Abstract
OBJECTIVES:
To compare sexual function and hormone profile in male patients with gynecomastia with matched controls.
MATERIALS-METHODS:
Forty-seven male subjects with gynecomastia and thirty healthy controls were enrolled in this study. Serum free T3, free T4, TSH, FSH, prolactin, estradiol, total testosterone, free testosterone, DHEA-SO4, LH and total PSA were measured in the patients and controls. Sexual function of the patients and controls were evaluated using International Index of Erectile Function (IIEF). The hormone values and IIEF scores of the patients were statistically compared with the controls’.
RESULTS:
The mean of age, body mass index, right and left testicular volume in the patient and control group were similar. The mean FSH and free T3 values of the patients were significantly lower than the controls (p = 0.007 and p = 0.03, respectively). The mean of the other hormone values in the both groups were found to be statistically similar (p > 0.05). The mean ±SD of total IIEF scores in the patient and control group were 60.14 ± 8.78 and 65.24 ± 5.52, respectively (p = 0.007). Although the mean IIEF-erectile function, orgasmic function and intercourse satisfaction scores in the patient group were significantly lower than the control group (p < 0.001, p = 0.004 and p = 0.001, respectively), the mean IIEF-desire score of the patients was significantly higher than the controls (p = 0.002).
CONCLUSION:
We found that the hormone profiles (except FSH and free T3) of the patients with gynecomastia were similar with the controls. However, gynecomastia adversely affected male sexual function.
Keywords
Introduction
Gynecomastia is the benign enlargement of the male breast as a result of the proliferation of ductal tissue, and is usually caused by a hormonal imbalance as may often be seen postnatally, during puberty, and in the elderly [1,2]. Most cases of gynecomastia are idiopathic; however, pathological etiologies need to be ruled out; these include congenital and endocrine disorders, tumors, and drugs [2]. The prevalence of asymptomatic gynecomastia in neonates is estimated to be between 60 and 90% [3]. The second physiological peak of occurrence is at puberty between the ages of 10 and 16 years. Approximately 50–60% of adolescents have been estimated to have gynecomastia based upon early literature [4–6]. The last peak in incidence of gynecomastia is seen in men 50–85 years of age, and the reported prevalence is up to 70% [7]. A relative imbalance between serum estrogen and androgen levels may exist during a period of the pubertal process and may be the cause of pubertal gynecomastia. However, most of the adult men with gynecomastia have neither an increase in estrogen levels, nor any overt hypogonadism [1].
Erectile dysfunction (ED) has been broadly defined as the inability to achieve or maintain an erection sufficiently rigid for satisfying sexual intercourse. ED can have a profound negative impact on the quality of life and life satisfaction of the patient (and his partner), resulting in fear, loss of self-image and self-confidence, and depression [8]. The prevalences of severe, moderate, mild-moderate and mild ED in young men aged below 30 years were reported to be 2%, 2%, 10% and 18%, respectively. The International Index of Erectile Function (IIEF) is a multi-dimensional validated self-report questionnaire that evaluates male sexual function. Currently, IIEF has been validated in 32 languages and has been used as a primary endpoint in more than 50 clinical studies [9]. The purpose of this observational study was to compare hormone profile and sexual function between young adult men with gynecomastia and healthy controls.
Material-method
Participants
A total of 47 male subjects aged 18–40 years with gynecomastia who applied to Plastic and Reconstructive Surgery clinic and 30 healthy controls were included in the study. The controls were chosen from among healthy hospital staff. The patients were excluded when they had a history of medication which could affect to gynecomastia or genitourinary, psychological, metabolic, hormonal, or genetic disorders. The patients were asked detailed complete medical history and also family history of gynecomastia. After excluding other causes of gynecomastia, patients who were diagnosed as idiopathic gynecomastia were enrolled in this study. Detailed physical examination (including careful palpation of testes and mammary glands) was performed on all the participants. Patients with a palpable breast tissue of more than 2 cm in diameter were considered as having gynecomastia and they were all double-checked by ultrasonography [7]. Body weight and height were measured in the morning with light clothing and without shoes. The body mass index (BMI) was calculated as body weight in kilogram divided by height in meters squared. The volumes of the testes were calculated by using ultrasonography. Serum free T3, free T4, TSH, FSH, Prolactin, estradiol, total testosterone, free testosterone, DHEASO4, LH and total PSA were measured in the patients and controls. Blood samples of the participants were obtained between 8 and 10 am. IIEF was filled out by all the participants. The written consent forms were obtained from the participants. The study protocol was approved by the ethics committee of our institution (No: 20565498-319).
