Successful percutaneous dihydrotestosterone treatment of gynecomastia occurring during highly active antiretroviral therapy: four cases and a review of the literature

Association of Chronic Hepatitis B Infection and Antiviral Treatment With the Development of the Extrahepatic Malignancies: A Nationwide Cohort Study

PURPOSE

Epidemiologic studies suggest that chronic hepatitis B (CHB) is a risk factor for various primary extrahepatic malignancies. Our aim was to evaluate the associations of CHB and nucleos(t)ide analog (NA) treatment with the risk of the development of extrahepatic malignancies.

PATIENTS AND METHODS

We conducted an 18-month landmark analysis using nationwide claims data from the National Health Insurance Service of South Korea. Patients newly diagnosed with CHB in 2012-2014 (n = 90,944) and matched-controls (n = 685,436) were included. Patients with CHB were further classified as the NA-treated (CHB+/NA+, n = 6,539) or the NA-untreated (CHB+/NA-, n = 84,405) group. Inverse probability of treatment weighting analysis was applied to balance the treatment groups. Time-varying Cox analysis was performed to evaluate time-varying effect of NA treatment. The primary outcome was the development of any primary extrahepatic malignancy. Development of intrahepatic malignancy and death were considered as competing events.

RESULTS

During the study period (median = 47.4 months), 30,413 patients (3.9%) developed any extrahepatic malignancy. The CHB+/NA- group had a higher overall risk of extrahepatic malignancy than the CHB+/NA+ group (adjusted subdistribution hazard ratio [aSHR] = 1.28; 95% CI, 1.12 to 1.45; P < .001) or controls (aSHR = 1.22; 95% CI, 1.18 to 1.26; P < .001). There was no difference in the risk of extrahepatic malignancy between the CHB+/NA+ group and the controls (CHB+/NA+ v control: aSHR = 0.96; 95% CI, 0.84 to 1.08; P = .48). In time-varying Cox analysis, the CHB+/NA- patients were associated with a higher risk of extrahepatic malignancy than the CHB+/NA+ patients (aSHR = 1.37; 95% CI, 1.23 to 1.52; P < .001).

CONCLUSION

Patients with CHB have an elevated risk of developing primary extrahepatic malignancy. Long-term NA treatment was associated with a lower risk of extrahepatic malignancy development among patients with CHB.

The relationship between menopausal women infected with the human immunodeficiency virus and cervical atrophy: A cytologic study

BACKGROUND

With the advent of combined antiretroviral therapy (cART), HIV positive women are expected to live longer. The effect of chronic HIV infection and cART on cervical epithelial maturation has not been well studied in postmenopausal woman. The objective of this study was to determine whether HIV positive postmenopausal women on cART show expected atrophic changes in cervical Pap tests.

METHODS

The maturation index (MI) was performed on routine cervical smears from HIV-infected, postmenopausal women attending an HIV clinic in a tertiary hospital in Johannesburg, over a 4-year period from January 2009 to December 2012.

RESULTS

In Pap smears of 111 patients on cART, 58 (52%) showed an unexpected predominantly mature squamous epithelial pattern whereas 53 (48%) were predominantly immature or atrophic (P = .0001). There was no significant statistical difference in maturation according to cART use.

CONCLUSION

HIV-infected, postmenopausal women in this study had reduced rates of cervical atrophy than expected, irrespective of cART use and CD4 count. Initiation of cART before menopause was associated with greater cervical epithelium maturation than those women who started cART after menopause. Additional, larger studies are required to confirm this novel finding and to investigate the reason for this phenomenon.

Gynaecomastia--pathophysiology, diagnosis and treatment

Gynaecomastia (enlargement of the male breast tissue) is a common finding in the general population. Most cases of gynaecomastia are benign and of cosmetic, rather than clinical, importance. However, the condition might cause local pain and tenderness, could occasionally be the result of a serious underlying illness or a medication, or be inherited. Breast cancer in men is much less common than benign gynaecomastia, and the two conditions can usually be distinguished by a careful physical examination. Estrogens are known to stimulate the growth of breast tissue, whereas androgens inhibit it; most cases of gynaecomastia result from deficient androgen action or excessive estrogen action in the breast tissue. In some cases, such as pubertal gynaecomastia, the breast enlargement resolves spontaneously. In other situations, more active treatment might be required to correct an underlying condition (such as hyperthyroidism or a benign Leydig cell tumour of the testis) or medications that could cause breast enlargement (such as spironolactone) might need to be discontinued. For men with hypogonadism, administration of androgens might be helpful, as might antiestrogen therapy in men with endogenous overproduction of estrogens. Surgery to remove the enlarged breast tissue might be necessary when gynaecomastia does not resolve spontaneously or with medical therapy.

