Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
gynaecomastia
- John F Colin (1 April 2008)
-
re government guidelines for surgery for benign gynaecomastia realistic?
- Negin Shamsian, Luke Jones ST2 Surgery Oxford Rotation, Sudip Ghosh, Consultant Plastic Surgeon, Stoke Mandeville Hospital (1 April 2008)
-
Gynecomastia; There is not proven effective medical treatment
- Saul Malozowski (1 April 2008)
-
Gynaecomastia and anabolic steroid use
- Michael J Evans-Brown, Caryl Beynon, Jim McVeigh (16 April 2008)
-
Antipsychotics and hyperprolactinemia
- Kate S Robertson (21 April 2008)
-
Classification is essential to the understanding of the surgical management of gynaecomastia
- Roger JG Stevens (14 May 2008)
|
|
|||
|
John F Colin, retired consultant surgeon Norfolk and Norwich University hospital NR47UY
Send response to journal:
|
This article fails to mention the long list of drugs which can be associated with gynaecomastia,especially in the elderly.A list(produced by the Pharmacy of the Norfolk and Norwich University Hospital in 1993)has 69 drugs on it, including the commomly prescribed drugs allupurinol, amitriptylline, atenolol, ciprofloxacin, chlorpromazine, digoxin, enalapril, furosamide,nifedipine, verapamil and warfarin (the list is far too long to be included in a letter).In clinical practice medication is the commonest cause of gynaecomastia in the elderly. One important point in technique should also be mentioned in removing excess breast tissue in young men, is that if all the abnormal breast tissue is excised there will be an unsatisfactory cosmetic outcome as the enlarged breast will be replaced by a dent.A sufficient slice of breast tissue should be left to prevent this happening, and I have never encountered recurrent gynaecomastia despite adopting this technique over many years. Competing interests: None declared |
|||
|
|
|||
|
Negin Shamsian, Specialist Registrar Plastic Surgery Oxford Rotation, Luke Jones ST2 Surgery Oxford Rotation, Sudip Ghosh, Consultant Plastic Surgeon, Stoke Mandeville Hospital
Send response to journal:
|
Dear Editor, We read with interest the clinical review article written by Niewoehner CB, Schorer AE titled Gynaecomastia and breast cancer in men. Surgery for benign gynaecomastia in the UK has risen by 27% in 2007 in comparison to 2006.1 In men with benign gynaecomastia, surgical excision is considered to be a low priority aesthetic procedure. In some regions men with benign gynaecomastia would not be offered surgical treatment on the NHS. 2 In our region regional guidelines from 2006 suggest that 200 grams of tissue should be excised from each side to warrant surgery on the NHS.3 We carried out an audit of 48 men who underwent surgery for benign gynaecomastia on the NHS between 2003 and 2006, prior to the publication of the guidelines. Only 6.25% would have met the priorities committee guidelines for surgery on the NHS. We wonder whether the government guidelines for surgery for benign gynaecomastia are realistic. Luke Jones, ST2 Surgery Oxford Rotation
Contributors: NS and LJ carried out audit entitled A retrospective review of gynaecomastia - weights of tissue excised in 2007, Roger Ramcharan and Peter Budny were contributors on this audit. Competing interests: as above References 1. BAAPS Statistics 2007. http://www.baaps.org.uk/content/view/280/62/ 2. Oxfordshire NHS Trust Priorities Forum Policy statement - http://www.oxfordshire.nhs.uk/docs/lavender/policy6b2.pdf 3. Thames Valley Priorities Committee Plastic Surgery Guidelines on Gynaecomastia Miss N Shamsian
Competing interests: NS and LJ completed a gynaecomastia audit entitled A Retrospective review of Gynaecomastia surgery and weights of tissue excision in 2007. |
|||
|
|
|||
|
Saul Malozowski, MD, PhD, MBA Rockville, MD 20852
Send response to journal:
|
I would like to expand on the thoughtful review on gynecomastia by Niewoehner et al. 1 Examination of the testis is mandatory in all patients consulting for this sign. Location, size and turgor of the gonads provide invaluable information on the status of the hypothalamic pituitary testicular axis; subsequent tests could be prioritized based on this evaluation.2 Although idiopathic gynecomastia is highly prevalent with hundred of million of affected men, unfortunately, there is no proven medical therapy for this condition and the quality of the research using medications is very poor. As an example, the best publications available, for tamoxifen include only 332 individuals and of those only 10 (<3%) were studied in randomized trials. 3The literature showing efficacy for all other drugs is smaller and as unreliable mostly due to lack of proper controls. Given this uncertainty, it is problematic to draw conclusions regarding the use of any medication for the treatment of gynecomastia. Saul Malozowski, MD, PhD, MBA
References 1) Niewoehner CB, Schorer AE. BMJ 2008; 336:709-13 2) Santen RJ. Gynecomastia. In: DeGroot LJ and Jameson JL, eds. Endocrinology. 4th ed. Philadelphia, USA: WB Sounders, 2001:2335-43. 3) Braunstein GD. Gynecomastia. N Engl J Med, 2007;357:1229-37. Competing interests: None declared |
