Conditions Men Get, Too
by John Henkel
Seymour
Kramer noticed a patch of what looked like blood on his pajama
top three years ago and thought he had cut himself. But he
wasn't scratched. His doctor tested the discharge and told the
New Jersey man he had breast cancer.
Dan,
70, a retired Michigan engineer who asked that his last name
not be used, was pulling weeds three years ago. For no apparent
reason, he fractured two vertebrae. Doctors told him his bones
were wasting away. He has osteoporosis.
As
a teenager, Gary Grahl was obsessed with having a trim, "athletic"
body. The Wisconsin resident shunned food and exercised excessively.
Sometimes he'd do situps and pushups for three hours before school.
He ate little and shrank from 160 to an unhealthy 104 pounds.
Over a six-year period, he was hospitalized four times. Now
26, Grahl says he is "completely recovered" from his
eating disorder.
What
do these men have in common? They all suffer from illnesses
typically thought of as "women's diseases." Breast cancer,
osteoporosis, and eating disorders all occur in men, too, though
their prevalence is much greater in the female population. As
a result, many men, unaware that the diseases affect both sexes,
may fail to recognize symptoms. Likewise, doctors and families
often don't suspect these illnesses. This can delay therapy and
make disorders difficult to treat.
Medical
experts say men may shy away from seeking medical treatment for
disorders they feel are unmasculine. In support groups, men use
terms like "very scared" and "ashamed" to
describe initial feelings about their illnesses. Others express
frustration at the difficulty in finding information and therapy.
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Osteoporosis
High
on the list of such conditions is osteoporosis. Though women
are four times more likely to acquire it, about 5 million men
in this country have osteoporosis, according to the National Osteoporosis
Foundation. A disorder in which bones become weakened, osteoporosis
is sometimes called the "silent disease" because it
has no symptoms. It often manifests itself in fractures of the
hip, wrist, spine, and other bones. Among both sexes, it is responsible
for 1.5 million fractures a year. Scientists are still piecing
together just how osteoporosis develops, but it is well known
that a key factor is deficiency of the mineral calcium. Leo Lutwak,
M.D., Ph.D., a medical officer in FDA's Center for Drug Evaluation
and Research, emphasizes that calcium intake over a person's lifetime
is crucial to preventing bone loss. Ideally, he says, a diet adequate
in calcium starting in childhood "can maximize peak bone
mass," helping to ensure strong bones and make osteoporosis
less likely. The revised food label that went into effect in 1994
can help consumers pinpoint calcium-rich foods (see the May 1993
issue of FDA Consumer).
About
99 percent of the body's calcium is stored in bones and teeth.
Bone is continually being broken down and rebuilt. If the amount
of calcium absorbed equals the amount lost, a state of balance
occurs. When calcium absorption is greater than losses, the body
accrues a "positive balance" that it can use for bone
growth and repair. But when dietary intake of calcium can't meet
the body's needs, the body draws the mineral from bones to allow
a constant bloodstream supply. Ultimately, the breakdown process
can exceed deposits, causing a possible reduction in bone mass
and density.
Osteoporosis
is seen less often in men than in women for several reasons. Men
generally have greater bone mass than women, and in males, bone
loss begins later and advances more slowly. But men do have a
hormonal drop-off in testosterone similar to women's reduction
of estrogen after menopause. Testosterone may diminish as a result
of hypogonadism, a condition marked by decreased function of the
testicles. Testosterone levels may naturally become lower as a
man ages.
"Loss
of sex hormone results in accelerated bone loss in whomever it
occurs, whenever it occurs, for whatever reason," says Michael
Kleerekoper, M.D., deputy associate chairman of internal medicine
at Wayne State University. "Whether that translates to osteoporosis
depends on how much bone you have when the loss begins and how
quickly you lose it." Women find relief from osteoporosis
with estrogen therapy, and some men respond to testosterone injections.
But successes with hormone therapy come most often from "seeing
young men in the early stages" of the condition, Kleerekoper
says.
Another
therapy shown to slow bone breakdown and reduce pain associated
with fractures attributed to osteoporosis is the drug calcitonin,
marketed as Miacalcin or Calcimar. FDA has not approved these
drugs specifically for men, though some doctors prescribe them
to males if they feel the patient will benefit. Currently under
study for osteoporosis treatment are sodium fluoride, which some
researchers think may help increase bone mass; vitamin D, which
helps the body absorb calcium; and a nasal spray version of calcitonin.
