Cyproterone acetate in the treatment of sexual disorders: pharmacological base and clinical experience

Estrogenic potency of endocrine disrupting chemicals and their mixtures detected in environmental waters and wastewaters

Endocrine disrupting chemicals such as natural and synthetic steroid hormones and bisphenols are among the most important pollutants in the aquatic environment. We performed an environmental chemical analysis of five Slovenian water samples, two rivers, one groundwater, and the influent and effluent of wastewater treatment plants, with a highly sensitive analysis of twenty-five endocrine-disrupting compounds belonging to the groups of natural hormones, synthetic hormones, and bisphenols. Since these compounds are simultaneously present in the environment, it is important to study their individual effects as well as the effects of mixtures. We investigated in vitro the estrogenic potency of selected natural and synthetic steroid hormones and bisphenols detected in surface, ground and waste water in Slovenia using the OECD-validated transactivation assay on the cell line Hela9903. We predicted their mixture effects using the concentration addition model and compared them with experimentally determined values. Two mixing designs were used: a balanced design in which chemicals were combined in proportion to their individual EC₅₀ values, and an unbalanced design with compounds in proportion to their measured concentrations in the environmental samples. The estrogenic effects of the experimental mixtures followed the concentration addition model. Real water samples exhibited weaker estrogenic effects, showing the great heterogeneity of the real water samples.

Elderly Sexual Offenders

With the ever-aging population, the number of elderly sexual offenders are also on the rise. The courts and correctional system are increasingly faced with older individuals who have offended sexually. Previously, these older offenders were thought to be similar to younger sexual offenders. However, closer analysis suggests that many of these individuals pose a much lower risk to recidivate than the risk to recidivate of their younger counterparts. Still, an individualized approach to manage the risk of older offenders is required, as some may have particular risk factors relevant for their treatment and future stability, such as dementia or other mental health issues. Further, this population often has particular physical health issues and requires special consideration when being placed in the community. Assessment, treatment, and risk management in this special population of sexual offenders are discussed.

Environmental concentrations of anti-androgenic pharmaceuticals do not impact sexual disruption in fish alone or in combination with steroid oestrogens

Sexual disruption in wild fish has been linked to the contamination of river systems with steroid oestrogens, including the pharmaceutical 17α-ethinylestradiol, originating from domestic wastewaters. As analytical chemistry has advanced, more compounds derived from the human use of pharmaceuticals have been identified in the environment and questions have arisen as to whether these additional pharmaceuticals may also impact sexual disruption in fish. Indeed, pharmaceutical anti-androgens have been shown to induce such effects under laboratory conditions. These are of particular interest since anti-androgenic biological activity has been identified in the aquatic environment and is potentially implicated in sexual disruption alone and in combination with steroid oestrogens. Consequently, predictive modelling was employed to determine the concentrations of two anti-androgenic human pharmaceuticals, bicalutamide and cyproterone acetate, in UK sewage effluents and river catchments and their combined impacts on sexual disruption were then assessed in two fish models. Crucially, fish were also exposed to the anti-androgens in combination with steroid oestrogens to determine whether they had any additional impact on oestrogen induced feminisation. Modelling predicted that the anti-androgenic pharmaceuticals were likely to be widespread in UK river catchments. However, their concentrations were not sufficient to induce significant responses in plasma vitellogenin concentrations, secondary sexual characteristics or gross indices in male fathead minnow or intersex in Japanese medaka alone or in combination with steroid oestrogens. However, environmentally relevant mixtures of oestrone, 17β-oestradiol and 17α-ethinylestradiol did induce vitellogenin and intersex, supporting their role in sexual disruption in wild fish populations. Unexpectedly, a male dominated sex ratio (100% in controls) was induced in medaka and the potential cause and implications are briefly discussed, highlighting the potential of non-chemical modes of action on this endpoint.

WITHDRAWN: Managements for people with disorders of sexual preference and for convicted sexual offenders

This review has been withdrawn (Issue 9, 2012) as it is no longer current and is to be superseded by two new reviews.