|||
|
|
|||
|
Michael J Evans-Brown, Researcher in Ergogenic and Ancillary Drugs Centre for Public Health, Liverpool John Moores University, Castle House, Liverpool, L3 2AY, Caryl Beynon, Jim McVeigh
Send response to journal:
|
Whilst Niewoehner and Schorer note in their review of gynaecomastia and breast cancer in men that the use of anabolic steroids should be considered in the cause of gynecomastia [1], it is important to recognise the significant levels of use of these drugs for performance- and image-enhancing reasons within the general population [2, 3, 4]. Furthermore, many users practice complex, self-directed, polydrug regimes [2, 3, 5] that include not only the use of supraphysiologic doses of multiple types of anabolic steroids but also, inter alia, growth hormone, human chorionic gonadotropin, spironolactone and a wide variety of supplements (e.g. the prohormone dehydroepiandrosterone (DHEA)) [2, 3, 5, 6] — substances that have all been associated with gynecomastia. Given the high levels of self-reported gynecomastia in users [3] — and reflected in the widespread prophylactic use of self-prescribed tamoxifen [3, 6], (and, anecdotally, an increasing use of aromatase inhibitors) — we consider it particularly relevant to ask about use of anabolic steroids and ancillary substances (type of drugs, dose and duration of use) in individuals presenting with gynecomastia who have mesomorphic or hypermesomorphic body types (in this regard it is also noteworthy that use of these drugs is not just restricted to adolescents and those in their 20s [2, 3, 6]). As the authors of the review highlight, however, patients can feel embarrassed and anxious by their condition and this can be compounded in this population given the demonisation of anabolic steroids by society. Further, the historic low-level of engagement and trust by this population with health professionals [2, 3] may act on this, which could increase a reluctance to reveal their use of these substances [7, 8]. Alongside this, clinicians should also be cognisant to the ubiquity of counterfeit drugs in use by this population, which, not only differ in stated dose and drug, but also contain other substances not present on the labelling [9–11]. This, ultimately, may confound determination of the causative substance/agent. Finally, alongside the risk of gynaecomastia, it is important to recognise that this population have complex health needs [2, 3, 5, 12], not least added to by the fact that more than 70% of these individuals inject many of these drugs [2, 3]. Yet, aside from the provision of sterile injecting equipment, there are few opportunities for this population to engage with health professionals. From both the literature [2, 3] and our own experience of working with this population there are clearly a significant number of individuals who desire better engagement with health services. We would therefore suggest that we need to explore new ways of engaging with this population that are acceptable to them in order to reduce harm and promote health. 1. Niewoehner CB, Schorer AE. Gynaecomastia and breast cancer in men. BMJ. 2008;336(7646):709-713. 2. Korkia P, Stimson GV. Anabolic steroid use in Great Britain: an exploratory investigation. A report to the Department of Health, the Welsh Office and the Chief Scientist Office, Scottish Home and Health Department. London, United Kingdom: Her Majesty’s Stationery Office, 1993. 3. Lenehan P, Bellis M, McVeigh J. Anabolic steroid use in the North West of England. Journal of Performance Enhancing Drugs. 1996;1:57–70. 4. Roe S, Man L. Drug misuse declared: Findings from the 2006/07 British Crime Survey. London, United Kingdom: Home Office; 2007. 5. Dawson RT. Drugs in sport – the role of the physician. J Endocrinol. 2001;170:55-61. 6. Baker JS, Graham MR, Davies B. Steroid and prescription medicine abuse in the health and fitness community: A regional study. Eur J Intern Med. 2006;17(7):479–484. 7. van der Kuy PH, Stegeman A, Looij BJ Jr, Hooymans PM. Falsification of Thai dianabol. Pharm World Sci. 1997;19(4):208–209. 8. Ferenchick GS. Validity of self-report in identifying anabolic steroid use among weightlifters. J Gen Intern Med. 1996;11(9):554-556. 9. McVeigh J, Lenehan P. Counterfeits and fakes: a growing problem. Relay. 1994;1(1):8–9. 10. Perry H. Counterfeit-fake anabolic steroids and hazards of their use. Relay. 1995;1(4):9-12. 11. Musshoff F, Daldrup T, Ritsch M. [Anabolic steroids on the German black market]. Arch Kriminol. 1997;199(5-6):152–158. 12. Hartgens F, Kuipers H. Effects of androgenic-anabolic steroids in athletes. Sports Med. 2004;34(8):513-554. Competing interests: None declared |
|||
|
|
|||
|
Kate S Robertson, Staff grade psychiatrist Ardenleigh Centre, 385, Kingsbury Road, Erdington Birmingham B24 9SA
Send response to journal:
|
