Progestogens with antiandrogenic properties

How to diagnose and treat medically women with excessive hair

Excessive hair growth in women is common and due to a broad spectrum of causes. Management options comprise different pharmaceuticals, epilation methods, and aesthetic approaches. Because excessive hair growth in women may cause psychological and psychosocial problems, a holistic treatment approach, including support and emotional coping strategies, should be recommended. In this article, diagnostic procedures and treatment options for excessive hair growth in female patients are discussed.

Dissociating behavioral, autonomic, and neuroendocrine effects of androgen steroids in animal models

Developments in behavioral assessment, autonomic and/or baseline reactivity, psychopharmacology, and genetics, have contributed significantly to the assessment of performance-enhancing drugs in animal models. Particular classes of steroid hormones: androgenic steroids are of interest. Anecdotally, the performance enhancing effects of androgens are attributed to anabolic events. However, there is a discrepancy between anecdotal evidence and investigative data. While some androgen steroids may promote muscle growth (myogenesis), effects of androgens on performance enhancement are not always seen. Indeed, some effects of androgens on performance may be attributable to their psychological and cardiovascular effects. As such, we consider androgen effects in terms of their behavioral, autonomic, and neuroendocrine components. Techniques are discussed in this chapter, some of which are well established, while others have been more recently developed to study androgen action. Androgens may be considered for their positive impact, negative consequence, or psychotropic properties. Thus, this review aims to elucidate some of the effects and/or mechanisms of androgens on behavioral, autonomic, and/or neuroendocrine assessment that may underlie their controversial performance enhancing effects.

Scalp seborrheic dermatitis: prevalence and associated factors in male adolescents

BACKGROUND

The prevalence of seborrheic dermatitis (SD) in the general population is variable in the literature. Factors associated with SD are not well understood.

OBJECTIVE

To verify the prevalence of scalp SD in a selected survey of male adolescents on mandatory military service and to find possible associated factors (skin color, socioeconomic level, triceps skin fold, acne, and tobacco consumption).

METHODS

This cross-sectional study included 18-year-old male adolescents on compulsory military service in a southern Brazilian city. Scalp SD was considered as erythema and scaling in any part of the scalp. Skin color, socioeconomic level, triceps skin fold, acne, and tabagism comprised the independent variables studied in our population.

RESULTS

A total of 2201 adolescents entered the study. The global prevalence of scalp SD was 11%. White skin [adjusted prevalence ratio (PR) 1.42; 95% CI 1.06-1.92; P = 0.02] and triceps skin fold >19.5 mm (adjusted PR 1.56; 95% CI 1.12-2.18; P = 0.009) were significantly associated with scalp SD. The other variables were not associated with the outcome.

CONCLUSIONS

Prevalence of scalp SD in our survey of male adolescents was 11%. The occurrence of scalp SD was associated with white skin and a higher body fat content.

Skin improvement with two different oestroprogestins in patients affected by acne and polycystic ovary syndrome: clinical and instrumental evaluation

BACKGROUND

Despite it is accepted that acne is mostly caused by an hyper-responsiveness of the pilo-sebaceous unit to normal circulating androgen hormones, in a few patients, especially women, acneic lesions can be associated with increased serum androgen levels (hyperandrogenism), of which polycystic ovary syndrome (PCOS) is the most common cause. In women with acne and proven PCOS therapy with estroprogestins (EPs) can be an excellent option.

OBJECTIVE

The aim of the study was to assess the effects of two estroprogestins (EPs), ethinyl-estradiol (EE) 30 mcg/drospirenone (DRSP) 3 mg, and ethinyl-estradiol (EE) 30 mcg/chlormadinone acetate (CMA) 2 mg, both on increased serum androgen levels and on several skin parameters in women affected by mild to severe acne and polycystic ovary syndrome (PCOS).

METHODS

Fifty-nine women were randomized to receive EE/DRSP (n = 32) or EE/CMA (n = 27) for six months. Evaluation of serum androgen levels, grading of acne and hirsutism (respectively with Pillsbury and Ferriman-Gallwey score) and non-invasive assessment of skin hydration, transepidermal water loss (TEWL) and skin homogeneity were performed at baseline, at 3 and 6 months (end of treatment).

RESULTS

Both treatments were well tolerated and showed a significant improvement of skin and hormonal parameters, although EE/DRSP showed a more potent effect on acne and seborrhea.

CONCLUSIONS

Estroprogestins represent an effective and safe treatment in women with acne and polycystic ovary syndrome (PCOS). Nevertheless, the combination EE 30 mcg/DRSP 3 mg appears to be a more potent therapeutic option.

