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THE

BREAST

CASE REPORT

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

Summary Gynaecomastia is the commonest benign breast condition seen in men. Itis well recognised that certain drugs that alter the normal sex hormonal profile in thebody can induce gynaecomastia. Recently, an increasing use of androgenic-anabolicsteroids among young men especially body-builders has increased the incidence ofgynaecomastia. We report a case of a young weight-trainer who developedgynaecomastia due to oral intake of a herbal tablet which he used as a steroidalternative for body-building.& 2003 Elsevier Ltd. All rights reserved.

Introduction

Gynaecomastia is the commonest condition affect-ing the male breast.1,2 It can occur at any age and isdue to proliferation of glandular component of thebreast tissue secondary to an imbalance in the sexhormones.3,4 It is entirely benign and variousconditions that affect the normal sex hormonalprofile in the body such as hypogonadism, testicularneoplasms, liver failure, thyrotoxicosis and intakeof certain drugs can cause gynaecomastia, althoughin majority of young men the exact aetiology isunknown.5 Here we describe a case of a uniqueplant derivative which had induced gynaecomastiain an apparently healthy individual.

Case report

A 21-year-old gentleman who works as an aircraftfitter and is also a keen weight-trainer was referredby his general practitioner to the breast clinic witha 5 month history of a lump in his left breast whichwas occasionally painful. Seven years previously, hereported a similar swelling on the right side thathad settled spontaneously. He was otherwise fit andwell. He smoked 2 cigarettes a day and drank about10 units of alcohol a week. On examination therewas a well-defined nodule in the sub-areolar regionon the left side consistent with gynaecomastia. Thiswas causing him considerable discomfort especiallywhile playing sports and he requested surgicalremoval. In view of the patient’s symptoms andwishes, this was excised using a minimally invasivetechnique (mammotome probe and liposuction).6

Two weeks later at clinic follow-up, his woundhad completely healed and he was very pleasedwith the cosmetic result. The histology wasreported as atypical ductal hyperplasia (ADH),therefore he was not discharged but kept under

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KEYWORDS

Gynaecomastia;

Androgenic-anabolic ster-

oids;

Steroid alternatives;

Tribulis terrestris

*Corresponding author. Tel.: þ 44-1482-623077; fax: þ 44-1482-623274.E-mail address: p.j.drew@hull.ac.uk (P.J. Drew).

0960-9776/$ - see front matter & 2003 Elsevier Ltd. All rights reserved.doi:10.1016/j.breast.2003.10.013

The Breast (2004) 13, 428–430

surveillance. When reviewed in the clinic 3 monthslater, he presented with another nodule again inthe left sub-areolar region. On clinical evaluationand ultrasound imaging this nodule appearedbenign. Core-biopsy was reported as normal breasttissue with a possibility of gynaecomastia difficultto exclude. A complete sex hormonal profile wasrequested. This revealed a markedly decreasedfollicle-stimulating hormone (FSH), leutinising hor-mone (LH) and testosterone. FSH 0.59 IU/l (normal:1.0–7.0), LH 0.26 IU/l (normal: 1.0–8.0), testoster-one 1.3 nmol/l (normal: 10–50). Prolactin, oestra-diol and progesterone were within normal limits.

On closer questioning at this stage, the patientsaid that he had been taking a non-hormonalpreparation derived from a plant called Tribulisterrestris, in the form of tablets as a steroidalternative to supplement his weight-training. Onthe assumption that this substance had caused thehormonal imbalance and hence gynaecomastia, hewas advised to discontinue taking them. Twomonths later his sex-hormones were re-checkedand they had improved, FSH 11 IU/l, LH 6.1 IU/l,testosterone 15 nmol/l. The swelling in his leftbreast had also completely resolved.

Discussion

Gynaecomastia usually presents as a unilateraltender enlargement of the sub-areolar breasttissue. It can be physiological as in neonatal,pubertal and senescent hypertrophy. It can alsobe associated with specific diseases and intake ofcertain drugs.7 In any case, the hormonal changethat mediates the condition is a decrease inandrogens that can be due to either reducedproduction or androgen resistance. Increased cir-culating oestrogens that can be due to increasedperipheral aromatisation may also decrease andro-gen expression.

Androgenic-anabolic steroids (AAS) are the mostwidely misused group of drugs in competitivesport.8 They increase strength, lean body massimproving the athlete’s appearance and perfor-mance.9 AAS have many side-effects of which acne,striae and gynaecomastia were the most commonlyreported in one study on 100 athletes.10 Hence, anincreasing number of young men have turnedtowards steroid alternatives which could providethe benefits of AAS with minimal side-effects.

One such is the tablet taken by our patient,the active components of which are steroidalsaponins of furostanol type isolated from ‘‘abovethe ground’’ part of the plant ‘‘T. terrestris

L. bulgaricum’’. It is regarded as a natural herbalalternative to AAS. Its mechanism of action is notfully clear. It is believed to have a central effectand increase secretion of LH and therefore increasetestosterone levels. Alternatively, it may exert itseffect by being metabolised into androgen-likeproducts or stimulating the physiological transfor-mation of testosterone into more active dihydro-testosterone.11,12 In our patient both gonadotropinsand testosterone were markedly reduced aftertaking this preparation in contrast to experimentalstudies on this product which showed enhancementof LH and testosterone.12 In the absence of signs orsymptoms of pituitary insufficiency, in an otherwisehealthy individual, we believe that this could eitherbe due to the shut-down of the pituitary gonadalaxis in the presence of exogenous substances or dueto increased aromatisation and peripheral conver-sion into estrogens, both of which could contributeto development of gynaecomastia. Furthermorethe histology of the excised tissue revealed ADH.Although the pathologic interpretation is subject tointerobserver variability, it is well recognised thatADH falls on a pathologic continuum betweenbenign hyperplasia and ductal carcinoma and it isassociated with a 4-fold to 5-fold increased risk ofbreast carcinoma.13 In our patient the abnormaltissue was completely excised and a subsequentcore-biopsy did not show any ductal hyperplasia oratypia, however the development of ADH, a pre-cancerous condition raises concern on the safety ofthis plant preparation.

In summary, this preparation which is believed tobe a natural product with minimal side-effectsshould be regarded as a possible gynaecomastiainducing agent through its effect on sex hormonallevels in the body. Its link in the development ofADH may also suggest a possible carcinogenic effecton the breast tissue, although more definiteevidence on these aspects needs to be established.It is important for clinicians to keep an open mindwhile eliciting drug history and not discard thenatural products which many patients take but failto disclose, as this could play a major part in thepathogenesis and with appropriate timely interven-tion cure of the disease.

References

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