Niewoehner and Schorer’s review of breast cancer in men was thorough and informative, but may have under-emphasised the role of antipsychotic medication as a causal mechanism of hyperprolactinaemia. An increase in serum prolactin is a class effect of all antipsychotic medication, due to dopamine antagonism. ‘Typical’ antipsychotics (chlorpromazine, haloperidol) commonly induce elevations above the normal range, as do some of the newer antipsychotics, most notably risperidone (which is mentioned in the article) and amisulpride (which is not). Some 60 % of women and 40% of men treated with conventional or ‘prolactin raising’ antipsychotics will develop a prolactin level above the normal range; tenfold increases from baseline are possible (1,2). It is so common that a measurement of serum prolactin has been advocated as a useful guide to compliance (Maudsley Prescribing Guidelines 2005-2006) when ‘older, typical’ antipsychotics are used. In women, studies have (admittedly inconsistently) shown an increased rate of breast cancer (3), and this article notes that ‘the Food and Drug Administration has required product label warnings for conventional neuroleptics since the 1970s based on a possible association with breast cancer’. There are at least two case reports of breast cancer in men with hyperprolactinaemia (4,5), although in neither case was elevated prolactin due to treatment with antipsychotic medication. However, one factor which has bedevilled the studies searching for, and sometimes finding, the association with breast cancer and antipsychotic medication in women has been the time lag between treatment, prolactin elevation, and illness. Atypical antipsychotics, in particular risperidone, are being prescribed more frequently in an ever younger age group, as adjuncts to the treatment of ADHD, autism, and persistent aggression (all off licence). They are also in use as part of the move towards early intervention in psychosis, and the current recommendations are that treatment be continued for a period of years (6), if not indefinitely. We know almost nothing about the effects of hyperprolactinaemia starting in adolescence on the risk of breast cancer; other effects, such as that on bone density, are only now being fully recognised (7). The effects of long term hyperprolactinaemia in men also require further study; this article was a useful reminder of one more potential risk. References: 1) A.Wieck and P. M. Haddad; Antipsychotic-induced hyperprolactinaemia in women: pathophysiology, severity and consequences; selective literature review British Journal of Psychiatry (2003), 182 , 199- 204 2) P. M. Haddad, A. Wieck; Antipsychotic-induced hyperprolactinaemia: mechanisms, clinical features and management. Drugs, 2004, vol. 64, no. 20, p. 2291−314 3) Philip S. Wang, MD, DrPH; Alexander M. Walker, MD, DrPH; Ming T. Tsuang, MD, PhD, DSc; E. John Orav, PhD; Robert J. Glynn, PhD, ScD; Raisa Levin, MS; Jerry Avorn, MD Dopamine Antagonists and the Development of Breast Cancer Arch Gen Psychiatry. 2002;59:1147-1154 4) Forloni−F, Giovilli−M, Pecis−C, Bortolani−E, Preziosi−A, Barzaghi−M−E, Corti−D, Beck−Peccoz−P. Pituitary prolactin−secreting macroadenoma combined with bilateral breast cancer in a 45-year-old male; Journal of endocrinological investigation, Jun 2001, vol. 24, no. 6, p. 454−9 5) Gola−M, Papi−G, Tavernari−V, Pesenti−M, Ficarra−G, Velardo−A (Mammary carcinoma in a patient with hyperprolactinemia). Minerva endocrinologica, Dec 1997, vol. 22, no. 4, p. 107−10 6) NICE guidelines for schizophrenia: http://www.nice.org.uk/nicemedia/pdf/CG1NICEguidelineoster.pdf 7) A.M.Meaney, S. Smith,O. D. Howes, M.O’Brien, R. M. Murray and V.O’Keane; Effects of long-term prolactin-raising antipsychotic medication on bonemineral density in patients with schizophrenia, British Journal of Psychiatry (2004), 184 , 503-508 Competing interests: None declared |
|||
|
|
|||
|
Roger JG Stevens, clinical fellow in plastic surgery Chelsea & Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London SW10 9NH
Send response to journal:
|
In their review of gynaecomastia and breast cancer in men,1 Niewoehner and Schorer omitted the clinical classification of gynaecomastia. The system developed by Simon et al2 is the most commonly used classification and helps to understand the surgical correction of gynaecomastia. This classification is based on the extent of breast enlargement and the presence or absence of excess skin: • Grade 1: minor breast enlargement with no excess skin; • Grade 2a: moderate breast enlargement with no excess skin; • Grade 2b: moderate breast enlargement with excess skin; • Grade 3: marked breast enlargement with excess skin. Patients with grades 1 and 2a gynaecosmastia require no skin excision, but the breast development associated with grades 2b and 3 is so marked that excess skin must be removed. Although this classification is not applicable to the surgical management of men with breast cancer and gynaecomastia, it allows important management decisions to be made for the surgical correction of gynaecomastia. 1 Niewoehner CB, Schorer AE. Gynaecomastia and breast cancer in men. BMJ 2008;336:709-13. 2 Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg 1973;51:48-52. Competing interests: None declared |
|||