
Statistical analyses were run using SAS 9.2 software (SAS Institute, Inc., Cary, N.C.). Demographics and clinical information were compared between groups using Pearson chi-square tests or linear regressions. The effects of gynecomastia grade were also analyzed using linear regression models. A p value less than 0.05 was considered statistically significant for all analyses.
Between October of 2008 and December of 2011, 47 male patients diagnosed with gynecomastia and 92 healthy male adolescents participated in this study. The two groups were similar in age (16.51 ± 2.64 years versus 16.17 ± 2.49 years; p = 0.471) (Table 1). Participants with gynecomastia had a significantly higher mean body mass index than the control group (27.02 ± 5.90 kg/m2 versus 23.61 ± 4.11 kg/m2; p = 0.001) (Table 1). As expected based on differences in body mass index, a higher proportion of participants with gynecomastia were overweight or obese (64.4 percent) compared with control subjects (40.7 percent; p = 0.010) (Table 1).
Subjects with gynecomastia were moderately affected, with a mean grade of 2.19 ± 1.12. The majority of participants (n = 29, 61.7 percent) were given a grade of I or II (Table 1). In 100 percent of unilateral cases (n = 5), the right breast was affected. Of subjects exhibiting breast asymmetry (n = 10), the right breast was more severely affected in 70 percent of cases.
On the investigator-designed gynecomastia symptoms survey, no control subject reported carrying a prior diagnosis of gynecomastia. Five percent of controls responded affirmatively to the question “Are you worried that your chest looks too big (such as a woman's chest)?” In addition, 10 percent of control subjects in the study reported feeling uncomfortable taking their shirt off in public.
Participants diagnosed with gynecomastia scored significantly lower than control subjects in five Short Form-36 domains and the Rosenberg Self-Esteem Scale (Table 2). These Short Form-36 domains were general health, vitality, social functioning, role-emotional, and mental health. Scores in physical functioning, role-physical, and bodily pain were not different between the case and control groups (Table 2). Participants with gynecomastia also scored significantly higher on the Eating Attitudes Test-26 than the controls did (mean score 7.02 ± 7.13 versus 4.65 ± 5.04; p = 0.022) (Table 2). However, the prevalence of disordered eating (Eating Attitudes Test-26 score ≥20) was not different between the two groups.
We then explored the effects of body mass index category as a potential confounder of the relationship between gynecomastia and self-reported physical and mental health using linear regression models. Even after controlling for weight status, differences in the general health, social functioning, and mental health domains and the Rosenberg Self-Esteem Scale remained significant, with gynecomastia subjects scoring lower than controls (p < 0.005) (Table 2). However, scores on the Eating Attitudes Test-26 and the vitality and role-emotional domains no longer differed between participants with gynecomastia and controls after body mass index category was taken into account (Table 2).
We also looked at the effect of gynecomastia grade on survey scores. Using within-subjects linear regressions, only general health was found to be significantly associated with grade of gynecomastia; participants with higher grades reported feelings of lower overall health. After the addition of body mass index category to this model, gynecomastia grade was no longer a significant predictor of the general health score (Table 3).
To our knowledge, the present study is the first to prospectively measure the physical and emotional symptoms associated with the diagnosis of gynecomastia during adolescence using a large sample, validated surveys, and control subjects, building on the 2011 study by Kinsella et al.9 We are also the first to examine the association between the severity of gynecomastia and its psychosocial impact, and we believe our findings are of considerable interest to treating physicians and surgeons alike. We relied on three validated surveys that have been used to assess symptoms in other breast disorders as well as in adolescents.11,20 In our sample, self-reported social and mental health appear to be more highly impacted than physical health in adolescents with gynecomastia. Subjects with gynecomastia had a decreased health-related quality of life compared with healthy subjects, as measured by a lower rating of general health on the Short Form-36. In addition, subjects with gynecomastia exhibited a lower rating of social functioning and more disordered eating thoughts and behaviors as compared with unaffected adolescent male controls. These results suggest that gynecomastia significantly impacts the lives of affected adolescents.
Gynecomastia is strongly associated with obesity.13,26 – 28 In prior investigations, up to two-thirds of adolescents with gynecomastia were overweight or obese.13 Previous studies have also found that patients with gynecomastia exhibit physical limitations as a result of their condition, namely in the areas of sports and athletics.9,14 After controlling for body mass index, we found no differences in the physical functioning, role-physical, and bodily pain Short Form-36 domains between the subjects with gynecomastia and control participants. Our results suggest that the lower physical parameters of health-related quality of life in our subjects are due primarily to obesity and not gynecomastia.
Adolescents with gynecomastia have reported embarrassment, humiliation, rejection, and teasing as a result of their breast development.12,14,15 Case reports concerning adolescents with gynecomastia have described increased feelings of loneliness, restlessness, and tension in these patients.27 Related reports reveal a higher association of depression, anxiety, adjustment disorders, and suicidal ideation.9,11,12,14,15 Supporting this existing literature, the participants with gynecomastia in our study had a significantly lower rating of self-esteem as measured by the Rosenberg Self-Esteem Scale and the mental health, social functioning, and role-emotional domains of the Short Form-36 than male controls independent of body mass index, suggesting that these emotional impairments are due to gynecomastia and are not a product of being overweight. In addition, “adolescence” itself does not account for these differences, as there was no age difference between those with and without gynecomastia in our study.
