Chlormadinone acetate withdrawal syndrome under combined androgen blockade for advanced prostate cancer

Between July 1991 and December 1994 at Tsukuba Gakuen Hospital, we treated 19 consecutive men with advanced adenocarcinoma of the prostate (five at stage C, four at stage D1 and 10 at stage D2). Of these, 14 patients underwent castration (two patients) or received LH-RH analogue (12 patients) plus chlormadinone acetate for combined androgen blockade. We report three representative cases of sequential prostate specific antigen (PSA) elevation following initial response to this combined androgen blockade. Discontinuation of chlormadinone acetate resulted in decline of the serum PSA level. This suggests that trial chlormadinone acetate withdrawal in patients showing increasing levels of PSA during combined androgen blockade should be considered before initiation of alternative treatment.

Antiandrogen withdrawal syndrome in prostate cancer after treatment with steroidal antiandrogen chlormadinone acetate

OBJECTIVES

A case report is presented of 2 patients whose levels of serum prostate-specific antigen (PSA) improved after the withdrawal of a steroidal antiandrogen.

METHODS

Two cases with prostate cancer had been treated with surgical castration and the steroidal antiandrogen chlormadinone acetate (CMA), and, on disease progression, the administration of CMA was terminated.

RESULTS

Following withdrawal of CMA, a fall in PSA levels and remarkable clinical improvement were observed in both cases. One patient revealed a decrease and the other an increase in serum prostate acid phosphatase after the discontinuation of CMA. Serum levels of testosterone, prolactin, dehydroepiandrosterone, dehydroepiandrosterone sulfate, and androstenedione were not significantly elevated after CMA withdrawal.

CONCLUSIONS

Withdrawal of the steroidal antiandrogen CMA resulted in a decline in PSA levels and clinical improvement in prostate cancer patients with disease progression. Changes in testosterone, prolactin, or adrenal androgens were not a cause of the antiandrogen withdrawal syndrome.

[Study of clinical usefulness of an antiandrogen, TZP-4238, as a drug for treatment of benign prostatic hypertrophy--its influence on sexual function]

Using chlormadinone acetate (CMA) as the control drug, a double-blind study was carried out to examine not only the effects of 17 alpha-acetoxy-6-chloro-2-oxa-4,6-pregnadiene-3,20-dione (TZP-4238;) on subjective urinary symptoms but also, especially, that on the sexual function in patients with benign prostatic hypertrophy (BPH). The clinical efficacy rate in relation to the subjective urinary symptoms was about the same in the two treatment groups; 45.9% in the TZP-4238 group and 50.0% in the CMA group. However, the incidence of adverse effects on the sexual function showed a marked difference between the two groups. The TZP-4238 group revealed a lower suppressive effect on the function than the CMA group (45.1% vs. 71.4%). In relation to their causation of other adverse effects, there were no differences between the two drugs. Accordingly, in consideration of the facts that TZP-4238 with less influence on the sexual function affords a superior quality of life to elderly patients, while achieving effective treatment by means of a convenient single daily administration, TZP-4238 was surmised to be a more useful drug than CMA as an antiandrogen for the treatment of BPH.

Continuous hormone replacement therapy with estradiol valerate and chlormadinone acetate in adjustable dosages. A preliminary study

A group of 62 peri- and postmenopausal women suffering from vasomotor disturbances and a variety of other symptoms were treated with estradiol valerate and chlormadinone acetate continuously using an adjustable dosage regimen. They obtained complete relief from vasomotor symptoms. The continuation rate was 81% after 1 year. In 18 patients the dose had to be adjusted because of breakthrough bleeding (n = 12), mastodynia (n = 3), and for the prevention of bone loss. In 11/12 patients breakthrough bleeding could be stopped by adjusting the dosage. This regimen seems to offer a more flexible approach to hormone replacement therapy (HRT) in the postmenopause than presently available combined preparations for continuous use.

[Clinical evaluation of the long-term treatment with chlormadinone acetate in patients with benign prostatic hypertrophy]

Fifty patients with benign prostatic hypertrophy were treated with chlormadinone acetate (CMA) at the dose of 50 mg/day for 12 months. Subjective symptoms and objective findings were evaluated before, and after 4 and 12 months of treatment. Better improvement was observed in all of the subjective symptoms and in almost all the parameters of objective findings, in proportion to the period of CMA treatment. Generally speaking, 12 months of treatment was more effective than 4 months of treatment. Two patients had impotence (4.0%). Both of them complained of side effects within 4 months after treatment, but they were not severe. In conclusion, long-term treatment of benign prostatic hypertrophy with CMA was useful.

