Prevention of gynecomastia in men with prostate cancer
What is Gynecomastia?
Low testosterone levels in men can sometimes lead to a condition called gynecomastia, or the development of larger breasts.
Testosterone is a naturally occurring hormone. It’s responsible for male physical features and also affects a man’s sex drive and mood. When there’s an imbalance of the body’s hormones in men, including testosterone, gynecomastia can develop.
Both low testosterone and gynecomastia are often treatable. It’s important to first understand the underlying causes for each condition.
Gynecomastia may go away on its own. If it persists, medication or surgery may help.
Testosterone levels normally decrease as men age. This is called hypogonadism, or “low T.” According to the Urology Care Foundation, 1 in 4 men over the age of 45 have low T. Having low testosterone levels can lead to several complications:
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The primary symptom of gynecomastia is enlargement of the male breasts. As mentioned before, gynecomastia is the enlargement of glandular tissue rather than fatty tissue. It is typically symmetrical in location with regard to the nipple and may have a rubbery or firm feel. Gynecomastia usually occurs on both sides but can be unilateral in some cases. The enlargement may be greater on one side even if both sides are involved. Tenderness and sensitivity may be present, although there is typically no severe pain.
The most important distinction with gynecomastia is differentiation from male breast cancer, which accounts for about 1% of overall cases of breast cancer. Usually, cancer is confined to one side, is not necessarily centered around the nipple, feels hard or firm, and can be associated with dimpling of the skin, retraction of the nipple, nipple discharge, and enlargement of the underarm (axillary) lymph nodes.
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Gynecomastia is triggered by a decrease in the amount of the hormone testosterone compared with estrogen. The decrease can be caused by conditions that block the effects of testosterone, reduce testosterone or increase your estrogen level.
Several things can upset the hormone balance, including the following.
Natural hormone changes
The hormones testosterone and estrogen control sex characteristics in both men and women. Testosterone controls male traits, such as muscle mass and body hair. Estrogen controls female traits, including the growth of breasts.
Most people think of estrogen as an exclusively female hormone, but men also produce it — though normally in small quantities. Male estrogen levels that are too high or are out of balance with testosterone levels can cause gynecomastia.
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A number of medications can cause gynecomastia. These include:
Street drugs and alcohol
Substances that can cause gynecomastia include:
Several health conditions can cause gynecomastia by affecting the normal balance of hormones. These include:
Plant oils, such as tea tree or lavender, used in shampoos, soaps or lotions have been associated with gynecomastia. This is probably due to their weak estrogenic activity.
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The definition of gynecomastia is the presence of breast tissue greater than 0.5 cm in diameter in a male. As previously discussed, gynecomastia is the presence of true breast (glandular) tissue, generally located around the nipple. Fat deposition is not considered true gynecomastia.
In most cases, gynecomastia can be diagnosed by a physical examination. A careful medical history is also important, including medication and drug use. If there is a suspicion of cancer, a mammogram may be ordered by a health care practitioner. Further tests may be recommended to help establish the cause of gynecomastia in certain cases. These can include blood tests to examine liver, kidney, and thyroid function. Measurement of hormone levels in the bloodstream may also be recommended in some cases.
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Mild cases of gynecomastia in adolescence may be treated with advice on lifestyle habits such as proper diet and exercise with reassurance. In more severe cases, medical treatment may be tried including surgical intervention.
Medical treatment of gynecomastia is most effective when done within the first two years after the start of male breast enlargement. Selective estrogen receptor modulators (SERMs) such as tamoxifen, raloxifene, and clomifene may be beneficial in the treatment of gynecomastia but are not approved by the Food and Drug Administration for use in gynecomastia. Clomifene seems to be less effective than tamoxifen or raloxifene. Tamoxifen may be used for painful gynecomastia in adults. Aromatase inhibitors (AIs) such as anastrozole have been used off-label for cases of gynecomastia occurring during puberty but are less effective than SERMs.
A few cases of gynecomastia caused by the rare disorders aromatase excess syndrome and Peutz–Jeghers syndrome have responded to treatment with AIs such as anastrozole. Androgens/anabolic steroids may be effective for gynecomastia. Testosterone itself may not be suitable to treat gynecomastia as it can be aromatized into estradiol, but nonaromatizable androgens like topical androstanolone (dihydrotestosterone) can be useful.
Male with asymmetrical gynecomastia, before and after excision of the gland and liposuction of the waist
If chronic gynecomastia is untreated, surgical removal of glandular breast tissue is usually required. The American Board of Cosmetic Surgery reports surgery is the "most effective known treatment for gynecomastia." Surgical approaches to the treatment of gynecomastia include subcutaneous mastectomy, liposuction-assisted mastectomy, laser-assisted liposuction, and laser-lipolysis without liposuction. Complications of mastectomy may include hematoma, surgical wound infection, breast asymmetry, changes in sensation in the breast, necrosis of the areola or nipple, seroma, noticeable or painful scars, and contour deformities. In 2019, 24,123 male patients underwent surgical treatment for gynecomastia in the US, accounting for a 19% increase since 2000. Thirty-five percent of those patients were between the ages of 20 and 29, and 60% were younger than age 29 at the time of the operation.
Radiation therapy and tamoxifen have been shown to help prevent gynecomastia and breast pain from developing in prostate cancer patients who will be receiving androgen deprivation therapy. The efficacy of these treatments is limited once gynecomastia has occurred and are therefore most effective when used prophylactically.
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Prevention of gynecomastia in men with prostate cancer
Because androgen deprivation is one of the commonly used treatment modalities for advanced prostate cancer, its possible role in the development of gynecomastia is of particular concern to clinicians. Up to 80% of patients receiving non-steroidal anti-androgen therapy may develop gynecomastia, usually 6-9 months after hormonal treatment. Some patients may have painful and disfiguring gynecomastia. Several preventive strategies have been proposed: Tamoxifen has demonstrated its efficacy versus radiotherapy in preventing gynecomastia in patients receiving bicalutamide (Casodex) for prostate cancer in a randomized controlled trial. Boccardo et al showed 10% patients in the tamoxifen group (20 mg daily dose) developed gynecomastia, whereas 51% in the anastrozole group and 73% in placebo group had gynecomastia over a period of 48 weeks. Fradet et al showed tamoxifen reduced the incidence of gynecomastia in patients with prostate cancer receiving bicalutamide in dose dependent manner. Likewise, it has been shown that low dose tamoxifen (20 mg/week) is inferior to the daily regimen (20mg/day) in terms of the prevention and treatment of gynecomastia. Current data suggests tamoxifen 10-20mg per day is the optimum dose required for prophylaxis of gynecomastia in patients with prostate cancer receiving androgen deprivation therapy. Low dose prophylactic irradiation has been variably reported to reduce the rate of gynecomastia in men receiving estrogens or anti-androgens for prostate cancer. Some papers suggest that the new generation of anti-androgen therapy, such as abiraterone acetate, may be associated with less gynecomastia; further studies are required to confirm these results.
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