Gynecomastia has also previously been associated with disordered eating behaviors and thoughts.9,16 In our cohort, participants with gynecomastia scored higher than controls did on the Eating Attitudes Test-26, suggesting greater levels of distress with regard to eating and weight concerns. However, once body mass index category was taken into consideration, differences in Eating Attitudes Test-26 scores were no longer significant. In addition, the clinical relevance of our findings is unclear, as both groups scored below the established threshold for truly “disordered” eating thoughts and behaviors. Nevertheless, healthcare providers should be aware of the potential for disordered eating in this population and assess adolescent gynecomastia patients accordingly.
Due to the prevalence of adolescent obesity and the association of obesity with breast enlargement,26 subjects with gynecomastia are often advised to lose weight as a method of treatment.13 As a result, many surgeons and healthcare providers discourage treatment until weight loss is achieved, and then (1) the condition persists beyond the projected time of spontaneous resolution, (2) sufficient pain, embarrassment, or emotional or psychological distress is reported, or (3) physical or social function is significantly impaired.1,29 Physicians seeing these patients should know that while it is essential to provide counseling, support, and treatment for all obese or overweight adolescents, weight loss alone will not correct true glandular breast enlargement or correct severe skin excess. Furthermore, our findings suggest that many of the social and emotional sequelae of gynecomastia persist regardless of body mass index. Therefore, we believe that weight loss should be viewed as treatment for obesity that may have some benefits for gynecomastia patients, but it should not be presented as a treatment modality for gynecomastia per se. Interestingly, similar outcomes following gynecomastia surgery regardless of body mass index status, including patient satisfaction, have been reported.13
Adolescents who present with gynecomastia demonstrate a wide range of breast mound enlargement with variable degrees of skin, fat, and glandular excess. It was previously unknown whether those adolescents with higher grade or “worse” gynecomastia are impacted more severely. In the present study, no differences in physical and emotional well-being, self-esteem, and eating behaviors and attitudes were observed among participants with different grades of disease after controlling for differences in body mass index between the two groups. Merely having gynecomastia was sufficient to cause significant deficits in general health, social functioning, mental health, self-esteem, and eating behaviors and attitudes compared with controls. The findings of this study suggest that the severity of gynecomastia is strongly associated with obesity but that the negative impact on certain elements of health-related quality of life in these individuals is related to gynecomastia rather than obesity status. We have also shown that adolescents with only low-grade or “minor” gynecomastia may be impacted as severely as those with higher grade or more obvious breast enlargement. Because it is a condition with a predominantly psychological impact, a linear correlation between clinical severity of gynecomastia and patient impact should not be assumed.
Our findings suggest that adolescent gynecomastia, traditionally regarded as a “cosmetic issue,” has a significant psychosocial impact on patients that extends beyond age-related insecurity and is independent of clinical grade. As a result, early intervention and treatment for gynecomastia may be necessary to improve the negative physical and emotional symptoms. Surgical treatment for gynecomastia varies due to the amount of glandular, adipose, and skin tissue involved. Treatment for gynecomastia is largely without major complication and is done as an outpatient procedure. The current study provides a baseline for an evidence-based treatment study demonstrating the efficacy of surgical management of gynecomastia using a large sample, validated surveys, and a control group. Postoperative outcomes data are required, however, to measure the effect of surgical intervention on the physical and physiological symptoms of adolescent gynecomastia. It should be noted that insurance coverage remains a considerable barrier to surgical treatment of adolescent gynecomastia. At our institution from 2009 to 2011, of the 103 adolescents with gynecomastia who were appropriate candidates for surgery, only 37 (35 percent) of those patients received insurance coverage for their surgical treatment. This is markedly lower than rates of insurance coverage for female adolescents with macromastia seeking reduction mammaplasty at our institution (85 percent). This discrepancy may reflect the knowledge that gynecomastia for most adolescents is often self-resolving. In addition, our study supports the commonly held view that the negative effects of gynecomastia are often psychological, emotional or social rather than physical. Unfortunately, duration of gynecomastia and negative impact of persistent gynecomastia on health-related quality of life are not considered adequate criteria for intervention by most third-party payers.
Limitations should be addressed. No normative Short Form-36 values exist for adolescents, so we utilized a convenience sample of male adolescents as a control group. Broad inclusion criteria were utilized for our control group, and a considerable number of these “healthy” subjects had some chest-related concerns. These unexpected findings in our control group suggest a considerable prevalence of chest-related concerns within the adolescent male population. This may have led to selection bias, as patients with underlying but unreported concerns about their chest may have been more interested in participating in the study. However, we would have expected that differences between the two groups would have been attenuated by any subject misclassification that could have resulted. Because subjects were recruited from a tertiary care facility in an urban location, results may not be generalizable. We allowed up to 10 percent missing data, which may have affected results.
Adolescents with gynecomastia have significantly lower ratings of general health, self-esteem, social functioning, and mental health as compared with male adolescent controls independent of weight status. Adolescents with gynecomastia were uniformly affected, regardless of graded severity of disease. Physical limitation, bodily pain, and disordered eating thoughts and behaviors are prevalent in adolescents with gynecomastia but appear to be more strongly related to obesity status rather than gynecomastia. While weight control is essential for all overweight or obese patients, it should not be viewed as a primary treatment for gynecomastia. Our results indicate that careful and regular evaluation for gynecomastia may benefit adolescents regardless of body mass index status or severity of gynecomastia. Additional prospective studies examining treatment outcomes in this population are needed.
This work was supported by the Plastic Surgery Foundation (July of 2011). The authors thank providers in the Division of Adolescent/Young Adult Medicine and the Department of Plastic and Oral Surgery, Boston Children's Hospital, in addition to clinical research staff, for their role in subject recruitment. They also thank the Boston Children's Hospital Clinical Research Program for support in data management (Adam Simmons and Christian Botte). Finally, they thank the patients and parents and guardians for their willingness to participate in this study.
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