The editorial group responsible for this previously published document have withdrawn it from publication.

Cyproterone to treat aggressivity in dementia: a clinical case and systematic review

Aggressivity is a common problem in the management of elderly patients with dementia. Medications currently used to diminish aggressive behaviour in dementia can have problematic side effects. We present a case and systematic review of the current knowledge about the use of cyproterone acetate to treat aggressivity (excluding hypersexuality related behaviours) in dementia. An 82-year-old man required psychiatric inpatient admission due to agitation and aggressivity and was diagnosed with Alzheimer's disease. After failed trials of atypical antipsychotics (quetiapine 100 mg/day and risperidone 1 mg/day), drugs for dementia (memantine 20 mg/day and rivastigmine 9 mg/day) and benzodiazepines (lorazepam 0.5-1 mg prn) he was started on cyproterone acetate titrated up to 50 mg twice daily. After two weeks he was calmer and did not express aggressivity. Two months later he was discharged to a community placement where he subsequently remained settled on cyproterone. We reviewed literature on the use of cyproterone in aggressivity (excluding hypersexuality) associated with dementia. We searched the main medical databases including articles in English, Spanish, French and Italian. Only one randomized double-blind trial was found, comparing cyproterone with haloperidol (n = 27). Cyproterone was more effective controlling aggressivity and had lower incidence of side effects. In the one uncontrolled naturalistic observational study identified (n = 19), cyproterone was associated with significant reductions in aggressivity without causing major side effects. Further literature was limited to theoretical discussions. Despite there being evidence to support our observations of a useful role for cyproterone in aggressivity in dementia, further studies are needed to establish the efficacy and safety of this therapeutic option.

Behavioral and physiological responses of a wild teleost fish to cortisol and androgen manipulation during parental care

Proximate mediators of reproductive behaviors in vertebrates have a long history of study. In fishes, relatively few studies have focused on hormonal control of parental care, despite a comprehensive background on the general physiology of fishes, and the frequent occurrence of parental care behaviors. Studies on this taxon have repeatedly found that the relationships between androgens and paternal care do not follow the predictions made in the avian and mammalian literature. Glucocorticoids may also have a role in mediating parental behaviors, possibly through their role as regulators of metabolism. As such, we investigated the role of 11-ketotestosterone (11-KT) and cortisol in mediating parental effort of male smallmouth bass (Micropterus dolomieu) by manipulating hormone titers in wild fish. In smallmouth bass, males spawn annually with a single female and defend a single brood for up to 30 days. Treatment of parental fish with cyproterone acetate (CYA; an androgen receptor antagonist) resulted in a decrease in nest defense in response to a simulated brood predator; however, no changes in nest success, nest tending or biochemical indicators of nutritional status were detected. Treatment with exogenous cortisol did not change parental behavior, but did increase the rate of nest failure, possibly owing to the energetic cost of chronically elevated cortisol concentrations. We discuss these findings in the context of resource-driven trade-offs and highlight life history as an important factor controlling parental effort in species with costly parental care behaviors.

WITHDRAWN: Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

AUTHORS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

The physiological basis of human sexual arousal: neuroendocrine sexual asymmetry

Normal sexual arousal and response suppose an integrated process involving both physiological and psychological processes. However, the current understanding of sexual arousal does not provide a coherent model that accounts for the integration of multiple physiological systems that subsequently generate a coordinated sexual response at both the spinal peripheral and cerebral central levels. Herein we suggest a model that involves both sympathetic and parasympathetic activation during sexual arousal via the two classes of gonadal hormones, androgens and oestrogens. We discuss the manner in which gonadal hormones may activate such a system, transforming pre-pubertal (non-erotic) genital stimulation to post-pubertal erogenization of stimulation and subsequent sexual arousal. Finally, we indicate that the different balance of androgens and oestrogens in men and women may generate asymmetric effects on each of the components of the autonomic nervous system, thereby explaining some of the differences in patterns of sexual arousal and the responses cycle across the sexes.

Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

REVIEWERS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

Managements for people with disorders of sexual preference and for convicted sexual offenders

BACKGROUND

The reviewers recognise that it may be thought that convicted sex offenders and those with disorders of sexual preference are quite different groups. In combining them within this review we have taken the view that legal process alone should not define the population. Illegal behaviours in one jurisdiction may not be considered so in others. Studies of those who are convicted of sexual offending describe reconviction rates for sexual offences of up to 40-60%. It would seem important to know if there are interventions that might reduce this high rate of re-offending. This review examines antilibidinal management of those who have been convicted of sexual offences or who have disorders of sexual preference.

OBJECTIVES

To determine the effectiveness of a range of management techniques to assist people who have disorders of sexual preference and those who have been convicted of sexual offences.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Schizophrenia Group Register of Trials, The Cochrane Library, EMBASE, MEDLINE, and PsychLIT were searched. Further references were sought from published trials and their authors. Relevant pharmaceutical manufacturers were contacted.

SELECTION CRITERIA

All relevant randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently and analysed on an intention-to-treat basis. Data were extracted for short and medium term outcomes.

MAIN RESULTS

A single trial (McConaghy 1988) found the effect of antilibidinal medication (medroxyprogesterone acetate) plus imaginal desensitisation was no better than imaginal desensitisation for problematic/anomalous sexual behaviour and desire. A relapse prevention programme was trialed by Marques (Marques 1994) and participants were followed up for an average of 3 years. What data there are suggest that although there is no discernable effect on the outcome of sex offending (OR 0.76 CI 0. 26-2.28) those treated with response prevention do have less non-sexual violent offences (OR 0.3, CI 0.1-0.89, NNT 10 CI 5-85). In addition those committing both sexual and violent offences also declined in the response prevention group (OR 0.14 CI 0.02-0.98, NNT 20 CI 10-437). A large pragmatic trial investigated the value of group therapy for sex offenders (Romero 1983). This study finds no effect on recidivism at ten years.

REVIEWER'S CONCLUSIONS

It is disappointing to find that this area lacks a strong evidence base, particularly in light of the controversial nature of the treatment and the high levels of interest in the area. The relapse prevention programme did seem to have some effect on violent reoffending but large, well-conducted randomised trials of long duration are essential if the effectiveness or otherwise of these treatments are to be established.

Pharmacologic treatment of hypersexuality and paraphilias in nursing home residents

PURPOSE

To discuss the pharmacologic options for treatment of hypersexuality or paraphilias in nursing home residents.

DATA SOURCES

A MEDLINE search was conducted for English-language articles published over the past 20 years and was supplemented by a search of bibliographies of relevant articles.

STUDY SELECTION

Case reports of pharmacologic treatment of hypersexual or paraphilic behavior were selected only if the patient receiving treatment was an older person and/or cognitively impaired.

DATA EXTRACTION

Case reports were grouped according to the class of the pharmacologic agent used (antiandrogens, estrogens, GnRH analogues, or serotonergic drugs). Each case report was evaluated for pharmacologic agent administered, route of administration, duration of therapy, therapeutic response, and incidence of side effects.

CONCLUSIONS

Nursing home residents who display hypersexual or paraphilic behavior are extremely difficult to manage. Before initiating pharmacotherapy to control unwanted sexual behaviors, the current drug regimen should be evaluated carefully for drugs that may be causing or exacerbating the behavior. Case reports suggest that antiandrogens, estrogens, GnRH analogues, and serotonergic medications may be useful when other methods have failed. Controlled comparative trials of these agents are needed to establish their efficacy clearly.

Treatment of men with paraphilia with a long-acting analogue of gonadotropin-releasing hormone

BACKGROUND

Men with deviant sexual behavior, or paraphilia, are usually treated with psychotherapy, antidepressant drugs, progestins, and antiandrogens, but these treatments are often ineffective. Selective inhibition of pituitary-gonadal function with a long-acting agonist analogue of gonadotropin-releasing hormone may abolish the deviant sexual behavior by reducing testosterone secretion.

