A clinical case of gynecomastia on the background of hormonal imbalance in urological patients

N.S. Tselyuh; S.S. Goshko; І.І. Tsegelyk; Ya.B. Chulovsky

4th Communal City Clinical Hospital, Lviv

The article describes a clinical case of gynecomastia against the background of benign prostatic hyperplasia, hyperestrogenemia and nodal goiter. In order to optimize diagnostic and treatment tactics, performed by a urologist and an endocrinologist jointly, the necessity of establishing an individual pathogenetic diagnosis has been proved. The optimal scheme of patient therapy, aimed at elimination of the hormonal imbalance that underlies the development of gynecomastia, was presented.

Keywords: gynecomastia, hyperestrogenemia, benign prostatic hyperplasia, nodular goiter. 

Gynecomastia is a disease characterized by a single or bilateral breast growth in men due to hypertrophy of the glandular or adipose tissue. It may occur in different periods of life. Gynecomastia is manifested by induration and enlargement of the thoracic gland, a feeling of severity, discomfort and pain in palpation. There are over 30 causes of gynecomastia, including breast cancer. Since the regression of the disease is possible only at the initial stage untill the formation of fibrosis gland, so it is extremely important to determine a cause of the disease, to establish a pathogenic diagnosis and to appoint an effective treatment for the patients of this category as soon as possible.

Clinical case

On Septermber 12, 2016 Patient B., born in 1939, turned to urologist under the direction of the family doctor with complaints about the increased left breast and general weakness observed in several weeks ago. The examination has established that the left breast was enlarged, the tension of the tissues was palpated; axillary lymph nodes were not palpable; stomach was soft without pain; scrotum had no abnormalities. According to the results of per rectum study, the prostate was enlarged to grade 1 hyperplasia. It was homogeneous and elastic; the contours were clear and even. According to the ultrasound of the prostate, the gland in the size of 43 x 38 x 40 mm was visualized. The contour was clear, uneven, the echogenicity was elevated, the structure had multiple microcalcinates and sites of fibrosis, 2,5 cm adenoma, and the amount of residual urine was 40 ml. By using ultrasound, it was found that the left breast was thickened due to the growth of the hypodermic fat layer; volumetric formations were not detected. For a systematic and comprehensive examination of the patient, a special questionnaire was used.

According to the results of laboratory diagnosis, the level of prostate specific antigen was 1.7 ng/ml, free testosterone was 13.1 ng/ml (N 0.7-21.45 ng/ml), prolactin was 5.62 ng/ml (N 2.5-17 ng/ml), estradiol 69.2 ng/ml (N up to 56 ng/ml), bilirubin blood - 18 μmol/L; Thymol test - 1,2, ALT - 0,38 mmol/L, AST - 0,36 mmol/L (N 0,12-0,88 mmol/L and 0,18-0,78 mmol/L, respectively); urea concentration - 5.3 mmol/L, creatinine - 0.062 μmol/L. The parametres of general urinalysis were within the limits of the reference values. According to the results of the general blood test, the hemoglobin was 126 g/L, the number of leukocytes was 6.7 x 10⁹ / L, ESR - 12 mm/h, the blood glucose level - 6.2 mmol/L. According to the fluorography of the chest, at the 5th rib on the right, there was found an induration of interparticle pleura, lung roots had petrificates, and aorta was expanded. The patient denied any administration of drugs causing gynecomastia. Since a disease of thyroid gland could be the one of reasons, the patient was directed to endocrinologist who appointed the series of inspections.

According to the results of hormonal study, the level of free thyroxine was 13.24 pmol/L (N 12-22 pmol/L), thyroid stimulating hormone - 3.97 μIU/ml (N 0.27-4.2 μIU / ml), and ultrasound has revealed a node in the left region of the thyroid gland.

Considering the results of the above-mentioned studies, an individual pathogenetic diagnosis as "gynecomastia, grade 1 benign prostatic hyperplasia, hyperestrogenemia, nodular goiter" has been established to the patient. The following treatment has been appointed: endocrinologist — iodine- and selenium-containing preparation Yosene, 1 tablet per day for 3 months; urologist - herbal product Adruis, 1 tablet per day for 2 months.

At the end of the 2-month therapy, in the control examination the patient had no complaints; the left breast was not enlarged, palpation was not painful; according to laboratory studies, the level of estradiol in the blood was within the normal range (56.2 pg/ml).

