Gynecomastia and Its Management In Boys With Partial Androgen Insensitivity Syndrome

INTRODUCTION

Partial androgen insensitivity syndrome (PAIS) is a rare condition that is reported to be commonly associated with gynecomastia in males.

OBJECTIVES

To assess the management of gynecomastia in male PAIS.

MATERIALS AND METHODS

Retrospective review of males with PAIS over the age of 10 years in the I-DSD registry.

RESULTS

Of the 205 eligible cases, information was available for 57 from 13 centers. An androgen receptor gene variant was confirmed in 45 (79%) with a median age at first presentation of 1.0 year (range 0.1, 26.0). Of the 45 genetically confirmed cases, gynecomastia was present in 41 (91%) with a median age at the time of gynecomastia development of 13.5 years (11.0, 29.0). In the other 4 (9%) with no gynecomastia, the median age at last assessment was 15.7 years (10.6, 17.0). In 30 cases with information available, micropenis was present at the time of gynecomastia development in 23 (77%). Of the 35 with information available, 2 (6%) exhibited spontaneous resolution between the ages of 15 and 21 years and 25 (71%) had breast surgery at a median age of 15.7 years (14.0, 23.0). Of these 25, 9 (26%) had previously received medical therapy. The median clinician score of effectiveness for medical therapy was 3 (1, 8) compared to 10 (3, 10) for surgery (P < .0001). In 31 with information available, 13 (42%) had received psychology support.

CONCLUSION

Gynecomastia is common in PAIS but not universal. Surgical management may be more effective than medical therapy, but there is a need for further standardized and systematic studies.

17α-hydroxylase/17,20-lyase deficiency in 46, XY: our experience and review of literature

Context

There are more than 100 pathogenic variants in CYP17A1 that have been identified in patients with 17α-hydroxylase/17,20-lyase deficiency (17OHD).

Objective

We aimed to describe 46,XY patients with 17OHD from our center and review the literature.

Methods

We retrospectively analyzed genetically proven index cases of 17OHD from our 46,XY disorders of sex development cohort and reviewed similar cases from the literature (n = 150). Based on the phenotype, 17OHD probands were classified into combined severe deficiency (n = 128) and combined partial deficiency (n = 16). Additionally, patients with the apparent isolated 17,20-lyase deficiency (n = 7, from 6 families) were noted. Residual enzyme activities with the observed mutant enzymes were divided in 2 categories as < 1% and ≥ 1%, each for hydroxylase and lyase.

Results

We present 4 index cases of 46,XY 17OHD with a complete spectrum of undervirilization and 2 novel variants in CYP17A1. In the review, the combined severe deficiency was the most common form, with more frequent female sex of rearing, hypertension, hypokalemia, suppressed renin, higher plasma corticotropin, lower serum cortisol, and androgens. Immunoassay-measured serum aldosterone was frequently (68.2%) unsuppressed (>5 ng/dL). Elevated serum progesterone had high sensitivity for diagnosis of combined 17OHD, even in combined partial deficiency (83.3%). Among patients with clinical phenotype of combined severe deficiency, 11.5% had partial 17α-hydroxylase and complete 17,20-lyase deficiency (>1%/<1%) and had significantly higher serum cortisol than those with < 1%/<1% activity.

Conclusion

We report the first monocentric case series of Asian Indian 46,XY patients with 17OHD. We propose that a phenotype of severe undervirilization with milder cortisol deficiency may represent a distinct subtype of combined severe 17OHD with residual 17α-hydroxylase activity but severe 17,20-lyase deficiency (>1%/<1%), which needs further validation.

Clinical features, presentation and hormonal parameters in patients with pubertal gynecomastia

Objective:

Gynecomastia is benign enlargement of breast in male. It is postulated that its development is primarily due to a mismatch in ratio of oestrogen and androgen at breast tissue. The aim of this study was to highlight the clinical features, presentation and hormonal parameters at the time of consultation.

Methods:

All adolescent patients who attended endocrinology department with the complaint of breast enlargement were taken into study. We analysed their thyroid function test, oestrogen, testosterone, prolactin, alpha-fetoprotein, follicle-stimulating hormone, luteinizing hormone, beta HCG (human chorionic gonadotropin) and liver function. Clinical features and anthropometry were recorded.

Results:

Out of 50 patients enrolled, 34 (68%) had bilateral gynaecomastia while 16 patients (32%) had unilateral disease. Mastalgia was seen in 44 patients (88%). Psychological disturbance in the form of depression was seen in 60% of adolescent boys with gynecomastia. Tanner stage B had positive correlation with oestrogen to testosterone (E2/TTE) ratio (r = 0.47; P = 0.034). All other hormonal parameters were normal.

Conclusion:

Mastalgia was one of the presenting complaints in majority of patients and many had bilateral enlargement. Altered oestrogen to testosterone ratio is altered in majority of patients thus may be reason for pubertal gynecomastia.

European academy of andrology guidelines on Klinefelter Syndrome Endorsing Organization: European Society of Endocrinology

BACKGROUND

Knowledge about Klinefelter syndrome (KS) has increased substantially since its first description almost 80 years ago. A variety of treatment options concerning the spectrum of symptoms associated with KS exists, also regarding aspects beyond testicular dysfunction. Nevertheless, the diagnostic rate is still low in relation to prevalence and no international guidelines are available for KS.

OBJECTIVE

To create the first European Academy of Andrology (EAA) guidelines on KS.

METHODS

An expert group of academicians appointed by the EAA generated a consensus guideline according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system.