A novel steroidal antiandrogen targeting wild type and mutant androgen receptors

Prostate cancer (PCa) progression is enhanced by androgen and treatment with antiandrogens represents an alternative to castration. While patients initially respond favorably to androgen ablation therapy, most experience a relapse of the disease within 1-2 years by expressing androgen receptor (AR) mutants. Such mutations, indeed, promote unfavorable agonistic behavior from classical antagonists. Here, we have synthesized and screened 37 novel compounds derived from dihydrotestosterone (DHT), cyanolutamide and hydroxyflutamide. These derivatives were tested for their potential antagonistic activity using a luciferase reporter gene assay and binding properties were determined for wild type (WT) and mutant ARs (T877A, W741C, W741L, H874Y). In the absence and presence of antiandrogens, androgen dependent cellular proliferation and prostate specific antigen (PSA) expression were assayed in the prostate cancer cell line LNCaP by crystal violet, real time PCR and by Western blots. Also, cellular proliferation and PSA expression were assayed in 22Rv1. A novel compound RB346, derived from DHT, was found to be an antagonist for all tested AR forms, preventing DHT induced proliferation and PSA expression in LNCaP and 22Rv1 cells. RB346 displayed no agonistic activity, in contrast to the non-steroidal antiandrogen bicalutamide (Casodex) with unfavorable agonistic activity for W741L-AR. Additionally, RB346 has a slightly higher binding affinity for WT-AR, T877A-AR and H874Y-AR than bicalutamide. Thus, RB346 is the first potent steroidal antiandrogen with efficacy for WT and various AR mutants.

Effect of oral contraceptives on markers of hyperandrogenism and SHBG in women with polycystic ovary syndrome

BACKGROUND

This randomized study's aim was to compare the effect of four oral contraceptives (OCs) containing 30 mcg of ethinylestradiol (EE) and different progestogens [drospirenone, (DRSP), chlormadinone acetate (CMA), desogestrel (DSG), gestodene (GSD)] on biochemical and hormonal parameters of hyperandrogenism and sex hormone-binding globulin (SHBG) in women with polycystic ovary syndrome (PCOS).

STUDY DESIGN

Forty women with PCOS (age 16-35 years) were recruited and randomly assigned to one of four treatment groups of 10 women each, treated, respectively, with 3 mg DRSP/30 mcg EE (Yasmin, Bayer Shering), 2 mg CMA/30 mcg EE (Belara, Grunenthal), 75 mcg GSD/30 mcg EE (Minulet, Wyeth Lederle) and 150 mcg DSG/30 mcg EE (Practil 21, Organon Italia). Blood samples were obtained on day 6-8 of the control cycle and day 6-8 of the third treatment cycle for assay of the following hormones: androsteredione (A), total testosterone (T), free T, SHBG, dehydroepiandrosterone sulphate (DHEAS).

RESULTS

In all groups, mean concentrations of free T, total T and A dropped by 40-60%, and concentrations of DHEAS dropped by 20-50%. Formulations with DRSP and CMA caused a greater reduction of androgens and a progressive increase in serum concentrations of SHBG than those with DSG and GSD.

CONCLUSIONS

Clinical studies need to be performed to determine effects of these OCs upon clinical signs of hyperandrogenism.

Comprehensive clinical management of hirsutism

Hirsutism is an excessive body and facial hair growth in women in locations where is normally minimal or absent following a hair-male pattern. For this reason is not uncommon that hirsutism raises psychological, cosmetic and social concerns. There are many treatment modalities that can be summarised into two broad groups: pharmacologic and non-pharmacologic treatment. Until now, medical treatment has been designed to interfere with the synthesis of androgen at the ovarian or adrenal level, or inhibit the effect of androgen at the receptor level, although recent progresses test other options such as insulin modulators or ornithine decarboxylase inhibitors. Mechanical treatment includes laser hair removal, electrolysis, depilatory creams, plucking and waxing. This article presents a general overview of hirsutism treatment options.

Xeno-oestrogens and phyto-oestrogens are alternative ligands for the androgen receptor

