Prepubertal gynecomastia: indirect exposure to estrogen cream

Short-term serum and urinary changes in sex hormones of healthy pre-pubertal children after the consumption of commercially available whole milk powder: a randomized, two-level, controlled-intervention trial in China

Progesterone was found in commercial milk. After consuming this milk, compared with the control, serum progesterone levels after 3 h and urinary pregnanediol levels within 4 h increased, but those in urine after 48 h had no significant change.

Compounded bioidentical menopausal hormone therapy - a physician perspective

One of the defining moments of the 80-year evolution of menopausal hormone therapy (MHT) was the 2002 reveal of the initial results of the combined hormone therapy arm of the Women's Health Initiative (WHI) clinical trial. The exodus from regulatory approved MHT was prompt and profound and accompanied by a rapid acceleration of the compounding pharmacy 'bioidentical' hormone therapy industry. Compounders had recruited prescribers and promoted compounded bioidentical hormone therapy (cBHT) well before the WHI, yet the startling results provided a catalyst that enabled a leap in production of compounded hormones that were variably regulated, basically unstudied, and inconsistently labeled. In this review, the story of the rise of cBHT and the regulatory double standard is eclipsed only by the 2020 findings and recommendations of the US National Academies of Science, Engineering, and Medicine. Their investigation, commissioned by the US Food and Drug Administration, was tasked to: provide an evidence-based summary of the clinical utility of cBHT; evaluate whether the evidence of safety and efficacy supports the use of cBHT; and identify patient populations that might need cBHT in lieu of an approved drug product. Their conclusions are consistent with sound science and their recommendations are in harmony with global menopause societies.

Perturbation of Nuclear Hormone Receptors by Endocrine Disrupting Chemicals: Mechanisms and Pathological Consequences of Exposure

Much of the early work on Nuclear Hormone Receptors (NHRs) focused on their essential roles as mediators of sex steroid hormone signaling in reproductive development and function, and thyroid hormone-dependent formation of the central nervous system. However, as NHRs display tissue-specific distributions and activities, it is not surprising that they are involved and vital in numerous aspects of human development and essential for homeostasis of all organ systems. Much attention has recently been focused on the role of NHRs in energy balance, metabolism, and lipid homeostasis. Dysregulation of NHR function has been implicated in numerous pathologies including cancers, metabolic obesity and syndrome, Type II diabetes mellitus, cardiovascular disease, hyperlipidemia, male and female infertility and other reproductive disorders. This review will discuss the dysregulation of NHR function by environmental endocrine disrupting chemicals (EDCs), and the associated pathological consequences of exposure in numerous tissues and organ systems, as revealed by experimental, clinical, and epidemiological studies.

Estrogenic and anti-estrogenic activity of off-the-shelf hair and skin care products

Use of personal care products is widespread in the United States but tends to be greater among African Americans than whites. Of special concern is the possible hazard of absorption of chemicals with estrogenic activity (EA) or anti-EA (AEA) in these products. Such exposure may have adverse health effects, especially when it occurs during developmental windows (e.g., prepubertally) when estrogen levels are low. We assessed the ethanol extracts of eight commonly used hair and skin products popular among African Americans for EA and AEA using a cell proliferation assay with the estrogen sensitive MCF-7:WS8 cell line derived from a human breast cancer. Four of the eight personal care products tested (Oil Hair Lotion, Extra-dry Skin Lotion, Intensive Skin Lotion, Petroleum Jelly) demonstrated detectable EA, whereas three (Placenta Hair Conditioner, Tea-Tree Hair Conditioner, Cocoa Butter Skin Cream) exhibited AEA. Our data indicate that hair and skin care products can have EA or AEA, and suggest that laboratory studies are warranted to investigate the in vivo activity of such products under chronic exposure conditions as well as epidemiologic studies to investigate potential adverse health effects that might be associated with use of such products.