Dan,
the Michigan osteoporosis patient, receives biweekly testosterone
injections and takes daily supplements of 1,500 milligrams of
calcium with vitamin D. He also exercises in a swimming pool,
where water provides a beneficial resistance to movement. He says
his two fractured vertebrae three years ago made him realize that
osteoporosis gives no warnings.
Factors
that raise the risk of osteoporosis include cigarette smoking,
alcohol consumption in excess of two drinks a day, advanced age,
and an inactive lifestyle.
Eric,
45, says years of inactivity helped bring on his osteoporosis.
In his early 20s, the New York resident (who asked that his last
name not be used) had several sports accidents that seriously
impaired his mobility. An eating disorder in college also encouraged
development of the condition, he suspects. Now, his bone loss
is so severe that "anytime I have an x-ray, the doctors go
into shock," he says. He risks injury by simply taking a
walk and cannot stand barefoot on a hard floor without excruciating
pain. He is taking calcitonin, which he hopes will stabilize his
bone loss and allow him to do more walking.
Though
osteoporosis cannot be cured, it can be slowed down and steps
can be taken to prevent it. The National Osteoporosis Foundation
suggests these preventive measures:
* Eat a balanced diet rich in calcium.
* Exercise regularly, especially in weight-bearing activities.
* Don't smoke.
* If you drink alcohol, do so in moderation.
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Breast Cancer
Primarily
associated with women, breast cancer also occurs in men, although
rarely. According to the American Cancer Society (ACS), men will
make up 1,400 of the 183,400 new cases of breast cancer expected
in 1995.
Men
typically do not perform breast self-examinations to detect tumors,
and doctors do not ordinarily examine men for breast cancer during
physicals. Unlike women, men do not get routine mammograms. Consequently,
a tumor may be present and go undiscovered.
As
with breast cancer in women, symptoms include the presence of
a breast lump that is usually firm and painless. The nipple can
have an abnormality such as retraction, crusting, or a discharge.
Patients frequently are over 60.
Seymour
Kramer was 70 when a gooey, bloodlike discharge from his nipple
prompted him to seek medical attention. After analyzing the secretion,
doctors told him he had breast cancer and recommended a lumpectomy,
in which the nipple and a small amount of breast tissue are taken
out. He also had several lymph nodes removed, and he underwent
five weeks of radiation therapy to help ensure that residual cancer
cells were killed. Though his prognosis appears very good, Kramer
won't say he's been cured. But he expresses optimism: "Just
because I had cancer doesn't mean my life is over."
The
ACS says risk factors for male breast cancer include:
* hyperestrogenism, or abnormal secretion of the hormone estrogen
* Klinefelter's syndrome, a male disorder characterized by reduced
or absent sperm production, small testicles, and enlarged breasts
* gynecomastia, or enlargement of the male breast.
Though
medical professionals typically don't recommend detection exams
for the general male population, doctors may advise men with gynecomastia
to perform periodic breast self-examinations.
Because
in men the disease is often detected at an advanced stage when
the tumor has spread, radical mastectomy--removal of breast tissue
and pectoral muscle--is often the initial treatment. But if the
cancer is found before it spreads to surrounding tissue or to
the lymph nodes, a lumpectomy can be performed. Radiation sometimes
is used without surgery, but the verdict is still out on its effectiveness.
As in Kramer's case, radiation also can be employed after surgery
to reduce the chance of local recurrence and to relieve symptoms
in advanced cases. If cancer has spread into the lymph nodes,
some physicians use chemotherapy. A therapeutic "tumor vaccine"
for men and women to treat breast cancer that has already spread
is in clinical trials now.
Possible
complications after surgery or radiation include decreased shoulder
function, fluid retention in the arm, and pain or stiffness in
the operated or radiated area. The ACS emphasizes that besides
tending to the physical consequences of breast cancer therapy,
"attention should be paid to the psychological aftereffects."
Patients
also need follow-up monitoring--including regular exams, blood
chemistry, imaging (such as magnetic resonance imaging), and bone
scans--to discover any recurring tumors quickly.
Kramer
says his experience of being blindsided by the disease put him
on "a crusade" to inform men and medical professionals
about breast cancer in males. "During a routine physical
exam, I think doctors should run their hands across a man's breast
to see if there's anything irregular," he says. "I'm
not saying men have to go out and get wholesale mammograms. But
[as a rule] doctors don't do this [touch test] and men don't inspect
themselves. Those men who are not aware need to be shocked into
the fact that, 'Hey, guys, this could happen to you.'"