The androgen receptor (AR) plays a critical role in prostate cancer development and progression. This study aimed to use a computerized docking approach to examine the interactions between the human AR and phyto-oestrogens (genistein, daidzein, and flavone) and xeno-oestrogens (bisphenol A, 4-nonylphenol, dichlorodiphenyl trichloroethane [DDT], diethylstilbestrol [DES]). The predicted three-dimensional structure of AR and androgens was established using X-ray diffraction. The binding of four xeno-oestrogens and three phyto-oestrogens to AR was analysed. The steroids estradiol and dihydrotestosterone (DHT) were used as positive controls and thyroxine as negative control. All the ligands shared the same binding site except for thyroxine. The endogenous hormones DHT and 17beta-oestradiol showed the strongest binding with the lowest affinity energy (< -10 kcal mol(-1)). All three phyto-oestrogens and two xeno-oestrogens (bisphenol A and DES) showed strong binding to AR. The affinities of flavone, genistein, and daidzein were between -8.8 and -8.5 kcal mol(-1), while that of bisphenol A was -8.1 kcal mol(-1) and DES -8.3 kcal mol(-1). Another two xeno-oestrogens, 4-nonylphenol and DDT, although they fit within the binding domain of AR, showed weak affinity (-6.4 and -6.7 kcal mol(-1), respectively). The phyto-oestrogens genistein, daidzein and flavone, and the xeno-oestrogens bisphenol A and DES can be regarded as androgenic effectors. The xeno-oestrogens DDT and 4-nonylphenol bind only weakly to AR.

Endocrinological, metabolic and clinical features of treatment with oral contraceptive formulation containing ethinylestradiol plus chlormadinone acetate in nonobese women with polycystic ovary syndrome

BACKGROUND

Chlormadinone acetate (CMA) is a progestin compound similar to progesterone, with antiandrogenic properties. In healthy eumenorrheic women, it was demonstrated that the monophasic estroprogestin formulation containing CMA (2 mg) plus ethinyl estradiol (EE) (30 mcg) (EE30+CMA) is efficacious both in reducing hyperandrogenic symptoms, fat mass and in improving lipoprotein panel, without changes in insulin-glucose metabolism. These metabolic properties are important for women affected by polycystic ovary syndrome (PCOS) in whom there is a predisposition to insulin resistance.

STUDY DESIGN

We studied whether in young nonobese women with PCOS (15 subjects, EE30+CMA-PCOS group) a six-cycle treatment with EE30+CMA can reduce androgen levels, androgen bioavailability and the score of hirsutism and acne, and modify glucose-insulin metabolism evaluated by the oral glucose tolerance test and the body composition evaluated by bio-impedenziometry. These parameters were evaluated before (first visit) and during the sixth cycle of EE30+CMA (second visit). All the results were compared with those of a matched-age-group of nonobese PCOS women (15 subjects, no OC-PCOS group) evaluated before (first visit) and after six menstrual cycles in which they did not use any drug or oral contraceptive (second visit).

RESULTS

In the EE30+CMA-PCOS group women, androgen levels and bioavailability, hirsutism and acne score were significantly lower at the second than at the first visit, whereas they did not change in no OC-PCOS group. At the second visit, in both groups, glucose-insulin metabolism and body composition parameters were not affected.

CONCLUSIONS

A six-cycle treatment with EE30+CMA is efficacious in nonobese PCOS women to improve hyperandrogenic symptoms, without negative interferences both on body composition and on insulin-glucose metabolism.

Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for endocrine treatment of transsexual persons.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low.

CONSENSUS PROCESS

Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines.

CONCLUSIONS

Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person's genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person's desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.

Belara® – proven benefits in daily practice

Today, a contraceptive method is available to suit nearly every type of woman, every age and all preferences and expectations. All that seems to remain for users is to look for the right product to satisfy their personal requirements. The physician takes on the role of the adviser, responsible mainly for errors of judgement and undesirable effects. The choice of the suitable contraceptive depends on three factors: the patient profile, the profile of the method used and the user's life situation. In selecting the method of contraception, statistical measures such as the Pearl Index, rate of adverse events, risks and health benefits as well as the pharmacological profile, resulting intake modality and potential interactions should be considered. The patient profile includes both subjective wishes and standards of value relevant for world view, family planning and psychological well-being, as well as objective parameters such as age, BMI, medical history and the woman's sexual behaviour. Evaluation of these parameters by the physician is a major component of successful contraceptive counselling. Belara is a new oral contraceptive on the European market based on a monophasic combination of 2 mg chlormadinone acetate and 0.03 mg ethinylestradiol. As well as high contraceptive efficacy and a low rate of side effects, Belara features an outstanding safety profile due to its almost complete absence of mineralocorticoid and glucocorticoid action and its absent impact on hepatic metabolism. In daily practice, Belara exhibits mild antiandrogenic activity which also makes it suitable for users with antiandrogen-induced seborrhoea and moderate acne. Symptoms of PMS or unspecific dysmenorrhea and menstrual irregularities can also be alleviated or completely eliminated by taking Belara. Belara use has not been associated with any significant weight gain. In daily practice, Belara is suitable for every woman of every age without specific risk factors requiring safe contraception. Belara also has considerable additional health benefits that should also be considered when choosing a suitable contraceptive.