[Female contraception by a normal dose progestogen after 40 years of age. Possible association of nomegestrol--17-beta-estradiol acetate by percutaneous route]

Although fertility declines with age, the use of an effective contraceptive remains necessary in women over 40. Endocrine disorders, which are common in this age group, may also often require control. Conventional estroprogestogens, even those of the latest generation, cannot be used in women with a high cardiovascular risk, since age cannot be totally excluded as a possible risk factor. The contraceptive use of derivatives of 17-hydroxyprogesterone and 19-norprogesterone offer a promising alternative, despite the absence of any exhaustive investigation particularly in situations in which the blood level of estradiol has to be reduced. There are, however, some women who respond to this type of contraception by menstrual cycle irregularities, and sometimes by low blood levels of estradiol, regardless of the drug used. A preliminary study is described in which 5 mg of nomegestrol acetate was combined with 17-beta-estradiol by transcutaneous route and which has so-far demonstrated sustained contraceptive efficacy as well as excellent clinical and metabolic safety.

Combined oral contraceptives containing chlormadinone acetate and breast cancer: results of a case-control study

The main subject of this hospital-based case-control study was the possible relationship between use of combined oral contraceptives (OCs) containing chlormadinone acetate and breast cancer. Analyses were based on data from 490 cases with newly diagnosed breast cancer and 1,223 controls and were separately performed for combined OCs with and without chlormadinone. For either of the combined OCs, risk was not elevated in ever users, did not increase with duration of use and did not change with time since initial exposure or with time since most recent use. However, the relative risk was increased in current users: RR = 1.72 (0.88, 3.36) for combined OCs with chlormadinone and RR = 1.42 (1.01, 2.00) for combined OCs without chlormadinone, which is, however, explained as a screening effect. These results show that chlormadinone as a constituent of combined OCs does not influence breast cancer risk.

[Changes in arterial blood pressure of women using hormonal contraceptives in relation to their cardiovascular history]

The revealed correlation of blood pressure variation in the females who had used hormonal contraceptives and certain features of their cardiovascular histories were used to define the group of risk for borderline arterial hypertension during the intake of Ovidon or Non-Ovlon and to develop the criteria for differentiated choice of estrogen-gestagen drugs.

[Clinical effects of allylestrenol on benign prostatic hypertrophy by double-blind method]

A double blind comparative clinical trial was performed with allylestrenol (AE) and chlormadinone acetate (CMA) to investigate the clinical efficacy of AE on prostatic hypertrophy. Both drugs were administered orally for 12-16 weeks in a daily dose of 50 mg. With both drugs marked improvement of disorders of micturition and a slight decrease in the size of the hypertrophied prostatic node were observed. No significant difference was observed between the two drugs in the overall efficacy of the treatments. Significant improvement of practically all parameters used for evaluation of results was observed with both drugs following treatment. Ultrasonotomographic examination revealed diminution of the size of the prostatic node and x-ray examination of the ureter showed improvement in elevation of the fundus of the bladder. These improvements were better after CMA treatment than after AE treatment. With all other parameters used no significant difference was observed between the two drugs. Mild adverse effects such as loss of sexual desire and potency were observed in a few cases. The incidence of side-effects was lower following AE treatment, and the incidence of loss of sexual desire and potency was significantly lower after AE than after CMA. Taking into consideration efficacy and safety of the treatments, no significant difference was observed in usefulness between the two drugs, and we were able to confirm the usefulness of AE for the conservative treatment of prostatic hypertrophy.

[Effect of a new hormonal contraceptive (Neo-Eunomin) in females with androgenization symptoms]

The activity of Neo-Eunomin on androgenisation of the skin, seborrhoea, acne, alopecia and hirsutism was investigated in a long-term trial covering 165 patients over 3379 cycles. The age of the patients ranged from 19 to 47 years. The first three symptoms showed clear improvement after 6 months of treatment, and in many cases a cure was achieved after 12 months of therapy. No equally good results could at least be obtained in the treatment of hirsutism. In a further study Neo-Eunomin was compared with a contraceptive containing a nor-testosteron derivative (Conceplan 21). Neo-Eunomin showed convincingly better efficacy in the treatment of androgenisation of the skin than the preparation under comparison.

Recurrent hemolytic uremic syndrome during oral contraception

A 23-year-old multiparous normotensive woman developed a hemolytic uremic syndrome (HUS) five months postpartum, and four months after starting estro-progestogen contraception. Eight years later a recurrence appeared, five years after a successful cadaver kidney transplantation and ten months after resumption of the estro-progestogen intake. In the interval a pure progestogen contraceptive was prescribed without problems. This observation is consistent with the hypothesis that HUS can be triggered by oral estrogen intake in predisposed individuals.

[Changes in the serum triglyceride levels following treatment with ovulation inhibitors in tall girls]

The chronological course of serum triglycerides was determined in 12 girls aged 9--10 years, who have been cyclically treated with mestranol (80 microgram/d) and chlormadinonacetate during 3 1/2 years on average, because of constitutional tall stature. A significant increase of the triglycerides level from 80 to 130 mg/100 ml (0.91 to 1.49 mmol/l) could be noted, followed by normalisation within 6 months. Mechanism and metabolic risk of the reversible increase of serum triglycerides are discussed.