Biochemical endocrinology of the hypogonadal male

Hypogonadism in the male results from inadequate testicular function, especially defects in androgen synthesis and secretion, or action. Androgen action is important throughout normal male development: in the fetus, puberty, adult life and old age. Regulation is by variable activity of the hypothalamo-pituitary axis at different phases of the life span. Clinical aspects include: genetic aspects presenting at birth and pubertal failure/arrest. Aspects in adult life embrace sexuality, somatic symptoms and osteoporosis. Acquired causes of hypogonadism may arise from various forms of testicular damage (primary hypogonadism), pituitary and hypothalamic disorders, as well as aetiologies acting at several sites. Measurement of testosterone (T) is crucial to the diagnosis of hypogonadism and the technologies continue to develop, with recent major advances. A growing problem relates to the diagnosis and treatment of hypogonadism in the ageing male. T therapy is available in several forms, with major improvements in more newly available modalities.

Breast enlargement in an HIV-infected man on combined antiretroviral therapy: what if it was carcinoma?

We describe a case of an HIV-infected man on effective combined antiretroviral therapy, presenting with bilateral gynaecomastia revealing breast carcinoma. Gynaecomastia was first considered to be related to efavirenz and/or didanosine. Although breast carcinoma is rare among HIV-infected men, it should be considered as a potential cause of breast enlargement.

Impact level of dihydrotestosterone on the hypothalamic-pituitary-leydig cell axis in men

Dihydrotestosterone (DHT) the physiologically most potent androgen cannot be aromatised into oestrogen. DHT is used as a treatment for idiopathic gynaecomastia. In order to investigate the different sites of action of DHT on the hypothalamic-pituitary-testicular axis, two groups of adult men were studied. Group I included 10 gonadotropin-releasing hormone (GnRH)-deficient men who were evaluated before and during a pulsatile infusion of GnRH alone for 2 weeks and then in association with DHT given transdermally at doses used in the treatment of gynaecomastia for further two weeks. Luteinizing hormone (LH) pulsatility was assessed at the end of each step of the study. Plasma LH levels were measured every 15 min. Plasma testosterone (T), DHT, oestradiol (E2), free alpha-subunit (FAS) of glycoproteic hormones and LH bioactivity were measured on pooled plasma samples. Group II included 12 healthy men in whom plasma T, DHT and E2 were measured before and then 24, 48 and 72 h after the injection of 5000 IU hCG alone or in combination with either DHT or the pure anti-androgen nilutamide. Two weeks separated each of the 3 hCG testing. In group I, except for bioactive/immunoreactive (B/I) LH ratio which was unchanged, GnRH treatment induced significant rises (p < 0.01) in all plasma hormone levels, LH pulse amplitude and frequency. During treatment with GnRH+DHT, plasma DHT levels increased up to 16.8 +/- 2.5 nm, while plasma hormone levels, B/I LH ratio, LH pulse amplitude and frequency were similar to those obtained with GnRH alone. In group II, the peak of hCG-induced T rise was not modified by either DHT or nilutamide. In contrast, DHT reduced by 50% (p < 0.01) the E2 peak in response to hCG. These data show that DHT exerts no direct action on the pituitary to retroregulate LH secretion and to modify either B/I LH ratio or FAS secretion. Its reducing effect on LH secretion is likely mediated at the hypothalamic level. DHT does not appear to have a physiological influence on Leydig cells steroidogenesis. Administered at therapeutic doses, DHT directly reduces testicular aromatase activity that combined with its antigonadotropic effect leads to the gain in the symptomatic treatment of gynaecomastia.

Gynecomastia

Gynecomastia is common and may be asymptomatic. In most cases, a thorough history and physical examination, along with limited laboratory investigations, can help to exclude breast malignancy and serious underlying endocrine or systemic disease. Careful clinical observation may be all that is required in many cases, because gynecomastia often resolves spontaneously. Because gynecomastia is usually caused by an imbalance of androgenic and estrogenic effects on the breast, medical therapy may include antiestrogens, androgens, or aromatase inhibitors. Surgery is useful in the management of patients with long-standing symptomatic gynecomastia or when medical therapy is not successful.

Severe gynecomastia in an African boy with perinatally acquired human immunodeficiency virus infection receiving highly active antiretroviral therapy

Highly active antiretroviral therapy (HAART) slows the progression of human immunodeficiency virus (HIV) disease and lowers mortality and morbidity in children. Coincident with these advances, an increasing number of side effects are being reported. We describe an adolescent boy with perinatally acquired HIV infection who developed significant bilateral breast enlargement as a result of HAART. He required bilateral mastectomies. Pediatricians need to be aware of less common side effects of HAART.

Gynecomastia among HIV-Infected Patients Is Associated with Hypogonadism: A Case-Control Study

BACKGROUND

The prevalence, risk factors, and potential hormonal abnormalities associated with gynecomastia in a cohort of HIV-infected men are poorly understood.