Effects of an oral contraceptive containing chlormadinone and ethinylestradiol on acne-prone skin of women of different age groups: an open-label, single-centre, phase IV study

BACKGROUND AND OBJECTIVE

Acne-prone skin, a common skin condition not only in adolescents but also in adults, can significantly influence the affected individual's quality of life. The aim of this open-label, prospective, single-centre, phase IV study was to investigate the effects of an oral contraceptive containing chlormadinone 2 mg and ethinylestradiol 0.03 mg (Belara) on the physiology of acne-prone facial skin in healthy women aged 18-37 years.

METHODS

Forty-four Caucasian women requesting hormonal contraception divided into two age groups (group A: 18-27 years; group B: 28-37 years) were treated with chlormadinone/ethinylestradiol for six menstrual cycles. During each treatment phase, each subject took one tablet per day for 21 consecutive days, followed by a 7-day pill-free interval. Medication was commenced on the first day of menses. Changes in skin parameters were evaluated in terms of the clinical sum score (the primary outcome variable, calculated from the number of comedones, the number of papules/papulopustules, and the sebum secretion state), the evaluation of the pore size using standardized photography, and a range of biophysical in vivo measurements, assessed at baseline, after 12 weeks and after 24 weeks.

RESULTS

In both age groups, facial skin condition as quantified by the clinical sum score improved significantly after three and six treatment cycles, with reduced numbers of acne lesions (comedones and papules/papulopustules) and a reduction in seborrhoea. Moreover, there was a statistically significant decrease in pore size. Biophysical evaluations confirmed favourable effects of the medication on diverse skin parameters. Skin surface pH remained within the normal physiological range and there was an improvement in epidermal barrier function (as manifested by decreased transepidermal water loss from the skin of the forehead). Stratum corneum hydration increased in both age groups and the lipid content of the skin surface on the forehead decreased significantly after three treatment cycles in subjects aged 28-37 years. Ultrasound measurements verified that there was no retention of water within the dermis. There was no difference between the two age groups.

CONCLUSION

For the first time, improvements in several facial skin parameters during treatment with a combined oral contraceptive (chlormadinone/ethinyl-estradiol) were quantified by biophysical methods and a clinical sum score. The highly statistically significant improvements in clinical findings and various biophysical skin parameters observed in this study suggest that the antiandrogenic oral contraceptive chlormadinone/ethinylestradiol may be a major therapy option in women with acne-prone skin who request hormonal contraception.

Effects of two estroprogestins containing ethynilestradiol 30 microg and drospirenone 3 mg and ethynilestradiol 30 microg and chlormadinone 2 mg on skin and hormonal hyperandrogenic manifestations

Hyperandrogenic manifestation in women, such as seborrhea, acne and increased hair growth are common reasons of psychological distress. Skin appearance is very important for young women. This study evaluated the hormonal and skin effects of two estroprogestins (EPs) containing ethinyl-estradiol (EE) 30 microg associated with drospirenone (DRSP) 3 mg or chlormadinone acetate (CMA) 2 mg, respectively. Fifty-five women with signs and symptoms of hyperandrogenism (seborrhea, acne and increased hair growth) were enrolled in the study; randomly, 30 women were treated with EE 30 microg + DRSP 3 mg and 25 with EE 30 microg + CMA 2 mg. Follicle-stimulating hormone (FSH), luteinising hormone (LH), 17-hydroxyprogesterone (17OHP), androstenedione (A), testosterone (T), dehydroepiandrosterone sulfate (DHEAS), sex hormone binding globulin (SHBG) and free androgen index (T x 100/SHBG, FAI) were assessed at baseline, and after 3 and 6 months of treatment with EPs. Effects on seborrhea, acne and increased hair growth (as Ferriman-Gallwey score) were also evaluated at the same time points. Finally, skin hydration, transepidermal water loss (TEWL) and skin homogeneity were studied with non-invasive technique during the study. Treatment for 6 months with both EPs decreased significantly the circulating androgen levels (A, T, DHEAS) and FAI, and increased SHBG levels; also skin pattern was improved. EP containing EE and DRSP was better than EP containing EE and CMA as for skin changes, as seborrhea, acne, increased hair, hydration, homogeneity and overall quality of the skin; moreover, hormonal changes (as FAI) under therapy were more pronounced with EE/DRSP than EE/CMA. These effects may be considered in EP choice and could be important in improving patient's compliance and quality of life in hyperandrogenic women.

Insulin sensitivity and lipid metabolism with oral contraceptives containing chlormadinone acetate or desogestrel: a randomized trial

BACKGROUND

Second-generation and third-generation oral contraceptives containing 30 mcg or more of ethinylestradiol (EE) decrease insulin sensitivity (SI). In this study, we investigated whether SI is decreased by contraceptives containing lower doses EE or by progestins with antiandrogenic properties.