METHODS

In an uncontrolled observational study, we treated 30 men (mean age, 32 years) with severe long-standing paraphilia (25 with pedophilia and 5 with other types of abnormal behavior) with monthly injections of 3.75 mg of triptorelin and supportive psychotherapy for 8 to 42 months. The efficacy of therapy was evaluated monthly by the Intensity of Sexual Desire and Symptoms Scale and yearly by the Three Main Complaints questionnaire.

RESULTS

All the men had a decrease in the number of deviant sexual fantasies and desires, from a mean (+/-SD) of 48+/-10 per week before therapy to zero during therapy (P<0.001), and a decrease in the number of incidents of abnormal sexual behavior (from 5+/-2 per month to zero, P<0.001) while receiving triptorelin. These effects were evident after 3 to 10 months of therapy (P<0.001) and persisted in all 24 men who continued therapy for at least 1 year. The men's mean serum testosterone concentration fell from 545+/-196 ng per deciliter (18.9+/-6.8 nmol per liter) before therapy to 23+/-14 ng per deciliter (0.8+/-0.5 nmol per liter, P<0.001) after 42 months of triptorelin. The main side effects were erectile failure, hot flashes, and decrease in bone mineral density in some men.

CONCLUSIONS

Continuous administration of triptorelin, a long-acting agonist analogue of gonadotropin-releasing hormone, together with supportive psychotherapy, may be an effective treatment for men with severe paraphilia.

Molecular mechanisms of androgen action

Androgens directly regulate a vast number of physiological events. These direct androgen effects are mediated by a nuclear receptor that exhibits four major functions or activities: steroid binding, DNA binding, transactivation, and nuclear localization. The SBD consists of a hydrophobic pocket of amino acids that exhibits high-affinity, androgen-specific binding. Based on studies of mutant AR, it appears that a number of different amino acids contribute to the steroid binding characteristics of the AR. The DNA binding domain confers sequence-specific binding to structures called androgen-responsive elements. The specificity of steroid binding and DNA binding provides a crucial basis for androgen-specific regulation of target genes. The nuclear localization signal shares homology with known nuclear localization signals and, coupled with the presence of androgens, is responsible for localizing the AR to the nucleus. The transactivation functions reside mostly in the NH2 terminus but the responsible domains are as yet poorly defined. Though the different domains can act as independent moieties, one domain can clearly alter the behavior of another domain. For instance, the SBD appears to inhibit the transactivating functions until steroid is bound and the amino terminus prevents DNA binding activity until steroid is bound. The relative ease of introducing mutations with polymerase chain reaction technology will facilitate further delineation of critical amino acids and domains responsible for the various activities of the AR. The recent cloning and characterization of AR promoters revealed that the AR genes are driven by a TATA-less promoter characteristics of housekeeping genes. Analysis of transcription rates, mRNA levels, and protein levels indicates that androgens and pkA and pkC pathways modulate expression of AR mRNA and protein. This indicates that the same signal pathways that interact to regulate androgen target genes also regulate the levels of AR in the target tissues. Surprisingly few androgen-regulated genes have been well characterized for the mechanisms by which androgen regulates the gene. The C(3), Slp, probasin, PSA, and hKLK2 genes have provided examples where androgens regulate transcription. Posttranscriptional regulation by androgens has been demonstrated for the SVP1, 2, 3, and 4 and AR genes. The mechanisms underlying posttranscriptional regulation are poorly defined but substantial progress has been made in defining the critical elements that mediate transcriptional effects of androgens. Transcriptional effects are mediated through binding of androgen-AR complexes to specific DNA sequences called AREs. Simple AREs such as those found in C(3) and kallikrein genes tend to be permissive in that GR and PR can also act through the same element.(ABSTRACT TRUNCATED AT 400 WORDS)