Prepubertal unilateral gynecomastia: report of 2 cases

Prepubertal unilateral gynecomastia is an extremely rare condition. At present, its etiology and management strategy are not well known. Two unrelated prepubertal boys of ages 8 and 9 who presented with complaints of unilateral enlargement of breast tissue are reported. Physical examination, biochemical, hormonal and oncologic work-up findings were normal. Both patients were treated with peripheral liposuction successfully. Histopathological and immunohistochemical examinations showed benign fibroglandular gynecomastia and intensive (3+) estrogen receptor expression in 100% of periductal epithelial cells. Although an extremely rare and generally benign condition, patients with prepubertal unilateral gynecomastia should have a full endocrine and oncologic work-up.

Drug-induced gynecomastia

Drugs account for about 20% of gynecomastia cases in men. As a number of factors can alter the estrogen:androgen ratio, several pathophysiologic mechanisms are associated with drugs causing this disorder. Antiandrogens, protease inhibitors, and nucleoside reverse transcriptase inhibitors are the most common drug causes of gynecomastia, whereas first-generation antipsychotics, spironolactone, verapamil, and cimetidine are less common causes. Other drugs have been reported rarely as causes. Treatment may involve switching to an alternative agent or may require surgery or irradiation if the causative agent cannot be discontinued. We reviewed the literature on drug-induced gynecomastia and provided another perspective by reviewing data from the United States Food and Drug Administration's Adverse Event Reporting System. Epidemiologic studies are needed to provide a more accurate description of the frequency of drug-induced gynecomastia.

Hypothesis: exposure to endocrine-disrupting chemicals may interfere with timing of puberty

A recent decline in onset of puberty - especially among girls - has been observed, first in the US in the mid-1990s and now also in Europe. The development of breast tissue in girls occurs at a much younger age and the incidence of precocious puberty (PP) is increasing. Genetic factors and increasing prevalence of adiposity may contribute, but environmental factors are also likely to be involved. In particular, the widespread presence of endocrine-disrupting chemicals (EDCs) is suspected to contribute to the trend of earlier pubertal onset. The factors regulating the physiological onset of normal puberty are poorly understood. This hampers investigation of the possible role of environmental influences. There are many types of EDCs. One chemical may have more than one mode of action and the effects may depend on dose and duration of the exposure, as well as the developmental stage of the exposed individual. There may also be a wide range of genetic susceptibility to EDCs. Human exposure scenarios are complex and our knowledge about effects of mixtures of EDCs is limited. Importantly, the consequences of an exposure may not be apparent at the actual time of exposure, but may manifest later in life. Most known EDCs have oestrogenic and/or anti-androgenic actions and only few have androgenic or anti-oestrogenic effects. Thus, it appears plausible that they interfere with normal onset of puberty. The age at menarche has only declined by a few months whereas the age at breast development has declined by 1 year; thus, the time span from initiation of breast development to menarche has increased. This may indicate an oestrogen-like effect without concomitant central activation of the hypothalamic-pituitary axis. The effects may differ between boys and girls, as there are sex differences in age at onset of puberty, hormonal profiles and prevalence of precocius puberty.

Assessment of circulating sex steroid levels in prepubertal and pubertal boys and girls by a novel ultrasensitive gas chromatography-tandem mass spectrometry method

CONTEXT

Estrogens and androgens play key roles for pubertal onset and sexual maturation. Most currently used immunoassays are not sensitive enough to accurately measure the low circulating levels of sex steroids in children without any signs of puberty. However, this does not exclude that sex steroids have important biological roles in prepubertal children.

OBJECTIVES

To accurately determine levels of sex steroid hormones and their metabolites in serum of healthy children before any physical signs of puberty and to evaluate possible sex differences.

MAIN OUTCOME MEASURES

Total (unconjugated plus conjugated) serum levels of 17beta-testosterone, 17alpha-testosterone, 5alpha-dihydrotestosterone, 5beta-dihydrotestosterone, androsterone, etiocholanolone, estradiol, and estrone measured by an ultrasensitive method based on gas chromatography-tandem mass spectrometry in samples from 81 healthy schoolchildren (42 boys) without any signs of puberty. For comparison, 48 pubertal children were studied.