STUDY DESIGN

Twenty-eight young healthy women were randomly allocated to receive 20 mcg of EE and 150 mcg of desogestrel (DSG) (n=14) or 30 mcg of EE and 2 mg of chlormadinone acetate (CMA) (n=14) for 6 months. SI and glucose utilization independent of insulin (Sg) were investigated by the minimal model method. Lipid modifications were also analyzed.

RESULTS

SI decreased with EE/DSG (7.09+/-1.4 vs. 4.30+/-0.91; p=.04; n=12), but not with EE/CMA (5.79+/-0.93 vs. 6.79+/-1.1; p=.48; n=12). SI modifications observed in the two groups were significantly different (-2.79+/-1.15 vs. 1.0+/-1.38; p=.05). Sg did not vary with either treatment. The response of C-peptide to glucose increased, but significantly so only with EE/CMA (p=.01). The C-peptide/insulin response increased with both EE/DSG (p=.05) and EE/CMA (p=.04). High-density lipoprotein (HDL) cholesterol (p=.02) and triglycerides (p=.02 and p=.01) increased in both groups, but HDL/low-density lipoprotein cholesterol (p=.02), apoprotein A1 (Apo-A1) (p=.04) and Apo-A1/apoprotein B (p=.048) increased significantly only with EE/CMA.

CONCLUSIONS

The present study confirms that DSG, even when associated with low EE dose, decreases SI. By contrast, EE/CMA does not deteriorate SI and induces a favorable lipid profile.

Structure-activity relationships of synthetic progestins in a yeast-based in vitro androgen bioassay

The recent identification of tetrahydrogestrinone (THG), a non-marketed designer androgen used for sports doping but previously undetectable by established mass spectrometry-based urine drug screens, and its production by a facile chemical modification of gestrinone has raised concerns about the risks of developing designer androgens from numerous marketed progestins. We therefore have used yeast-based in vitro androgen and progesterone bioassays to conduct a structure-activity study assessing the intrinsic androgenic potential of commercially available progestins and their derivatives, to identify those compounds or structures with the highest risk of forming a basis for such misapplication. Progestins had a wide range of androgenic bioactivity that was not reliably predicted for individual steroids by their progestin bioactivity. 17alpha-Hydroxyprogesterone and 19-norprogesterone derivatives with their bulky 17beta-substituents were strong progestins but generally weak androgens. 17alpha-Ethynylated derivatives of testosterone, 19-nortestosterone and 18-methyl-19-nortestosterone such as gestrinone, ethisterone, norethisterone and norgestrel had the most significant intrinsic androgenicity of all the commercially marketed progestins. Facile chemical modification of the 17alpha-ethynyl group of each of these progestins produces 17alpha-methyl, ethyl and allyl derivatives, including THG and norbolethone, which further enhanced androgenic bioactivity. Thus by using the rapid and sensitive yeast bioassay we have screened a comprehensive set of progestins and associated structures and identified the ethynylated testosterone, 19-nortestosterone and 18-methyl-19-nortestosterone derivatives as possessing the highest risk for abuse and potential for conversion to still more potent androgens. By contrast, modern progestins such as progesterone, 17alpha-hydroxyprogesterone and 19-norprogesterone derivatives had minimal androgenic bioactivity and pose low risk.

Glucocorticoid and Sex Hormone Receptors: Clinical Implications and Therapeutic Relevance

In general, steroid hormones exert their effects through intracellular receptors, the glucocorticoid (GR), mineralocorticoid (MR), androgen (AR), estrogen (ER), and progesterone (PR) receptors. In this brief review, we will focus on glucocorticoid and sex hormone actions in the skin through their distinct receptors and discuss their clinical relevance.

Switching hormonal contraceptives to a chlormadinone acetate-containing oral contraceptive. The Contraceptive Switch Study

PURPOSE

This prospective observational noninterventional study aimed at collecting information on changes in cycle control, dysmenorrhea, androgen-related skin conditions and tolerability in a large cohort of women who switched their oral contraceptive (OC) to 2.0 mg chlormadinone acetate (CMA)/0.03 mg ethinylestradiol (EE) (Belara).

MATERIALS AND METHODS

In a total of 20,897 women who were enrolled in a four-cycle clinical evaluation at 1597 gynecological practices throughout Germany, there are 16,781 women who switched from another contraceptive.

RESULTS

The most frequently mentioned complaint for switching contraceptive was seborrhea/acne (6933/16,781 women; 41.3%). This was followed by cycle irregularities (18.8%), headache (15.9%), breast tension (15.1%), amenorrhea (14.9%), spotting (12.8%) and dysmenorrhea (11.7%). After switching to CMA/EE treatment, these symptoms decreased substantially or even disappeared in a large number of women. The vast majority of study participants scored both tolerability and well-being on CMA/EE intake as 'very good' or 'good'. The results revealed that 13,508 women (80.5%) stated being more satisfied or even much more satisfied on CMA/EE intake compared to their previously used contraceptive; most of them had taken progestins of the nortestosterone type. CMA/EE produced beneficial effects on skin conditions and well-being in OC switchers who experienced dissatisfaction with their previous contraceptive regimen.