RESULTS

Clinical features are highly variable among patients with KS, although common characteristics are severely attenuated spermatogenesis and Leydig cell impairment, resulting in azoospermia and hypergonadotropic hypogonadism. In addition, various manifestations of neurocognitive and psychosocial phenotypes have been described as well as an increased prevalence of adverse cardiovascular, metabolic and bone-related conditions which might explain the increased morbidity/mortality in KS. Moreover, compared to the general male population, a higher prevalence of dental, coagulation and autoimmune disorders is likely to exist in patients with KS. Both genetic and epigenetic effects due to the supernumerary X chromosome as well as testosterone deficiency contribute to this pathological pattern. The majority of patients with KS is diagnosed during adulthood, but symptoms can already become obvious during infancy, childhood or adolescence. The paediatric and juvenile patients with KS require specific attention regarding their development and fertility.

CONCLUSION

These guidelines provide recommendations and suggestions to care for patients with KS in various developmental stages ranging from childhood and adolescence to adulthood. This advice is based on recent research data and respective evaluations as well as validations performed by a group of experts.

The relationship between lavender and tea tree essential oils and pediatric endocrine disorders: A systematic review of the literature

OBJECTIVES

Essential oils are common ingredients in personal care products, little is known about the effects of chronic exposure to these ingredients in human health. It has been suggested that these two essential oils cause prepubertal gynecomastia and premature thelarche in children. The purpose of this study was to systematically review the evidence related to the proposed link between these essential oils and endocrine disruption METHODS: This study sought to investigate the proposed link between LEO and TTEO and endocrine disrupting outcomes by identifying and evaluating the clinical evidence regarding this topic. Studies qualified if the participants included prepubertal children who have experienced either prepubertal gynecomastia or premature thelarche. The Case Series Critical Appraisal Tool (CSCAT) was used to identify the reliability of the identified case series. The potential for evidence of causality was evaluated using the tool proposed by Murad.

RESULTS

A total of four manuscripts were identified, describing a total of eleven cases reported to have experienced both the exposure and the outcome. Reporting of inclusion, demographic data, clinical data, and the potential for causality was found to be insufficient. This study did not find evidence to support the claim that tea tree essential oil is related to endocrine disruption in children, and little to no evidence to substantiate the proposed link between lavender essential oil and endocrine disruption in children.

CONCLUSION

Because this potential link remains a concern among pediatric care providers and parents, epidemiological research to address the proposed link is needed.

Klinefelter Syndrome: Integrating Genetics, Neuropsychology, and Endocrinology

Although first identified over 70 years ago, Klinefelter syndrome (KS) continues to pose substantial diagnostic challenges, as many patients are still misdiagnosed, or remain undiagnosed. In fact, as few as 25% of patients with KS are accurately diagnosed and most of these diagnoses are not made until adulthood. Classic characteristics of KS include small testes, infertility, hypergonadothropic hypogonadism, and cognitive impairment. However, the pathophysiology behind KS is not well understood, although genetic effects are also thought to play a role. For example, recent developments in genetics and genomics point to a fundamental change in our understanding of KS, with global epigenetic and RNA expression changes playing a central role for the phenotype. KS is also associated with more general health markers, including higher morbidity and mortality rates and lower socioeconomic status (which likely affect both morbidity and mortality). In addition, hypogonadism is associated with greater risk of metabolic syndrome, type 2 diabetes, cardiovascular disease, breast cancer, and extragonadal germ cell tumors. Medical treatment typically focuses on testosterone replacement therapy (TRT), although the effects of this therapy have not been studied rigorously, and future studies need to evaluate the effects of TRT on metabolic risk and neurocognitive outcomes. This review presents a comprehensive interdisciplinary examination of recent developments in genetic, endocrine, and neurocognitive science, including the study of animal models. It provides a number of recommendations for improving the effectiveness of research and clinical practice, including neonatal KS screening programs, and a multidisciplinary approach to KS treatment from childhood until senescence.

Bilateral Mastectomy as Radical Treatment of Gynecomastia Secondary to Antiretroviral Therapy in a Low-Income Setting: A Case Report

Gynecomastia is a common finding in males, with an incidence that varies widely globally. In 10–25% of cases, it is caused by drugs. Its pathophysiologic mechanism includes exposure to exogenous estrogens and medications that cause hypogonadism, antiandrogenic effects and hyperprolactinemia. Gynecomastia is associated with exposure to antiretroviral therapy (ART), particularly efavirenz. Sometimes surgery may be required as treatment. We report a case of a 46-year-old man receiving ART presenting with a marked bilateral breast enlargement who underwent bilateral mastectomy as the only successful treatment in a low-income setting.

A boy with 46,X,+mar presenting gynecomastia and short stature

A 15-year-old boy was referred due to gynecomastia and short stature. He was overweight and showed the knuckle-dimple sign on the left hand, a short fourth toe on the left foot, and male external genitalia with a small phallus. His levels of estradiol and follicle-stimulating hormone were increased, and his testosterone concentration was normal. Other hormonal tests were within the normal range. Radiographs showed short fourth and fifth metacarpals and fourth metatarsal bones. The karyotype was reported as 46,X,+mar, and the marker chromosome was shown to originate from the Y chromosome, which was identified by fluorescence in situ hybridization. Polymerase chain reaction and direct sequencing were used to clarify the deleted loci of the Y chromosome by making use of Y-specific sequence-tagged sites (STSs). The sex-determining region Y and centromere were verified, and there were microdeletions on the long arm of the Y chromosome. The azoospermia factor (AZF) b region was partially deleted, and AZFa and AZFc were completely deleted. Two STS probes of sY143 and the Y chromosome RNA recognition motif in AZFb showed positive signals corresponding to Yq11.223. The karyotype of the patient was interpreted as 46,X,der(Y)del(Y)(q11.21q11.222)del(Y)(q11.23qter). Herein, we report a rare case of a boy presenting with gynecomastia and short stature with 46, X, +mar, which originated from the Y chromosome, which was identified to have Yq microdeletions.