RESULTS

17beta-Estradiol levels in prepubertal boys were undetectable or extremely low (median < 3.7 pmol/liter), whereas levels in prepubertal girls were significantly higher (median 9.6 pmol/liter, P < 0.001). Among the older prepubertal children (>8 yr), girls had significantly higher androsterone (4.07 vs. 1.45 nmol/liter, P < 0.05), etiocholanolone (5.45 vs. 1.95 nmol/liter, P < 0.0001), 5alpha-dihydrotestosterone (0.11 vs. <0.10 nmol/liter, P < 0.01), and 17beta-testosterone concentrations (0.69 vs. 0.47 nmol/liter, P < 0.05) compared with similarly aged prepubertal boys.

CONCLUSION

Using an accurate and sensitive method, we found significantly higher levels of estrogens as well as androgen metabolites in prepubertal girls compared with age-matched boys. The higher prepubertal sex steroid levels in girls may contribute to their earlier onset of puberty including pubic hair development.

Estrogen exposure in a child from hair lotion used by her mother: clinical and hair analysis data

Premature estrogenic effects may result from exogenous exposure to estrogenic substances. We report the case of a 36-month-old girl who presented with vaginal bleeding, uterus enlargement, and thelarche. Questioning of the parents revealed that the child's mother had used hormone-based hair lotions on her own scalp and that the child was in the habit of playing with her mother's hair while falling asleep, and that the girl played with her mother's combs and the empty lotion vials. The onset of hyperestrogenic syndrome was temporally related to the handling of lotions containing ethynylestradiol 0.5%. Analysis of long scalp hairs from the girl and her mother identified ethynylestradiol in concentrations of 10.6 and 46.6 microg/g, respectively. Six months after the mother discontinued use of the estrogen-containing hair lotion, the girl's hyperestrogenic signs resolved. This case highlights the importance of obtaining histories of possible food and non-food environmental sources of contamination, the suitability of hair sampling to identify the origin of the contamination, and the opportunity to warn parents about hazards related not only to oral contraceptives, but also custom-compounded topical hormone preparations.

Exposure assessment of prepubertal children to steroid endocrine disruptors. 2. Determination of steroid hormones in milk, egg, and meat samples

In the present study, the occurrence of the main sex steroid hormones in milk, egg, and meat was evaluated on the basis of a highly specific gas chromatography-tandem mass spectrometry measurement method. Globally, the results indicated that targeted estrogens and androgens occurred at similar levels (concentration levels in the 10-100 ng kg (-1) range) in the analyzed muscle and milk samples. The same compounds occurred at about 10-fold higher concentrations (i.e., in the 100-1000 ng kg (-1) range) in eggs and kidney samples. More precisely, egg and milk appeared as a non-negligible sources of estradiol (i.e., 2.2 +/- 0.8 and 3.1 +/- 2.0 ng day (-1), respectively), whereas testosterone exposure is caused by ingestion of meat and/or egg (i.e., 12.2 +/- 48.2 and 5.2 +/- 2.3 ng day (-1), respectively). The provided exposure data will be further exploited in the scope of a risk assessment study regarding endocrine disruption associated with these molecules.

Neurofibromatosis: a cause of prepubertal gynecomastia

BACKGROUND

Atypical presentations of gynecomastia not associated with obesity are often underappreciated. Unilateral manifestation, prepubertal onset, and a history of associated disorders may contribute to a unique clinical presentation for which the diagnosis and management may remain uncertain. This report reviews neurofibromatosis as a cause for atypical presentation of gynecomastia in prepubertal boys to help establish guidelines for diagnosis and management.

METHODS

Six nonobese male patients (body mass index <or=20) had an onset of gynecomastia at younger than 9 years and were referred for evaluation between June of 1994 and December of 2006.