CONCLUSION

The results of this observational study support that 2.0 mg CMA/0.03 mg EE is well tolerated, provides a reliable cycle stability and is very effective in diminishing dysmenorrhea and other cycle-related complaints. Women suffering from problems on hormonal contraception received benefit from switching to the progesterone derivative CMA-containing OC.

Effect of Prolactin and Bromocriptine on the Population of Prostate Neuroendocrine Cells from Intact and Cyproterone Acetate-Treated Rats: Stereological and Immunohistochemical Study

This work deals with the quantification of serotonin-immunoreactive prostate neuroendocrine cells (NECs) in rats exposed to prolactin in normal, cyproterone acetate-exposed, and bromocriptine-exposed animals to establish the possible influence of prolactin with or without androgenic blockade on this cell population. Thirty male peripubertal Sprague-Dawley rats were grouped as controls (CT) and those treated with cyproterone acetate (CA), cyproterone acetate plus prolactin, cyproterone acetate plus bromocriptine, prolactin (PL), and bromocriptine (BC). The volume of ductal epithelium (Vep) and total number (NSER) of the NECs serotonin-immunoreactive were measured. NECs were detected in the periurethral ducts. Compared to CT, Vep was increased in PL and BC and NSER was decreased in CA and increased in the prolactin or bromocriptine groups. The androgenic blockade decreases NSER in rat prostate; PL induces in normal and cyproterone acetate-treated rats the increase of NSER; and BC exerts a local effect over the prostate similar to that described for PL.

Pharmacokinetics of chlormadinone acetate following single and multiple oral dosing of chlormadinone acetate (2 mg) and ethinylestradiol (0.03 mg) and elimination and clearance of a single dose of radiolabeled chlormadinone acetate

BACKGROUND

Published data on pharmacokinetic parameters for chlormadinone acetate (CMA) are in part contradictory, especially with regard to terminal half-life (t(1/2,z)).

MATERIALS AND METHODS

Single and multiple doses of CMA (2 mg) and ethinylestradiol (EE; 0.03 mg) were administered to healthy female volunteers for six menstrual cycles. Plasma concentrations of CMA and EE were determined by gas chromatography-mass spectrometry. Single-dose and steady-state pharmacokinetic parameters were calculated. In a separate study, healthy female volunteers were given a single 2-mg dose of radiolabeled CMA. Concentrations of radioactivity in fecal and urine samples were determined via liquid scintillation. Excretion of total radioactivity was calculated as percentage of administered dose.

RESULTS

Eighteen women completed the repeated-dose study. Peak plasma concentrations for CMA and EE were reached within 1 and 2 h after taking the study drug. Peak plasma concentrations of CMA were approximately 1600 pg/mL after single-dose administration and 2000 pg/mL after multiple dosing. CMA and EE showed linear pharmacokinetics throughout six cycles, with constant trough values of approximately 400-500 pg/mL for CMA and 20-40 pg/mL for EE. Mass balance factors were 1.2-1.4 for CMA and 1.6-1.7 for EE, and accumulation factors were 1.7-2 for CMA and 1.7-1.8 for EE. Mean t(1/2,z) of CMA was approximately 25 h after single dosing and 36-39 h at steady state. In the excretion balance study, mean dose of CMA recovered was 87.3+/-6.4%, with urinary and fecal excretion accounting for 45% and 42%, respectively.

CONCLUSIONS

The pharmacokinetics of CMA and EE is linear after multiple dosing and remains stable during long-term administration, once steady state is reached. The t(1/2,z) of CMA was 36-39 h after multiple dosing, which is considerably shorter than the 80 h often quoted in the literature.

Recent advances in the treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex and heterogeneous disorder that presents a challenge for clinical investigators. It is the most common endocrine disorder of reproductive-aged women, yet the optimal therapeutic approach is unknown because the pathophysiological and molecular basis of the syndrome is not fully understood. Currently, the treatment is targeted to the patient's primary complaint. Treatment strategies focus on the reduction of clinical manifestations of hyperandrogenism (e.g., hirsutism), restoration of regular menses and achieving pregnancy. Pharmacological agents available for the treatment of hirsutism include androgen suppressors and peripheral androgen blockers. Combined oral contraceptive pills are the most commonly used androgen suppressor and the treatment of choice for menstrual dysfunction in PCOS patients who do not desire pregnancy. The first-line treatment for infertility in PCOS is clomiphene-citrate, whereas parenteral gonadotropins are commonly used in clomiphene-resistant patients. The benefits of insulin-sensitising agents for PCOS patients have become increasingly clear over the last decade. Metabolic disturbances associated with PCOS appear to have important long-term health implications and require further attention. This review summarises the current and emerging therapeutic strategies for the management of PCOS.

