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What is small breast: When the size of breast in girls is less than 36” which is considered ideal, is termed as small breast.( also known as micro-mastia).

How Normal Breast develops: All girls have same size of breast tissue in childhood. At the time of puberty i.e. beginning of sexual development female hormone estradiol, adrenal hormone androstenidione, 17-oh Progesterone, DHEAS, Growth hormone, LH, FSH, increases & SHBG decreases, Thyroid Hormone also plays the role. These hormones changes lead to increased concentration of Free Testosterone, DHT & some more hormones. These hormones then act on the various sensors (called receptors) in the breast tissue. After the interaction of hormones & receptors certain changes occurs in the functioning of cells of breast tissue so that breast cells starts growing in thickness & size & more & more fat starts depositing in the breast . thus breast size gradually starts increasing. Simultaneously it also increases the blood supply to breast tissue leading to more availability of growth factors to the breast tissue resulting in faster growth of breast tissue. These hormones & growth factors are in high concentration during peak of secondary sexual characters development i. e. puberty leading to persistent stimulation of breast tissue for next two to three years i. e. up to completion of sexual development. Thus in normal girls in two to three years full breast develop. 

Causes of Small Breast:  In girls the small breast can be due to following causes:

1) Female sex hormones deficiency i.e. estradiol in body due to many of the below mentioned causes as leading to absence of estrogen production (hypogonadotropic

hypogonadism). Craniopharyngioma, Germinoma, Hamartoma, Hand Schuller Christan disease, Teratoma, Endodermal, sinus tumors, metastatic carcinoma, Infection and other disorders : Tuberculosis, Syphilis, Encephalitis/meningitis, sarcoidosis, kallmann syndrome, idiopathic hypogonadotropic hypogonadism, Chronic debilitating disease,  

 Pituitary  other hormone-screening pituitary tumors (ACTH, thyrotropin-stimulating hormone, growth hormone), non-functional tumors (craniophyaryngioma), Metastatic carinoma, Space-occupying lesions : Empty sella syndrome, Arterial aneuysm, Necrosis : Sheehan syndrome, Panhypopituitarism, Inflammatory /infiltrative : Sarcoidosis, Hemachoromatosis. Gonadal agenesis, Gonadal dysgenesis, Turner syndrome 45, X, Mosaicism, Pure gonadal dysgenesis, 46, XX, 46,XX (Swyer syndrome), Ovarian enzymatic deficiency as 17a-Hydroxylase deficiency, 17, 20-Lyase deficiency, Premature Ovarian failure : Idiopathic – premature menopause, injury, mumps oophoritis, radiation, chemotherapy, Resistant ovary (Savage syndrome), Autoimmune disease, Galactosemia. 

2) Second cause for small breast is resistance of breast tissue to normal level of female hormone in the body. So that even though female hormone is normal in the body, but the breast tissue of these girls do not have sufficient receptors for female hormone leading to insufficient estrogen action meaning that female hormone is unable to work & breast do not grow well. But when female hormone level is further increased by female hormone replacement treatment & certain more medicines are given so that female hormones becomes more effective on breast, then breast tissue starts growing. Breast size then fully normalizes in six months to one-year time.
3)  Growth factor deficiency
4)  Zinc Deficiency
5)  Estrogen biosynthetic defects
6)  Congenital adrenal hyperplasia
7)  Congenital absence of breast bud
8)  Lipoatrophy generalized
9)   Ninth Cause is resistance of hair roots to normal level of male hormones, in this disorder male hormone is normal in blood even then hair root do not grow because in hair root there is less male hormone receptor (i.e. sensor of male hormone) so that male hormone is unable to work & hair do not grow well. But when male hormone level is further increased by male hormone replacement treatment & certain more medicines are given so that male hormones becomes more effective on hair roots, then hair roots starts growing. Beard & moustaches then fully normalizes in six months to one-year time.
10) Absence of estrogen receptors in breast tissue
12)  Growth hormone deficiency due to hypopituiarism, pituitary disorders
13) Progeria
12) DRUGS:  Cytotoxic Agents, Cyclophoamide, Vincristine,Ionising radiation, Azathioprine
13) Overmastectomy
14) Structural Defects Of body fat cell so that they do not grow
15) Generalized hypoplastic syndrome

Investigations & Diagnosis:
For diagnosis of cause of absent or small breast we do following tests.

Complete hormone profile: LH, FSH, total testosterone, Prolactin, Androstenidione, SHBG, 17 HYDROXYPROGESTERONE, DHEAS, Estradiol, Progesterone
Suppression & Stimulation Tests, 
Karyotype
Genetic testing
Choromosome analysis
Pro. Challenge test 
High Resolution Ultrasound
Mammography
E2 CHALLENGE TEST
Diagnostic Therapeutic Response Test

16) Dysmorphic Syndrome

Investigations & Diagnosis:

For diagnosis of cause of absent or small breast we do following tests.
Complete hormone profile: LH, FSH, total testosterone, Prolactin, Androstenidione, SHBG, 17 HYDROXYPROGESTERONE, DHEAS, Estradiol, Progesterone
Suppression & Stimulation Tests, 
Karyotype
Genetic testing
Choromosome analysis
Pro. Challenge test 
High Resolution Ultrasound
Mammography
E2 CHALLENGE TEST
Diagnostic Therapeutic Response Test

Treatment Options for Breast Enlargement

Before starting treatment for enlargement of breast all above causes are investigated and proper diagnosis is made. Then we test whether breast enlargement is possible or not.