RESULTS

The median age of onset of breast enlargement was 7(1/2) years (range, 4 to 8 years). Three had bilateral involvement, four had localized involvement of the nipple-areola complex, and two had diffusely involved breast tissue. Five of the six patients were African American (compared with 20 percent for classic gynecomastia). Median postoperative follow-up was 7 years, and all were followed beyond puberty. No recurrences were seen, although one patient developed a metachronous lesion in the contralateral breast. No patient had an abnormal endocrine metabolic workup.

CONCLUSIONS

Atypical gynecomastia may present in the prepubertal boy and appears more prevalent in African Americans. For neurofibromatosis, it is more likely unilateral, can be localized to the nipple-areola complex, or entails diffuse breast involvement. An endocrine workup appears to be noncontributory.

Fifteen years after "Wingspread"--environmental endocrine disrupters and human and wildlife health: where we are today and where we need to go

In 1991, a group of expert scientists at a Wingspread work session on endocrine-disrupting chemicals (EDCs) concluded that "Many compounds introduced into the environment by human activity are capable of disrupting the endocrine system of animals, including fish, wildlife, and humans. Endocrine disruption can be profound because of the crucial role hormones play in controlling development." Since that time, there have been numerous documented examples of adverse effects of EDCs in invertebrates, fish, wildlife, domestic animals, and humans. Hormonal systems can be disrupted by numerous different anthropogenic chemicals including antiandrogens, androgens, estrogens, AhR agonists, inhibitors of steroid hormone synthesis, antithyroid substances, and retinoid agonists. In addition, pathways and targets for endocrine disruption extend beyond the traditional estrogen/androgen/thyroid receptor-mediated reproductive and developmental systems. For example, scientists have expressed concern about the potential role of EDCs in increasing trends in early puberty in girls, obesity and type II diabetes in the United States and other populations. New concerns include complex endocrine alterations induced by mixtures of chemicals, an issue broadened due to the growing awareness that EDCs present in the environment include a variety of potent human and veterinary pharmaceutical products, personal care products, nutraceuticals and phytosterols. In this review we (1) address what have we learned about the effects of EDCs on fish, wildlife, and human health, (2) discuss representative animal studies on (anti)androgens, estrogens and 2,3,7,8-tetrachlorodibenzo-p-dioxin-like chemicals, and (3) evaluate regulatory proposals being considered for screening and testing these chemicals.

Role of environmental factors in the timing of puberty

Puberty-timing measures have historically been used as indicators of adequate nutrition and growth. More recently, these measures have been examined in relation to exposure to estrogenic or antiandrogenic agents, as well as other environmental factors. The scientific community has debated whether puberty timing is occurring earlier today than in the mid-1900s in the United States and, if so, whether environmental factors play a role; however, no one has asked a multidisciplinary panel to resolve this question. Thus, a multidisciplinary expert panel jointly sponsored by the US Environmental Protection Agency, the National Institute of Environmental Health Sciences, and Serono Symposia International was convened to examine the evidence of a secular trend, identify potential environmental factors of concern, and identify research needs regarding environmental factors and puberty timing at "The Role of Environmental Factors on the Timing and Progression of Puberty" workshop. The majority of the panelists concluded that the girls' data are sufficient to suggest a secular trend toward earlier breast development onset and menarche from 1940 to 1994 but that the boys' data are insufficient to suggest a trend during this same period. The weight-of-the-evidence evaluation of human and animal studies suggest that endocrine-disrupting chemicals, particularly the estrogen mimics and antiandrogens, and body fat are important factors associated in altered puberty timing. A change in the timing of puberty markers was considered adverse from a public health perspective. The panel recommended research areas to further our understanding of the relationships among environmental factors, puberty-timing outcomes, and other reproductive and adult disease at the individual and population levels.