Chlormadinone acetate (CMA) in oral contraception--a new opportunity

Chlormadinone acetate (CMA) is a derivative of naturally secreted progesterone that shows high affinity and activity at the progesterone receptor. It has an anti-estrogenic effect and, in contrast to natural progesterone, shows moderate anti-androgenic properties. CMA acts by blocking androgen receptors in target organs and by reducing the activity of skin 5alpha-reductase. It suppresses gonadotropin secretion and thereby reduces ovarian and adrenal androgen production. CMA shows high contraceptive efficacy by inhibiting ovulation due to its ability to suppress or disrupt endogenous gonadotropin secretion and, by this, inhibits follicular growth and maturation. In addition, it suppresses endometrial thickness and increases the viscosity of cervical mucus. Pharmacokinetic studies have shown rapid and almost complete absorption after oral administration, and CMA is being bound to albumin rather than SHBG (Sex-Hormone-Binding-Globulin). Multiple dosing studies have demonstrated that steady state is reached by day 7 after oral administration with peak plasma concentrations in the region of 2 ng/ml. After a single dose of CMA the half-life time is around 34 hours and after multiple dose administration approximately 38 hours. Safety studies have indicated that CMA has no clinically relevant effect on a wide range of metabolic parameters in normal subjects. Further studies in groups at high thromboembolic risk have shown that CMA alone produces a relative risk of 0.8 which is not considered significant. These results indicated the potential for CMA to be combined with ethinylestradiol in an oral contraceptive which provides highly effective contraception and excellent cycle control.

Systemische Aknetherapie

The development of scarring in inflammatory acne may induce permanent disfigurement and considerable psychosocial impact on the lives of affected individuals. The early use of systemic acne therapy can help to prevent these unfortunate consequences. Antiinflammatory antibiotics such as tetracyclines are required in moderate to severe papulopustular acne. The recommended treatment duration is 3 months; combination with topical retinoids and benzoyl peroxide increases the speed and efficacy of lesion reduction and helps to prevent bacterial resistance. Oral isotretinoin is the treatment of choice in severe acne resistant to adequate conventional therapy. Hormonal treatment represents an alternative regimen for women with acne and is the first choice in late-onset acne and in those with clinical signs of hyperandrogenism.

Management of hair loss

The management of patients with hair loss requires a customized plan. Diagnosis, prognosis, psychosocial impact, treatment options, and patient preference are key determinants. This article discusses current agents for the treatment of three commonly encountered nonscarring alopecias: male- and female-pattern hair loss, telogen effluvium, and alopecia areata. Algorithmic approaches to management are provided.

Androgenic progestins in oral contraceptives and the risk of epithelial ovarian cancer

OBJECTIVE

Oral contraceptives (OCs) have been consistently linked to reduced risk of ovarian cancer. Oral contraceptive formulations display varying degrees of androgenicity. Data linking androgens to ovarian cancer suggest that OC androgenicity may impact efficacy in preventing ovarian cancer. The authors investigated whether OC efficacy might differ according to androgenicity by using data from a large, population-based, case-control study (the Steroid Hormones and Reproductions [SHARE] Study).

METHODS

Detailed data on OC formulation was obtained by an in-person interview for 568 cases and 1,026 controls. Multivariable logistic regression was used to assess the association of OC androgenicity with ovarian cancer while controlling for the known potential confounders of age, parity, family history of ovarian cancer, and tubal ligation.

RESULTS

Androgenic and nonandrogenic OCs conferred a similar and significant reduction in ovarian cancer risk (odds ratio 0.52, 95% confidence interval 0.35-0.76 and odds ratio 0.59, 95% confidence interval 0.45-0.78, respectively). No differences in duration of use, age at first use, and time since last use were found between androgenic and nonandrogenic formulations.

CONCLUSION

In general, the androgenicity of an OC does not alter chemopreventive efficacy.

LEVEL OF EVIDENCE

II-2.

Practical Approach to the Hormonal Treatment of Acne

Acne is a disease of the pilosebaceous units and these are mainly under hormonal control. In female patients, hormonal therapy is a unique opportunity for the treatment of acne. Several combined oral contraceptives (COCs), cyproterone acetate, spironolactone, flutamide, and others, have been tried for the control of acne. An overview on the use of the most useful drugs in clinical practice was conducted. COCs are thoroughly discussed, also taking into consideration their potential side effects. A practical approach with guidelines on the use of COC in acne is proposed.

