Can an orchiectomy (surgical removal of one or both testicles) cause gynecomastia (breast tissue growth in males)?

Orchiectomy and Gynecomastia: Relationship and Management

Yes, an orchiectomy can cause gynecomastia due to the resulting hormonal imbalance from testosterone reduction and relative estrogen predominance.

Mechanism of Gynecomastia After Orchiectomy

• Orchiectomy leads to hypotestosteronemia (low testosterone levels), which disrupts the normal testosterone-to-estrogen ratio in males 1
• This hormonal imbalance, with relatively higher estrogen compared to testosterone, can stimulate breast tissue growth in males 1
• Bilateral orchiectomy causes testosterone to rapidly fall to castrate levels (≤10 ng/mL), creating a more significant hormonal shift than unilateral orchiectomy 1

Incidence and Risk

• Gynecomastia is a known adverse effect following orchiectomy performed for prostate cancer treatment 2
• While bilateral orchiectomy for prostate cancer has the lowest incidence of gynecomastia compared to other hormonal therapies (such as nonsteroidal antiandrogens, diethylstilbestrol, and estrogen), it still carries this risk 2
• The severity of gynecomastia is typically mild to moderate but can be significant enough to cause patient distress 2

Clinical Presentation and Evaluation

• Patients with testicular cancer may present with gynecomastia as an initial symptom, which should prompt thorough examination 1
• Clinical assessment of patients with testicular masses should include examination for gynecomastia, as it may indicate hormonal activity of the tumor 1
• In patients who develop gynecomastia after orchiectomy, evaluation should include hormonal assessment to determine the extent of testosterone deficiency 3

Prevention and Management Options

• Prophylactic measures can be considered in patients at high risk for developing gynecomastia after orchiectomy:

  • Prophylactic radiotherapy can decrease the incidence of hormone-induced gynecomastia by more than 50% 2
  • Prophylactic tamoxifen may be used as a convenient alternative to prevent gynecomastia 2

• For established gynecomastia after orchiectomy:

  • Early intervention with tamoxifen during the proliferative phase may help mitigate or resolve gynecomastia 2
  • For severe, long-standing gynecomastia, surgical intervention may be necessary as medical therapies are less likely to be effective 2
  • Testosterone replacement therapy may be considered in cases of bilateral orchiectomy to restore hormonal balance 1

Associated Metabolic Consequences

• Long-term castrate levels of testosterone following orchiectomy can lead to additional complications:
  • Osteopenia (bone density loss) 1
  • Hypercholesterolemia 1
  • Increased risk of metabolic syndrome, particularly in hypogonadal patients 4
  • Vasoactive symptoms, weight gain, mood lability, fatigue, cognitive changes, and loss of libido 1

Clinical Pitfalls to Avoid

• Failing to recognize gynecomastia as a potential consequence of orchiectomy before surgery 2
• Not discussing the risk of gynecomastia with patients prior to orchiectomy 2
• Overlooking the need for hormonal assessment in patients who develop gynecomastia after orchiectomy 3
• Delaying treatment of gynecomastia, which may lead to more established changes that are harder to reverse 2

Special Considerations

• Patients undergoing orchiectomy for testicular cancer should be informed about the potential risk of gynecomastia 1
• In cases where fertility preservation is desired, sperm banking should be offered before bilateral orchiectomy 5
• Patients with unilateral orchiectomy have a lower risk of significant hormonal imbalance compared to those with bilateral orchiectomy 1