Discussion

Gynecomastia (growth of mammary glands in males) occurs as a result of hormonal disorders, in which androgens and estrogens ratio varies in favor of the latter. There are two forms of this disease: pathological form and physiological form as a norm in certain age periods. Pathological form is a symptom of serious disorders in the body – endocrinopathy, in which the synthesis of testosterone is disturbed, adrenal cancer, pituitary gland, hyperthyroidism, renal or hepatic insufficiency and liver cirrhosis.

Physiological gynecomastia occurs:

• in newborns due to the action of the mother's estrogens, which enter the body of the baby in utero, and disappears after 2-3 weeks;
• in more than a third of adolescents aged 12-14 years. It is accompanied by minor discomfort and usually lasts for a year. Breast enlargement is mostly found in boys with obesity and positively correlates with the body mass index;
• in men aged 50-80 years due to the lowered level of testosterone and the predominance of estrogens.

There are three stages of the disease:

• I – initial stage – the first 4 months of illness during which it is possible to reverse the development of gynecomastia with appropriate medication therapy;
• ІІ — intermediate stage – maturation of the glandular tissue of the mammary gland lasts from 4 months to a year;
• ІІІ — fibrosis stage – growth of connective and adipose tissue in the mammary gland. The reverse process is practically impossible.

Prolonged gynecomastia is a risk factor for the development of breast cancer in men. For example in Germany, every year, about 600 cases of breast cancer in the male population are recorded. A preventive examination in men is carried out for the prostate cancer, but not for breast cancer. When a tumor is detected at an early stage, the prognosis is favorable. Chemotherapy and radiotherapy may be performed to such patients.

If the disease has already spread, it becomes more difficult to achieve recovery. That is why it is necessary to differentiate gynecomastia from breast cancer. Considering that lots of diseases can cause gynecomastia, it is very difficult to establish the diagnosis in a particular patient.

To date, scientists have not reached a consensus on the peculiarities of iodine exchange in the thyroid gland in case of castration and on the background of androgen replacement therapy. In particular, Money has studied that the effect of testosterone is associated with an increased size of thyroid gland cells, the enhancement of its function, and iodine absorption. However, Federman has found that the administration of testosterone to men within 7 weeks had no effect on the absorption of iodine by thyroid gland. Although these data are controversial, they still suggest that the thyroid gland plays an important role in the complex chain of changes associated with impaired male genital function. E.M. Meares explains the onset of gynecomastia by disturbed ratio of testosterone and estradiol levels. The processes of androgens and estrogens production (mainly testosterone and estradiol) are interconnected: a greater (70%) proportion of estradiol in men is synthesized from testosterone in peripheral tissues, and the rest is formed by Leydig cells in the testicles. The ratio of testosterone / estradiol in the body is regulated; its change in favor of estradiol is accompanied by the manifestation of the effects of this hormone, in particular in the mammary glands. In turn this causes the increase of mammary glands.

In the presented clinical case, a questionnaire was used to select the appropriate patient management tactics. Thanks to the questionnaire, it was possible to systematically carry out the survey, to involve an endocrinologist for consultation and to appease the patient about the absence of his breast cancer. In addition, the hormonal imbalance (against the background of normal testosterone levels, the blood estradiol concentrations were increased (69.2 ng/ml)) and the node in the thyroid gland were detected. After endocrinologist’s consultation with regard to the presence of thyroid disease in the patient, nodular goiter has been diagnosed. As a result, there were established two possible causes of gynecomastia: hyperestrogenemia and nodular goiter.

As soon as an individual pathogenetic diagnosis as "gynecomastia, grade 1 benign prostatic hyperplasia, hyperestrogenemia, nodular goiter" has been established, the treatment with Adrius and Yosen preparations (1 table per day for 2 months) was appointed.

Adrius is a herbal preparation, which consists of eight components such as velvet bean seeds extract, withania root and leaves, which help to increase the formation of testosterone; Yams bulbulis rhizome extract stimulates the production of gonadotropic pituitary hormones. Yosen is a medicinal product used as a source of iodine and selenium for the normalization of the thyroid gland function (iodine is required for the synthesis of thyroid hormones, selenium is part of the enzymes that contribute to the absorption of iodine by thyroid gland).

After a 2-month course of treatment, clinical and laboratory healing was diagnosed in the patient: no complaints, clinical examination of the breast showed no increase, blood estradiol concentrations were in the normal range.

Conclusion

• For the effective treatment of a patient with gynecomastia it is necessary to establish an individual pathogenetic diagnosis.
• Using the questionnaire when examining a patient makes it possible to perform the therapy in more systematic, comprehensive and economical way.
• The relationship between male sex hormonal imbalance and thyroid diseases in elderly patients requires a more in-depth study.

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