International index of erectile function
IIEF is used to assess the male sexual function. The scale consists of 15 items divided into five subscales including erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction with 6, 2, 2, 3, and 2 items, respectively. The severity of sexual dysfunction is divided into five groups, according to the erectile function score: no sexual dysfunction [26–30], mild sexual dysfunction [22–25], mild to moderate sexual dysfunction [17–21], moderate sexual dysfunction [11–16] and severe sexual dysfunction [6–10], with a higher score indicating better sexual function. Turkish version of the IIEF was validated by Turkish Society of Andrology [10].
Statistical methods
Student’s t test was used for comparison between data of the patient and control groups. Statistical analyses were done using the SPSS 13.0 (SPSS Inc.).P value less than 0.05 was considered significant.
Results
The mean age ± SD (range) of the patients and controls were found to be 23.02 ± 5.34 [18–40] and 23.23. ± 4.40 [18–33], respectively (p = 0.35). The values of renal and liver function tests of the patients were normal. None of the patients had abnormal findings on breast ultrasonography. The mean BMI, right and left testes volume in the patient and control groups were similar (Table 1). The mean free T3 value of the patients was significantly lower than the controls (3.31 and 3.61, respectively (p = 0.03)). Also, the mean FSH value of the patient group was significantly lower than the control group (4.32 and 5.64, respectively (p = 0.007)). The mean of the other hormone levels were statistically similar between the patient and control groups (Table 1).
The mean IIEF-total scores in the patient and control group were 60.14 ± 8.78 and 65.24 ± 5.52, respectively (p = 0.005). The mean of IIEF-erectile function, orgasmic function and intercourse satisfaction scores in the patient group were significantly lower than the control group (Table 2). The mean of IIEF-erectile function score in the patient and control groups were 23.93 ± 3.67 (mild sexual dysfunction) and 27.45 ± 2.41 (no sexual dysfunction), respectively. In contrast, the mean IIEF-sexual desire score of the patients was significantly higher than the controls (8.71 ± 0.80 and 7.75 ± 1.39, respectively (p = 0.002)).
Discussion
Two of most common types of gynecomastia are idiopathic gynecomastia and gynecomastia due to sexual maturity [11]. Some previous studies have compared the hormone profiles between the patients with idiopathic gynecomastia and the controls. Ersoz et al. [1] reported that the LH and total testosterone levels of the young patients with gynecomastia were significantly lower than the controls. However, TSH, free T3 and T4 were not evaluated in their study and the number of patients were small in the study (n = 31). Yazici et al. [12] noticed that LH, FSH and total testosterone levels of the patients (n = 31) aged 20–30 years with idiopathic gynecomastia were significantly higher than the healthy controls. In their study, the other sex hormones and TSH levels in the patient and control group were statistically similar. In our study, although FSH and free T3 levels of the patients were significantly lower than the controls (Table 1). However, the free T3 and FSH values of the patients were all within normal range (2.5–4.2
There is no study in literature that compares sexual functions between young men with gynecomastia and healthy controls. Only a study investigated the prevalence of gynecomastia (after excluding Klinefelter’s syndrome patients) in the patients with sexual dysfunction (n = 4023) [13]. The prevalence of gynecomastia in this population was found to be 3.1%, and that these patients with gynecomastia had significantly lower testosterone levels. However, the most important limitation of this study was the lack of a healthy control group. Our data showed that the IIEF total score and subscale scores except sexual desire of the patients with gynecomastia were lower than the controls. Conversely, IIEF sexual desire score of the patients was higher than the controls. Although there were no differences in the sex hormones (including total, free testosterone, estradiol and DHEASO4) between the patients and controls, the sexual functions of the patients were poorer than the controls. These data were thought that sexual dysfunction in gynecomastia may not due to organic pathologic events. Although the patients with gynecomastia have lower scores of IIEF related to intercourse such as erectile, orgasmic function and satisfaction, they have higher IIEF-sexual desire score than the controls. We think that may be due to the psychological effect caused by gynecomastia, the young adult men with gynecomastia want to have sex, but they have some problems during sexual intercourse. The psychological impact may be caused by the appearance of patients’ breasts after taking off their clothes. We suggest that the patients with gynecomastia have sexual desire, but they cannot continue sexual intercourse.
Conclusion
When compared with healthy controls, sexual functions except desire of young men with gynecomastia are adversely affected. This may be due to the psychological effect of gynecomastia during sexual intercourse, because the sex hormone levels of the patients and controls were similar. This result was also supported that the sexual desire of the patients with gynecomastia was higher than the controls. Further studies may contribute to the evaluation of both sexual and psychological functions of young men with gynecomastia. We suggest that young men with gynecomastia should be also examined for sexual function.
Footnotes
Conflict of interest
No conflict of interest was declared by the authors.
Funding
No funding was declared by the authors.