METHODS

Breast enlargement was assessed in consecutively evaluated HIV-infected men, and gynecomastia was subsequently confirmed with sonography. For each patient with breast enlargement, a randomly selected control subject without breast enlargement was studied. Clinical data were obtained, including age, body mass index, clinically evident lipodystrophy, prior symptomatic hyperlactatemia, current antiretroviral therapy and duration of exposure to each antiretroviral drug, history of injection drug use, and serological status regarding hepatitis B and hepatitis C. Laboratory parameters, including plasma HIV-1 RNA load, CD4 cell count, free testosterone index, and levels of fasting triglycerides, cholesterol, prolactin, total testosterone, sex hormone-binding globulin, 17-beta-estradiol, follicle-stimulating hormone, luteinizing hormone, and thyroid-stimulating hormone, were measured.

RESULTS

There were 44 of 2275 patients with breast enlargement, of whom 40 (1.8%) had gynecomastia. The mean free testosterone index (+/-SD) was significantly lower among the 40 patients with gynecomastia (42.6%+/-24.0%) than among the 44 control subjects (58.0%+/-25.3%) (P=.006). Although the proportion of patients who were receiving treatment with zidovudine, stavudine, and/or efavirenz at the time of the present study was significantly different between case patients and control subjects, the duration of exposure to each individual antiretroviral drug was not. Lipoatrophy (adjusted odds ratio [OR], 5.6; 95% confidence interval [CI], 1.7-18.6; P=.005), hepatitis C (adjusted OR, 6.1; 95% CI, 1.8-20.6; P=.003), and hypogonadism (adjusted OR, 7.6; 95% CI, 1.8-32.2; P=.003) were independent factors associated with gynecomastia.

CONCLUSIONS

The data suggest that gynecomastia among HIV-infected patients is related to hypogonadism, rather than to an adverse effect of antiretroviral drugs.

Gynaecomastia in HIV-Infected Men on Highly Active Antiretroviral Therapy: Association with Efavirenz and Didanosine Treatment

Background

Gynaecomastia has been described in HIV-infected men undergoing highly active antiretroviral therapy (HAART). However, there are insufficient data on the relationship between gynaecomastia and any specific antiretroviral drug and hormone abnormality.

Objective

To assess the frequency of gynaecomastia in HIV-infected men receiving HAART and its association with antiretroviral drugs and hormone abnormalities.

Methods

We carried out a prospective study of 1304 HIV-infected men undergoing HAART. In addition, we included a case (with gynaecomastia)-control (without gynaecomastia) analysis in the second part of this study. Cases and controls were matched according to age, HIV infection CDC clinical category, HCV infection, the date of study and the physician responsible for the patient. Patients bearing known causes of gynaecomastia were excluded. We analysed epidemiological, clinical, haematological and immunological characteristics and the use and duration of the antiretroviral therapy. In 13 cases and 13 controls a sexual hormone profile was carried out.

Results

A total of 30 (2.3%) HIV-infected men presented with gynaecomastia of unexplained cause. In 22 (73%) of these individuals, gynaecomastia completely resolved after a median time of 9 months (range: 5–22 months). The percentage of individuals who were receiving efavirenz and didanosine at the time of the study was higher among patients with gynaecomastia [57% vs 17% ( P=0.004) and 50% vs 13% ( P=0.003), respectively]. Plasma total testosterone, free testosterone index and bioavailable testosterone levels were lower in patients with gynaecomastia, whereas plasma free testosterone levels were not significantly different in either population.

Conclusions

Gynaecomastia is not uncommon in HIV-infected men undergoing HAART and it is usually transient. Efavirenz and didanosine treatment are associated with the emergence of gynaecomastia. An underlying hypoandrogenism seems to contribute to the emergence of this disorder in these patients.

Gynecomastia in HIV-infected patients receiving antiretroviral therapy

Thirty-four HIV-positive men with gynecomastia were seen in an HIV outclinic during a 20-month period (incidence of 2.4 cases/100 patients receiving HAART per year). It developed mainly in subjects having good immunologic and virologic status, after an average of 3 years of HAART. No hormone abnormalities were found, or association with specific drugs. Although initially unilateral, more than half of cases progressed to bilateral gynecomastia. Spontaneous resolution occurred in most subjects with 12 months without modifying therapy.

Maintenance of breast size reduction after mastoplasty and switch to a protease inhibitor-sparing regimen in an HIV-positive woman with highly active antiretroviral therapy-associated massive breast enlargement

Fat distribution disorders are among the most frequent side effects of antiretroviral treatment. The pathophysiologic mechanism(s) for these events remains unclear, and a casual link to a specific drug or class of drugs is uncertain. The physical changes associated with the lipodystrophy syndrome can be divided into three major types: lipoatrophy or fat wasting; lipohypertrophy or fat accumulation; and mixed forms with atrophy and hypertrophy coexisting in different body regions. Fat accumulation can occur in one or more of several areas including dorsal-cervical and abdominal regions and breasts. Withdrawal of antiretroviral therapy does not seem to influence the stabilized lesions significantly, and no one of the therapeutic strategies adopted so far was capable to achieve substantial improvements. Here we describe the successful and lasting treatment of a massive and movement/posture-hampering breast hypertrophy with reductive mastoplasty.