Environmental factors and puberty timing: expert panel research needs

Serono Symposia International convened an expert panel to review the impact of environmental influences on the regulation of pubertal onset and progression while identifying critical data gaps and future research priorities. An expert panel reviewed the literature on endocrine-disrupting chemicals, body size, and puberty. The panel concluded that available experimental animal and human data support a possible role of endocrine-disrupting chemicals and body size in relation to alterations in pubertal onset and progression in boys and girls. Critical data gaps prioritized for future research initiatives include (1) etiologic research that focus on environmentally relevant levels of endocrine-disrupting chemicals and body size in relation to normal puberty as well as its variants, (2) exposure assessment of relevant endocrine-disrupting chemicals during critical windows of human development, and (3) basic research to identify the primary signal(s) for the onset of gonadotropin-releasing hormone-dependent/central puberty and gonadotropin-releasing hormone-independent/peripheral puberty. Prospective studies of couples who are planning pregnancies or pregnant women are needed to capture the continuum of exposures at critical windows while assessing a spectrum of pubertal markers as outcomes. Coupled with comparative species studies, such research may provide insight regarding the causal ordering of events that underlie pubertal onset and progression and their role in the pathway of adult-onset disease.

Exposição ambiental a interferentes endócrinos com atividade estrogênica e sua associação com distúrbios puberais em crianças

A substância exógena que causa efeitos adversos na saúde de um organismo ou sua descendência, como resultado de distúrbios na função hormonal, é denominada interferente endócrino. Nos últimos anos, produtos ambientais com atividades hormonais têm sido documentados como causadores de anormalidades puberais ou reprodutivas em animais. Os poucos casos comprovados em humanos foram aqueles relacionados a exposições acidentais. Apesar disso, pediatras e pais recomendam a suspensão de todos os alimentos potencialmente contaminados, em especial carne (aves, gado) e derivados da soja quando a criança apresenta alguma alteração puberal. Estas recomendações, se não embasadas cientificamente, podem ter conseqüências deletérias, não apenas pela eliminação de fontes protéicas da dieta, como também por retardar a investigação de causas tratáveis. Por outro lado, a não investigação dos efeitos adversos destes produtos é da mesma forma danosa. Esta revisão descreve os principais interferentes endócrinos responsáveis por alterações puberais em humanos e conclui que, excetuando exposições acidentais a altas quantidades destes produtos, mais estudos são necessários para responsabilizar a ação crônica e em baixas doses destas substâncias na alteração do tempo de desenvolvimento puberal em nossa espécie.

The sensitivity of the child to sex steroids: possible impact of exogenous estrogens

The current trends of increasing incidences of testis, breast and prostate cancers are poorly understood, although it is assumed that sex hormones play a role. Disrupted sex hormone action is also believed to be involved in the increased occurrence of genital abnormalities among newborn boys and precocious puberty in girls. In this article, recent literature on sex steroid levels and their physiological roles during childhood is reviewed. It is concluded that (i) circulating levels of estradiol in prepubertal children are lower than originally claimed; (ii) children are extremely sensitive to estradiol and may respond with increased growth and/or breast development even at serum levels below the current detection limits; (iii) no threshold has been established, below which no hormonal effects can be seen in children exposed to exogenous steroids or endocrine disruptors; (iv) changes in hormone levels during fetal and prepubertal development may have severe effects in adult life and (v) the daily production rates of sex steroids in children estimated by the Food and Drug Administration in 1999 and still used in risk assessments are highly overestimated and should be revised. Because no lower threshold for estrogenic action has been established, caution should be taken to avoid unnecessary exposure of fetuses and children to exogenous sex steroids and endocrine disruptors, even at very low levels.

