|
Lawrence
and colleagues report their experience with the use of either raloxifene or tamoxifen,
both antiestrogenic agents, in reducing breast size in adolescent boys with
benign gynecomastia. The data presented are from a retrospective review of 37
patients: 12 received reassurance alone, 10 received raloxifene (60 mg once
daily for 3 to 9 months), and 15 received tamoxifen (10 to 20 mg twice dialy for
3 to 9 months). Baseline studies including LH, FSH, testosterone, and estradiol
levels were normal in all subjects and there were no significant differences
among the groups with regard to age at initiation of treatment, Tanner stage, BMI
or baseline hormone levels. Significant reductions in breast diameter were
measured with both raloxifene (2.5cm, 66% reduction) and tamoxifen (2.1cm, 46%
reduction). However, a 50% or greater reduction was seen more often in the
raloxifene treated group (86% vs 41%). No side effects of the medications were
reported.
Telephone
follow-up was attempted to determine the rate of surgical treatment following
the study. Approximately 40% of subjects contacted in each group underwent
surgery. The authors concluded that treatment with the estrogen receptor
inhibitors, raloxifene and tamoxifen, is both safe and effective, but admit
that surgical intervention occurred despite the treatment. They further suggest
that future studies need to utilize more precise methods for measuring
glandular breast tissue and also for evaluating the psychosocial impact of various
treatments.
Lawrence SE, Faught KA, Vethamuthu J, Lawson ML. Beneficial effects of raloxifene and tamoxifen in the treatment of pubertal gynecomastia. J Pediatr 2004;145:71-76.
First Editor’s Comment: Pubertal gynecomastia remains a significant diagnosis in pediatric
endocrine clinics. As obesity becomes more prevalent, gynecomastia referrals
are being seen with increasing frequency. Benign breast enlargement is very
common; in adolescents reassurance is usually considered the safest and most
reasonable treatment option. Only occasionally will surgery be recommended for
those boys who are not obese and for whom gynecomastia is associated with
significant psychosocial morbidity. Clearly a safe and effective medical
therapy would be appreciated. Both anti-estrogen medications studied demonstrated
a reduction in breast size. Unfortunately the study was retrospective, and the
boys for whom reassurance was prescribed were not followed. The post-treatment telephone
survey however, was revealing. The rate of surgical intervention was not
influenced by the treatment regimen. The same number of boys underwent surgery regardless
of therapy (reassurance along vs antiestrogens). Thus, although the medications
were effective in reducing breast size, they did not produce satisfactory
results for the patients. Clearly more detailed, perhaps longer, prospective
randomized trials are needed. And as the authors point out, these studies must
include evaluations of psychosocial factors.
William L. Clarke, MD
Second Editor’s Comment: Breast tissue in an adolescent boy can
be emotionally distressing with its associated embarrassment causing the
affected individual to avoid social activities in which the chest is exposed,
ie swimming. In extreme cases this situation is associated with a depressed
mood and/or an anxious state. Given the prevalence gynecomastia and its
psychosocial burden, it is surprising that a MEDLINE® and PsycINFO® literature (keywords
gynecomastia, psychiatry, psychological benefits of breast tissue removal) yielded
no results since 1990. However, a controlled study of psychosocial sequelae of esthetic
deformities suggested a significant benefit after correction through plastic
surgery.1 Although quality of life improved, it would be wise to
consider the importance of careful selection and preparation of candidates for
surgery since, “The core value of the surgery lies not in the objective beauty
of the visible result, but in the patient's opinion of and response to the
change. Good patient management includes selecting candidates with clear and
realistic expectations who are free of psychopathology. There must be true
informed consent and attention to psychological issues must continue into the
postoperative period”.2 Excess tissue in the breast region of
males, whether of glandular or adipose origin, arguably exerts comparable
emotional distress in the adolescent. Given the secular increase in the
incidence of obesity in industrialized nations, it is reasonable to speculate
that both pediatric endocrinologists and plastic surgeons will be spending
increasing time pondering this topic.
David E. Sandberg, PhD
References - (linked to  )
- Simis KJ, Hovius SE, de Beaufort ID, Verhulst FC, Koot HM. After plastic surgery: adolescent-reported appearance ratings and appearance-related burdens in patient and general population groups. Plast Reconstr Surg 2002;109:9-17.
- McGrath MH, Mukerji S. Plastic surgery and the teenage patient. J Pediatr Adoldesc Gynecol 2000;13:105-118.
|
Current GGH - Vol. 24 No. 1
Printer Friendly
Email Paper