ARTICLE IN PRESS
The Breast (2004) 13, 428–430
Gynaecomastia and the plant product ‘‘Tribulis terrestris’’
J.K.A. Jameel, P.J. Kneeshaw, V.S.R. Rao, P.J. Drew*
Academic Surgical Unit, Castle Hill Hospital, University of Hull, Cottingham, East Yorkshire HU16 5JQ , UK
Received 15 September 2003; accepted 27 October 2003
Gynaecomastia; Androgenic-anabolic steroids; Steroid alternatives; Tribulis terrestris
Summary Gynaecomastia is the commonest benign breast condition seen in men. It is well recognised that certain drugs that alter the normal sex hormonal proﬁle in the body can induce gynaecomastia. Recently, an increasing use of androgenic-anabolic steroids among young men especially body-builders has increased the incidence of gynaecomastia. We report a case of a young weight-trainer who developed gynaecomastia due to oral intake of a herbal tablet which he used as a steroid alternative for body-building. & 2003 Elsevier Ltd. All rights reserved.
Gynaecomastia is the commonest condition affecting the male breast.1,2 It can occur at any age and is due to proliferation of glandular component of the breast tissue secondary to an imbalance in the sex hormones.3,4 It is entirely benign and various conditions that affect the normal sex hormonal proﬁle in the body such as hypogonadism, testicular neoplasms, liver failure, thyrotoxicosis and intake of certain drugs can cause gynaecomastia, although in majority of young men the exact aetiology is unknown.5 Here we describe a case of a unique plant derivative which had induced gynaecomastia in an apparently healthy individual.
A 21-year-old gentleman who works as an aircraft ﬁtter and is also a keen weight-trainer was referred by his general practitioner to the breast clinic with a 5 month history of a lump in his left breast which was occasionally painful. Seven years previously, he reported a similar swelling on the right side that had settled spontaneously. He was otherwise ﬁt and well. He smoked 2 cigarettes a day and drank about 10 units of alcohol a week. On examination there was a well-deﬁned nodule in the sub-areolar region on the left side consistent with gynaecomastia. This was causing him considerable discomfort especially while playing sports and he requested surgical removal. In view of the patient’s symptoms and wishes, this was excised using a minimally invasive technique (mammotome probe and liposuction).6 Two weeks later at clinic follow-up, his wound had completely healed and he was very pleased with the cosmetic result. The histology was reported as atypical ductal hyperplasia (ADH), therefore he was not discharged but kept under
*Corresponding author. Tel.: þ 44-1482-623077; fax: þ 441482-623274. E-mail address: firstname.lastname@example.org (P.J. Drew).
0960-9776/$ - see front matter & 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2003.10.013
testosterone 1.0–8. On the assumption that this substance had caused the hormonal imbalance and hence gynaecomastia. LH 6. Layer GT. On closer questioning at this stage. Alternatively.38:596–607.8 They increase strength. FSH 0.3 nmol/l (normal: 10–50). It can also be associated with speciﬁc diseases and intake of certain drugs.10 Hence. Androgenic-anabolic steroids (AAS) are the most widely misused group of drugs in competitive sport. Furthermore the histology of the excised tissue revealed ADH.26 IU/l (normal: 1. oestradiol and progesterone were within normal limits. we believe that this could either be due to the shut-down of the pituitary gonadal axis in the presence of exogenous substances or due to increased aromatisation and peripheral conversion into estrogens. When reviewed in the clinic 3 months later. It is regarded as a natural herbal alternative to AAS.
Gynaecomastia usually presents as a unilateral tender enlargement of the sub-areolar breast tissue. In summary. Its link in the development of ADH may also suggest a possible carcinogenic effect on the breast tissue. Gynaecomastia (Review). Prolactin.29(5):437–9. the patient said that he had been taking a non-hormonal preparation derived from a plant called Tribulis terrestris.
1. This revealed a markedly decreased follicle-stimulating hormone (FSH). the active components of which are steroidal saponins of furostanol type isolated from ‘‘above the ground’’ part of the plant ‘‘T. Ismail AA.7 In any case. LH 0.13 In our patient the abnormal tissue was completely excised and a subsequent core-biopsy did not show any ductal hyperplasia or atypia. Daniels IR. testosterone 15 nmol/l.167(12):885–92. striae and gynaecomastia were the most commonly reported in one study on 100 athletes. Layer GT. lean body mass improving the athlete’s appearance and performance. 3. although more deﬁnite evidence on these aspects needs to be established.0–7.11. Daniels IR. in the form of tablets as a steroid alternative to supplement his weight-training.
. Eur J Surg 2001. he presented with another nodule again in the left sub-areolar region. FSH 11 IU/l. terrestris
L. both of which could contribute to development of gynaecomastia. Testicular tumours presenting as gynaecomastia. The swelling in his left breast had also completely resolved.0). Although the pathologic interpretation is subject to interobserver variability. it is well recognised that ADH falls on a pathologic continuum between benign hyperplasia and ductal carcinoma and it is associated with a 4-fold to 5-fold increased risk of breast carcinoma. 2. however the development of ADH. Its mechanism of action is not fully clear.59 IU/l (normal: 1. it may exert its effect by being metabolised into androgen-like products or stimulating the physiological transformation of testosterone into more active dihydrotestosterone. One such is the tablet taken by our patient. It can be physiological as in neonatal. A complete sex hormonal proﬁle was requested. Ann Clin Biochem 2001. bulgaricum’’. as this could play a major part in the pathogenesis and with appropriate timely intervention cure of the disease. in an otherwise healthy individual. Eur J Surg Oncol 2003. Two months later his sex-hormones were re-checked and they had improved. Endocrinology of gynaecomastia.12 In our patient both gonadotropins and testosterone were markedly reduced after taking this preparation in contrast to experimental studies on this product which showed enhancement of LH and testosterone. It is important for clinicians to keep an open mind while eliciting drug history and not discard the natural products which many patients take but fail to disclose. an increasing number of young men have turned towards steroid alternatives which could provide the beneﬁts of AAS with minimal side-effects. It is believed to have a central effect and increase secretion of LH and therefore increase testosterone levels.12 In the absence of signs or symptoms of pituitary insufﬁciency. On clinical evaluation and ultrasound imaging this nodule appeared benign. Core-biopsy was reported as normal breast tissue with a possibility of gynaecomastia difﬁcult to exclude. he was advised to discontinue taking them.0).1 IU/l. this preparation which is believed to be a natural product with minimal side-effects should be regarded as a possible gynaecomastia inducing agent through its effect on sex hormonal levels in the body. the hormonal change that mediates the condition is a decrease in androgens that can be due to either reduced production or androgen resistance. Barth JH.9 AAS have many side-effects of which acne. pubertal and senescent hypertrophy. a precancerous condition raises concern on the safety of this plant preparation. Increased circulating oestrogens that can be due to increased peripheral aromatisation may also decrease androgen expression. leutinising hormone (LH) and testosterone.ARTICLE IN PRESS
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. Ultrasound guided minimally invasive breast surgery (UMIBS): a superior technique for gynaecomastia. Br J Sports Med 1997. Ilsley D. Evans NA. 2nd ed.2].
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