A 68-year-old man has been diagnosed with benign prostatic hyperplasia

A 68-year-old man has been diagnosed with benign prostatic hyperplasia (BPH). Which is the most significant pathophysiology that contributes to the development of this condition? a) Decreased testosterone production b) Increased insulin-like growth factor c) Increased estrogen levels d) Reduced blood supply

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The answer is c) Increased estrogen levels.

Here is the full explanation, drawn directly from Robbins & Kumar Basic Pathology:

BPH Pathophysiology

The core driver of BPH is androgen-dependent proliferation of prostatic stromal and glandular cells, mediated primarily by dihydrotestosterone (DHT). DHT is synthesized from circulating testosterone within the prostate via 5α-reductase type 2, and is ~10× more potent than testosterone at the androgen receptor. It promotes both stromal cell proliferation and reduced epithelial cell apoptosis.

The key hormonal shift with aging is:

"With aging, testosterone levels decline while estrogen levels remain unchanged and may increase due to peripheral conversion of androgens; estrogens may act synergistically with DHT to drive growth of epithelial and stromal cells, both of which express estrogen receptors." — Robbins & Kumar Basic Pathology, p. 659

This relative increase in estrogen (combined with declining testosterone) creates a favorable environment for DHT-mediated prostatic growth. Estrogen acts synergistically with DHT on cells that express estrogen receptors, amplifying the hyperplastic stimulus.

Why the Other Options Are Wrong

Option	Why Incorrect
a) Decreased testosterone	Testosterone does fall with age, but this alone does not cause BPH — in fact, BPH is driven by DHT activity, not testosterone directly. Reduced testosterone is a consequence of aging, not the key driver.
b) Increased insulin-like growth factor	IGF plays a minor modulatory role, but is not considered the most significant pathophysiological contributor.
d) Reduced blood supply	Ischemia is not a recognized primary mechanism in BPH development.

Answer: c) Increased estrogen levels

The age-related shift toward a relatively higher estrogen-to-testosterone ratio synergizes with DHT to drive the stromal and glandular proliferation that defines BPH. This is also why 5α-reductase inhibitors (e.g., finasteride, dutasteride) are effective treatments — they block DHT synthesis and partially reverse the hormonal imbalance driving glandular growth.

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