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.
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
* 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.
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.'"
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.
FDA Consumer magazine (July-August 1995)