Combined oral contraceptives in the treatment of polycystic ovary syndrome

Combined oral contraceptives (COC) are the most often used treatment modality for polycystic ovary syndrome (PCOS). Undisputedly, COC suppress androgen production, thus ameliorating skin androgenic symptoms and improving menstrual dysfunction. On the other hand, there are still many unresolved issues concerning their metabolic effects. COC could decrease insulin sensitivity and deteriorate glucose tolerance, although the negative influence on insulin sensitivity is dependent on other factors (especially obesity) and this need not be expressed in non-obese patients. It is probable that the impairment of glucose tolerance is reversible, as the incidence of diabetes is not increased in past COC users. The effects of COC on the lipid spectrum are dependent on the type of gestagen, but lipid levels usually remain within the reference limits. Combination therapy of COC with weight reduction or insulin sensitizers could further suppress androgen levels and improve metabolic parameters. The establishment of COC after laparoscopic ovarian drilling may further decrease androgen levels. The combination of COC and GnRH analogues is not superior to COC therapy alone. Prospective data about the influence of COC on the risk of diabetes mellitus, coronary artery disease and endometrial cancer in PCOS women are lacking.

Role of progestins with partial antiandrogenic effects

An experts' meeting on the 'Role of progestins with partial antiandrogenic effects' was held in Berlin from January 19 to 22, 2001. The meeting was chaired by Dr R. Sitruk-Ware (New York, USA) and participants included Ms F. Fruzzetti (Pisa, Italy), J. Hanker (Trier, Germany), J. Huber (Vienna, Austria), F. Husmann (Bad Sassendorf, Germany), S. O. Skouby (Copenhagen, Denmark), J. H. H. Thijssen (Utrecht, The Netherlands), and R. Druckmann (Nice, France). The present paper reports the conclusions of the meeting. However, the publication of the Women's Health Initiative study, which appeared after the meeting, led to additional comments and revisions.

Induction of androgen receptor activity by norgestimate and norelgestromin in MDA-MB 231 breast cancer cells

The function and clinical significance of the androgen receptor (AR) in human breast cancer are still not clear. The synthetic progestins, norgestimate and norelgestromin, were designed to minimize the adverse effects such as acne, hirsuitism and metabolic changes observed with older oral contraceptives while maintaining contraceptive effectiveness and cycle control. AR-mediated effects of these synthetic progestins were studied in an in vitro transactivation assay, employing DNA co-transfection of an AR expression vector and luciferase reporter gene construct in the MDA-MB 231 human breast cancer cell line. Testosterone acetate and 5alpha-dihydrotestosterone induced the reporter gene transcription, whereas incubation of the transfected cells with the natural progestin 17alpha-hydroxyprogesterone did not markedly induce luciferase activity. The progestins norgestimate and norelgestromin exerted a very low androgenic activity. Our data suggest that norgestimate and its metabolite norelgestromin possess weak androgen-like properties. The use of these compounds for clinical application may be of great advantage in the treatment of breast cancer as well as hyperandrogenism in women.

Hirsutism: diagnosis and management

Hirsutism can be a source of great distress and social embarrassment and in some cases can indicate underlying endocrine or malignant disease. More is known about the metabolic consequences of hyperandrogenism including risk of developing cardiovascular disease, insulin resistance or diabetes. Full assessment is vital in light of the potential health consequences of hirsutism.

Identification of monohydroxy progesterones produced by CYP106A2 using comparative HPLC and electrospray ionisation collision-induced dissociation mass spectrometry

Two previously uncharacterised products, produced by recombinant CYP106A2 of Bacillus megaterium ATCC 13368 using progesterone as substrate, were identified. For this purpose a combination of comparative HPLC and electrospray ionisation collision induced dissociation mass spectrometry (ESI CID MS) was established and applied for rapid identification of the steroids, which were identified as 11alpha-hydroxyprogesterone and 9alpha-hydroxyprogesterone. The pharmaceutical relevance of these steroids is discussed. Furthermore, the hydroxylation activity was quantified for all monohydroxylation products (15beta-hydroxyprogesterone, 6beta-hydroxyprogesterone, 11alpha-hydroxyprogesterone, and 9alpha-hydroxyprogesterone). The V(max) values for 15beta-hydroxyprogesterone, 6beta-hydroxyprogesterone, 11alpha-hydroxyprogesterone, and 9alpha-hydroxyprogesterone were determined as 337.3+/-43.7, 22.3+/-0.9, 17.5+/-0.9, and 6.5+/-0.3nmol product/min/nmol CYP106A2, respectively.