Effects of obesity on growth and puberty

Nutrition is an important regulator of the tempo of human growth. Infancy may represent a critical "window" where variations in nutrition have longer-term consequences for growth and development. Rapid weight gain during infancy is associated with accelerated growth and early pubertal development. Rapid weight gain in infancy is also associated with the development of insulin resistance and an exaggerated adrenarche. Such circulating hormonal changes, together with elevated leptin levels and integral effects of fat cells on hormone action through local 11beta-steroid dehydrogenase and aromatase activity could effect rate of progression of pubertal development in obese subjects. The secular trends in growth and maturation are partly attributed to changing nutrition. Recent data suggest that age at menarche may be static, but there is a debate as to whether the first signs of puberty are being seen much earlier in obese girls. Rapid early weight gain, obesity and early development may have implications for later health through the development of PCOS and overall association with cancer risk.

Estradiol levels in prepubertal boys and girls--analytical challenges

Increasing evidence points at an important function of low concentrations of estradiol (E2) in prepubertal boys and girls. E2 serum levels in prepubertal children are, however, often immeasurable in conventional E2 assays. This strongly hampers further investigation of the physiological relevance of E2 in children. In addition, there is an increasing concern of the potential effect of exposure to endocrine disrupters with estrogenic or antiandrogenic activity on pubertal development. A requirement of assessing the instance for this concern, adds further to the demands for applicable methodologies for the evaluation of the sensitivity of the organism to low E2 concentrations. Traditionally, E2 is measured by use of the radioimmunoassay (RIA). As an ultrasensitive alternative to the RIA, a recombinant cell bioassay has been developed. In this review, methodological aspects for these methods of analysis are examined and their applicability for evaluation of low E2 serum concentrations in children is estimated. Furthermore, available data on E2 levels in prepubertal boys and girls are evaluated and discussed, taking into consideration the limitations of the methods of analysis. In conclusion, there is a pronounced demand for new and improved methods of analysis for accurate and sensitive evaluation of low concentrations of E2.

Prepubertal gynaecomastia: aetiology, course and outcome

BACKGROUND

Palpable and measurable glandular breast tissue is a rare finding in prepubertal boys and warrants thorough evaluation to rule out an underlying pathology.

OBJECTIVE

To characterize the course and outcome of prepubertal gynaecomastia, examine its effect on puberty, and try to identify its underlying cause.

PATIENTS AND METHODS

Twenty-nine out of 581 (5%) boys referred to our clinic for evaluation of gynaecomastia between 1980 and 2000 were prepubertal at diagnosis. Data on age at appearance of gynaecomastia, general and endocrine evaluation, course of growth and puberty, and treatment were collected from the medical files.

RESULTS

Prepubertal gynaecomastia was diagnosed at mean age of 8.9 +/- 2.2 years. In 27 of the 29 boys (93.2%) no underlying cause was identified. The remaining two boys (6.8%) had hyperaromatase syndrome. Nine boys (31%) were obese. Spontaneous resolution was recorded in six boys (20.5%), no change in 15 (52%), and further breast enlargement in eight (including the two with hyperaromatase syndrome) (27.5%). Accelerated growth and bone maturation rates were noted only in the two boys with hyperaromatase syndrome. Pubertal onset was documented in 13 boys at 11.8 +/- 1.1 years.

CONCLUSIONS

According to our large single tertiary care centre experience, 5% of boys referred for evaluation of gynaecomastia were prepubertal. The development of gynaecomastia was the only abnormality and was not associated with other pubertal signs or accelerated growth rate. In most cases, the gynaecomastia was idiopathic. Further prospective studies are needed to evaluate the pathophysiological mechanisms responsible for this phenomenon.

Synergistic tumor promoter effects of estrone and progesterone in methylnitrosourea-induced rat mammary cancer

Tumor promoter effects of steroid hormones were tested in ovariectomized rats treated with the tumor initiator, methylnitrosourea. Continuous treatment with low doses of estrone induced tumor in 55% of experimental animals while intact control animals had a 96-100% incidence. Although progesterone alone produced no tumors in ovariectomized, methylnitrosourea-treated animals, estrone and progesterone acted synergistically, inducing tumorigenesis in 88% of treated rats. These results point to an important interaction between estrogens and progestins in promoting mammary tumorigenesis.