Highly active antiretroviral therapy (HAART) has greatly reduced death rates from complications of AIDS in North America, Western Europe and Australia. But HAART regimens can be complex and have side effects. One of the more rare side effects is breast enlargement (gynecomastia). Although the previous report highlighted the occurrence of breast enlargement in efavirenz-users, readers should note that breast enlargement can occur with other anti-HIV drugs. Until recently doctors were at a loss for how to relieve this distressing problem. Now researchers in Paris, France, have reported their success in treating breast enlargement with the use of a form of testosterone called DTH (dihydrotestosterone).
The doctors reported on four HIV positive male patients who had been taking various combinations of HAART for several years before they experienced breast enlargement. Technicians analysed blood samples from the four patients and found normal levels of the following hormones:
The doctors prescribed DTH gel, 5 grams daily, applied to the enlarged breasts. In three of the four cases, the breasts returned to their normal size after 10 to 30 days. In the remaining case, although his breast size did decrease, it did not shrink to its normal size.
The researchers aren't certain why breast enlargement occurred but they have a theory. They noted that in HIV negative people a similar problem can happen when certain drugs — digitalis, tricyclic antidepressants — are used. In such cases, gynecomastia likely occurs because these drugs somehow mimic the hormone estrogen and/or progesterone or increase the body's production of the hormone prolactin. Since all four men had normal levels of prolactin, the dramatic reduction in breast size associated with the use of DTH reinforces their theory that HAART drugs may somehow mimic the effect of estrogen on breasts.
Further investigation on the reasons for HAART-associated breast enlargement needs to be conducted as the findings from France are preliminary. Another puzzling aspect of this story is why breast enlargement is not a more common side effect of HAART.
Readers should note that the use of testosterone may be dangerous in men who have prostate cancer or who are at high risk of prostate cancer. The French team noted that what makes DTH different from other forms of testosterone is that it cannot be converted into estrogen by breast tissue. Although DTH is not licensed in Canada, it is available in France and other countries of the European Union. In France, DTH gel is sold under the brand name Andractim and is made by Laboratoires Besins-Iscovesco. Canadian physicians who wish to order non-approved drugs can discuss their request with Health Canada's Special Access Program at 613.941.2108 between the hours of 8:30 am and 4:30 pm Eastern time.
REFERENCE
1. Benveniste O, Simon A and Herson S. Successful percutaneous dihydrotestosterone treatment of gynecomastia occurring during highly active antiretroviral therapy: four cases and a review of the literature. Clinical Infectious Diseases 2001;33:891-893.
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Copyright © 2001 - TreatmentUpdate. Reproduced with permission. Reproduction of this article (other than one copy for personal reference) must be cleared through the Editor, The Canadian AIDS Treatment Information Exchange, 555 Richmond St. West, Suite 505, Box 1104, Toronto, ON, M5V 3B1 • Phone: 416-203-7122 • Toll Free: 1-800-263-1638 • Fax: 416-203-8284 http://www.catie.ca.
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