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Eating Disorders
Though
many people associate eating disorders with women, these illnesses
also occur in males. In one disorder, anorexia nervosa, the
person limits food intake to the point of starvation. In another,
bulimia nervosa, sufferers alternate between eating large amounts
of food and ridding the body of it through vomiting or laxative
use. About half of those with anorexia also have bulimia symptoms.
According
to the National Association of Anorexia Nervosa and Associated
Disorders (ANAD), men make up about 1 million of the 8 million
Americans with eating disorders.
"It's
a myth that these are illnesses of rich, white, perfectionist
women," says Chris Athas, ANAD vice president. "Just
as a man or woman may become an alcoholic, either may fall victim
to an eating disorder."
Medical
professionals say the disorders most often surface during the
teen years, but in rare cases, men as old as 60 and boys as young
as 8 can be afflicted. In both sexes, the illnesses can lead to
lifelong medical and psychological complications. An estimated
6 percent of cases result in death. Most people find it difficult
to halt the behavior without professional assistance. Though some
men ultimately seek help, many continue untreated with the disorders,
often for years, and sometimes for a decade or more.
Diagnosis
is complicated by a reluctance some men have to seek medical help
for disorders that are "still primarily women's," Athas
says. "We live in a 'macho' society. Many men simply are
ashamed to have an illness of this type." Thus, they suffer
in silence.
Another
problem, says ANAD, is that a great number of doctors and health-care
professionals are not trained to identify or treat male eating
disorders, especially anorexia. Families, too, often fail to see
the diseases' symptoms. The illnesses then can progress to a more
advanced stage where they are harder to treat.
During
recovery, men sometimes are unwilling to participate in support-group
sessions because the groups are mostly female. "Men as a
whole are not comfortable in eating disorder support groups,"
says Athas. "But we encourage them to go anyway."
Unlike
many women, who acquire eating disorders because they "feel"
fat, men often are medically obese at some point in the illness
and feel pressure to be thin. Sometimes athletic activities induce
this struggle to be lean, prompting not only the eating disorder
but also compulsive exercising. Men also may adopt disease behaviors
when teased or criticized about being fat at critical development
stages, such as puberty.
Treatment
can be very effective, according to Arnold Andersen, M.D., an
expert on eating disorders in men who has written a book on the
subject. He describes a regimen of inpatient or outpatient hospital
treatment, depending on the illness severity. Conditions such
as anemia or depression are treated, and patients gradually relearn
proper eating habits. Treatment also usually includes psychotherapy,
which helps patients understand why they have the illness.
One
antidepressant drug, Prozac (fluoxetine hydrochloride), is under
review by FDA as a treatment for bulimia. Other antidepressants
also are being studied. One, Wellbutrin (bupropion), was shown
to induce seizures in both anorexia and bulimia patients. Doctors
sometimes prescribe tricyclic drugs--a class that includes Elavil
(amitriptyline), Tofranil (imipramine), and Norpramin (desipramine).
FDA has approved tricyclics for other uses but not specifically
for eating disorders. However, doctors may prescribe approved
drugs for "off-label" uses if, in their judgment, the
patient will benefit.
Patients
also undergo what Andersen calls "nutritional rehabilitation,"
which allows them to regain a desirable body weight. Treatment
is followed by weeks, months, even years of follow-up to ensure
complete recovery.
Men
in support groups for eating disorders, as well as those for breast
cancer and osteoporosis, say the public gradually is becoming
more aware that these disorders can occur in men. They also say
there's a long way to go. Some think doctors need to be enlightened.
Others bemoan the lack of research. But most seem to agree that
men should be educated about the disorders and how to detect them.
As
breast cancer patient Seymour Kramer says: "Men need to get
the word that, yes, this is a woman's disease. But you're not
immune. It can happen to you."
John
Henkel is a staff writer for FDA Consumer.
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For More Information
Sources of information and support for the disorders described
in this article include:
National Association of Anorexia Nervosa and Associated
Disorders, Box 7, Highland Park, IL 60035--Offers free programs
to help victims and families, including counseling, support groups,
health-care referrals, and a newsletter; telephone (708) 831-3438.
National Osteoporosis Foundation, 1150 17th St.,
N.W., Suite 500, Washington, DC 20036--Will send information packet
and can refer patients to support groups; telephone (1-800) 223-9994.
The Cancer Information Service, 550 N. Broadway,
Suite 300, Baltimore, MD 21205-2004--Will provide information
on male breast cancer and can refer callers to cancer centers
and support groups; telephone (1-800) 4-CANCER.
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