What is the likely diagnosis for a 26-year-old male patient presenting with painful masses in his left breast, who has been taking Progesterone (Prometrium) 200 milligrams (mg) orally once daily, Estradiol (Estrace) 4 mg orally twice daily, Spironolactone (Aldactone) 150 mg orally twice daily, and Prenatal (Prenatal/Folic Acid) tablets daily for the past three years?

From the Guidelines

The patient's breast masses are likely related to his hormone therapy regimen, specifically the combination of estradiol and progesterone, which can cause breast development and painful masses as a known side effect. The patient's symptoms are consistent with the expected effects of gender-affirming hormone therapy, as described in a recent study published in the Mayo Clinic Proceedings 1. Estradiol and progesterone are commonly used to promote breast growth and other physical traits that support gender embodiment, and the addition of spironolactone, an anti-androgen, further enhances this effect by lowering endogenous testosterone levels and blocking receptor binding of androgen.

The patient's medication regimen, which includes estradiol 8mg daily, progesterone 200mg daily, and spironolactone 300mg daily, is consistent with feminizing hormone therapy for transgender women. However, the doses are relatively high, which may contribute to the breast symptoms. A dose adjustment might be considered depending on the ultrasound results and the patient's hormone levels. Additionally, monitoring estradiol, testosterone, and prolactin levels would be valuable to ensure they're within target ranges, as hormone therapy can affect pain processing and have important effects on endocrinologic factors, as noted in the study 1.

Some key points to consider in this patient's case include:

• The potential for breast development and painful masses as a side effect of hormone therapy
• The importance of monitoring hormone levels to ensure they're within target ranges
• The need for further evaluation, such as an ultrasound, to characterize the breast masses and rule out other pathologies
• The potential for dose adjustment or other modifications to the hormone therapy regimen to minimize side effects and optimize treatment outcomes. The prenatal vitamin is likely being used for its supportive nutrients during hormone therapy, but its impact on the patient's breast symptoms is unlikely. Overall, the patient's breast masses warrant investigation to exclude other conditions like cysts or rarely, malignancy, and a comprehensive approach to their care should prioritize their overall health and well-being, including their physical and emotional health, as well as their quality of life.

From the FDA Drug Label

The use of estrogen plus progestin has been reported to result in an increase in abnormal mammograms requiring further evaluation. Spironolactone can cause gynecomastia. In a Randomized Spironolactone Evaluation Study, patients with heart failure treated with a mean dose of 26 mg of spironolactone once daily, about 9% of the male subjects developed gynecomastia.

The patient's symptoms of painful breast masses could be related to the use of estrogen plus progestin therapy, which may increase the risk of abnormal mammograms, or to spironolactone therapy, which can cause gynecomastia 2 3.

• The patient's medication regimen includes estrogen and progestin, which may contribute to the development of breast masses.
• The patient is also taking spironolactone, which has been associated with an increased risk of gynecomastia in male patients. It is essential to further assess the patient's condition with an ultrasound of the left breast to determine the cause of the breast masses.

From the Research

Patient Assessment and Medication

• The patient is a 26-year-old male presenting with two small masses in the left breast, which are reported to be painful.
• The patient has been taking the following medications for the last three years:
  • Progesterone (Prometrium) 200 mg cap QD
  • Estradiol Tab (Estrace) 4 mg Tab BID
  • Spironolactone Tab (Aldactone) 150 mg Tab BID
  • Prenatal Tab (Prenatal/Folic Acid) 27-1 mg Tab QD
• According to the study 4, the use of progestational agents, such as progesterone, does not increase breast cancer risk and could even be protective.

Imaging Recommendations

• An ultrasound of the left breast has been requested for further assessment.
• The study 5 reviews the indications for breast ultrasound, which is a widely used adjuvant to mammography for the detection of breast cancer.
• According to the study 6, ultrasound is usually the appropriate initial imaging for women under 30 years of age, and the patient's age and symptoms align with this recommendation.
• The study 7 discusses the role of ultrasound in breast cancer screening, highlighting its efficacy and utility as a supplemental screening tool.

Breast Cancer Risk and Imaging

• The study 8 reviews the imaging modalities and pregnancy-associated breast cancer, highlighting the importance of selecting the appropriate imaging workup and intervention.
• Although the patient is male, the studies 4, 5, 6, 7, and 8 provide relevant information on breast cancer risk and imaging recommendations that can be applied to this case.