Clinical Manifestations Of Endocrine Disorders Of The Breasts: Trophy, Hypertrophy And Gynecomastia
Hypertrophy Of The Breasts
Trophy And Hypertrophy Of The Breast
The breasts develop from the mammary crest of the ectoderm called the milk line. Though, the mammary gland is rudimentary at birth, sometimes the high prolactin levels derived from the mother may induce transient milk secretion in the newborn (witch’s milk). The breasts grow and areola enlarge with puberty depending on the influence of estrogens and progesterone.
Only during pregnancy, mammary glands develop fully with the formation of alveoli and they start functioning. During early pregnancy, the breasts enlarge and become nodular. The areola become pigmented with the development of Montgomery’s tubercles. Later, colostrums is secreted.
Hormonal interaction: Estradiol stimulates growth of mammary ducts and nipples and the formation of progesterone receptors. Cortisol and growth hormone potentiate the effects of estrogens. Further development of lobules and alveoli are mediated by four hormones- estradiol, progesterone, growth hormone and prolactin. Progesterone inhibits the formation of estrogen receptors. Lactation is initiated by the increase in prolactin and the sudden reduction in progesterone level on delivery of the placenta. Oxytocin facilitates ejection of milk by contraction of myoepithelial cells of the alveoli. Regular suckling stimulates prolactin secretion by a neuroendocrine reflex and this is responsible for maintenance of lactation. Other hormones like growth hormone, ACTH, thyroxine, human placental lactogen and insulin also play a role in the maintenance of optimal milk secretion.
In health, the sizes of the breasts vary. The two sides are not symmetrical. During menstrual cycles, premenstrual pain and tenderness may develop even in normal women. Though, generally mild, sometimes the pain and discomfort may be severe. These symptoms are promptly relieved by diuretics, progesterone or bromocriptine. Lactation can be suppressed by high doses of estrogens or bromnocriptine.
Trophy Of Breasts
This commonly occurs when the estrogen levels fall as in hypogonadism or menopause. Disorders occurring before puberty lead to abnormal breast development. Lesions occurring thereafter result in regression of size of the breasts. Breast atrophy is also common in hyperandrogenism due to any cause- adrenal, ovarian or iatrogenic.
Hypertrophy Of Breasts
Hyperprolactinemia may give rise to bilateral hypertrophy of breasts with galactorrhea. This may be idiopathic in some rare cases. Unilateral breast enlargement is usually due to juvenile fibroadenoma, malignant tumours or infiltrations as in acute leukemia. Bilateral fibroadenosis is associated with premenstrual pain and it commonly develops after puberty.
Breasts In Males
Gynecomastia And Galactorrhea
The increase of glandular and stromal tissue of male breast is termed gynecomastia. True glandular enlargement has to be differentiated from adipose tissue deposition. Carcinoma or neurofibromatosis by careful examination. Increased levels of estrogens with or without a reduction of androgens lead to gynecomastia. If prolactin is also increased, galactorrhea follows.
Causes of gynecomastia:
- About 50- 70% of normal boys develop transient gynecomastia during puberty.
- Primary testicular failure as in Klinefelter’s syndrome, cryptorchism, leprosy.
- Testicular tumours- seminoma or teratoma.
- Hepatic cirrhosis.
- Endocrine disorders like hyperthyroidism, hypothyroidism, adrenal cortical overactivity.
- Paraneoplastic syndromes, e.g. bronchogenic carcinoma, renal carcinoma, Hodgkin’s disease.
- Drugs, e.g. estrogens, digitalis, spironolactone, reserpin, marijuana, etc.
- Trauma to chest wall.
The serum levels of testosterone, 17B-estradiol and gonadotropins are normal in idiopathic gynecomastia. High serum LH levels indicate primary testicular failure or HGH secreting choriocarcinoma of the testes. A very high level of serum 17B-estradiol should suggest a feminizing adrenal carcinoma.
Treatment: Pubertal gynecomastia often self-limiting and this may be left alone after assuring the individual of its benign nature. In others, the cause should be detected and treated. In some cases, surgical excision is done for cosmetic reasons and to prevent neoplasia later.
Nonphysiological secretion of milk from the breast is known as galactorrhea. It is seen in both sexes and the amount of milk may vary from a few drops to large volumes. Amenorrhea accompanying galactorrhea suggests a hypothalamopituitary disorder.
- Hypothalamopituitary disease
- Hypothalamic lesions, e.g. tumours, granulomas, histiocytosis X, postencephalic sequelae, trauma, pituitary stalk section.
- Pituitary disease, e.g. prolactinoma, acromegaly, empty sella syndrome, Cushing’s syndrome.
- Functional hyperprolactinemia
- Drug e.g. Oral contraceptives, digoxin, chlorpromazine, reserpine, methyldopa and several others.
- Chest wall lesions, surgery, herpes zoster, burns.
- Other endocrine disorders, e.g. myxodema, adrenal cortical disorders.
- Ectopic prolactin secretion and paraneoplastic syndromes, e.g. bronchogenic carcinoma, hyperhephroma, Hodgkin’s disease.
- Chronic renal failure
Diagnosis: Galactorrhea may be an isolated symptom or this may be part of other endocrine manifestations. Many patients do not volunteer this symptom and, therefore, it is likely to be missed if not careful looked for.
Management: Therapy depends upon the cause. Endocrine disorders should be treated appropriately. Drug induced galactorrhea responds promptly to drug withdrawal. When the cause is obscure, bromoscriptine in a dose of 5 mg/day may be tried. It stops galactorrhea, within a few weeks. Adverse side effects of bromocriptine include nausea, vomiting and hypotension.
In conclusion, the manifestations of such disease; Gynecomastia, Galactorrhea, hypertrophy and trophy of the Breasts are muti-caused, but due to the large part of hormonal function played in their presentations, an endocrine pathology is first put into consideration before any other cause or aggravating factor. Their increase occurrence is becoming of huge concern in our global health environment.
© 2014 Funom Theophilus Makama