From the Research
The management of gynecomastia associated with androgen resistance typically involves a combination of surgical intervention and hormonal therapy, with surgical options being the mainstay of treatment, as recommended by the most recent and highest quality study 1. The approach to managing gynecomastia associated with androgen resistance should prioritize the patient's quality of life, morbidity, and mortality.
- The underlying mechanism of gynecomastia in androgen resistance involves an imbalance in the estrogen-to-androgen ratio, where estrogen effects predominate due to the inability of tissues to respond to androgens, leading to breast development even in genetic males.
- Surgical options are the primary approach to remove excess breast tissue, with subcutaneous mastectomy being the most common procedure, which can be performed using various techniques including periareolar incision, liposuction-assisted mastectomy, or endoscopic techniques depending on the severity and patient characteristics, as suggested by 2.
- For hormonal management, testosterone replacement therapy is often prescribed, typically starting with testosterone enanthate or cypionate at 100-200 mg intramuscularly every 2 weeks, or topical testosterone gel 50-100 mg applied daily, as recommended by 1.
- In cases of complete androgen insensitivity syndrome (CAIS), estrogen replacement may be necessary after gonadectomy, typically with estradiol 1-2 mg daily.
- Psychological support is also crucial, as patients may experience body image concerns and gender identity issues.
- The use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), or non-aromatizable androgens is not justified in general, as stated by 2.
- Watchful waiting is recommended after treatment of underlying pathology or discontinuation of substances associated with gynecomastia, as suggested by 2.
- Breast imaging may be used whenever the clinical examination is equivocal, and core needle biopsy should be performed if the clinical picture is suspicious for a malignant lesion, as recommended by 2.