First We Test Whether Breast Enlargement Is Possible Or Not 

After above investigation we make the decision about whether breast enlargement possible or not. We prescribe the hormone treatment only if the above investigations suggest for the scope of further breast enlargement.

                                       Diagnostic & Therapeutic Response Test

This procedure is required in some patient, if above test still does not clarifies of the possibility of breast enlargement. For this hormone & other treatment is given for three month in the form of female hormone tablet, local hormone application at breast skin, or vaginal gels & additional other therapy. If breast enlarges in size i.e. it grows in size by more than 2 cm in these three months, it means breast of that patient has potential for further growth. Once it is decided by above test that breast has potential for further growth, in such patient further courses of hormone therapy is given. By few courses of hormone treatment breast enlarges to normal size in approximately one year time. By this therapy breast size as well its consistency in firmness also increases. Thus breast becomes large in size, more attractive & develops firm protruding look. This breast enlargement treatment is very effective in those patient’s in whom investigations & physical examination shows significant abnormality. Thus most patients achieve fully normal breast. As breast size increases in size patient's confidence increases and feeling of well-being is achieved.

How this treatment works:  

When we give below-mentioned hormones by any of the below-mentioned routes. The concentration of these hormones in blood circulation rises. This leads to binding of more hormones on estrogen receptors of breast. After binding with receptors these hormones leads to certain changes in the breast tissue. This leads to multiplication of breast tissue leading to further growth. This continued multiplication of breast tissue leads to further breast growth. This continued multiplication of breast tissue under the effect of above mentioned hormone treatment continues till breast size normalizes. Usually in one-year time breast size as well as texture i.e. firmness normalizes. Unluckily most doctors have less knowledge about hormone treatment for this problem & also they think the problem of small breast as more of cosmetic problem so that they neither investigate the patient nor give hormone or other medical therapy for breast growth.
Various therapeutic options of breast enlargement are available as:
This treatment can be either:

Hormone & Other Medicine Therapy: available as pills, hormonal skin patches or vaginal creams & other adjuvant drugs are prescribed

Surgical therapy: Breast enlargement surgeries

Medicine Treatment of Small Breast 

We start medical treatment only when above tests shows that breast has capacity to enlarge. It is given in the form replacement of female hormones & other hormone as growth hormone & growth factor replacement. These hormones can be given in the form of oral tablets, skin patches, ointments, gel or creams. 
As this treatment has no side effects, is economical and easy to take either as oral tablets, skin patches, or as gel, thus it is most preferred form of breast enlargement therapy.
The various Treatment options are: 
Treatment of specific disease: Once the cause for absent or small breast is found by above tests then treatment started. Abnormalities of the pituitary and abnormalities in the adrenal glands can be treated by appropriate medicines. Normally patient starts getting improvement in breast size in three to six months.
The various drugs which are required are as follows: 

1) Female hormones replacement: The replacement of female hormones is one of the common treatments for breast enlargement. The various female hormones are as follows: 
a) Estradiol
b) Conjugated equine estrogen
c) Estriol
d) Natural estrogens
e) Prohormones
f) Estrogen skin patches
g) Estrogen vaginal creams
h) Medroxyprogesterone
i) Oral E & P Combination Pill
j) Desgestro
k) Megestrol
L) Norethisterone
N)Hydroxyprogesterone
2) Growths Hormones Therapy: Growth hormone is given when somatotropin deficiency is found & that was cause of small breast..
3) IGF-1 therapy:  is given when somatomedin-c deficiency is the cause.
5) Gonadotropin therapy is also very effective in breast enlargement in many patient.
6) Gonadotropin releasing hormone therapy is effective in many cases of under developed breast.
7) Medicine to increase the fat in breast tissue & body.

But unluckily many doctors do not take the problem seriously leading to patient not given proper treatment. Thus many patients remain having small size of breast & associated lifelong inferiority complex.

Response of Medical Treatment:

In properly selected patient, when any of above treatment is started the response is very good & has no side effects. In many scientific studies when the above treatment started breast  size increases from previous size of hardly visible breast to as big as 36 inches & in some even larger size of 38 or 40 inches. Thus the trial of treatment should be given to all patients with small breast before asking them to go for surgery.  It has no side effects if given in proper disease and in-patients when it is really indicated.

 Breast Enlargement Surgery

Surgical Treatment is required when medicine are not effective then there are various surgical procedures which can lead long lasting good size firm breast. Our Cosmetic surgeon performs all breast increasing surgery.


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