The antiandrogen cyproterone acetate: discovery, chemistry, basic pharmacology, clinical use and tool in basic research

Synthesis and clinical application of small-molecule drugs approved to treat prostatic cancer

Prostate cancer is a prevalent form of cancer that primarily affects men, with a high incidence and mortality rate. It is the second most common cancer among males, following lung cancer. Typically occurring in individuals aged 50 and above, this malignant tumor originates from abnormal cells in the prostate tissue. If left untreated, it can spread to nearby tissues, lymph nodes, and even bones. Current treatment methods include surgery, radiotherapy, and chemotherapy. However, these treatments have certain limitations and side effects. Therefore, researching and developing new small-molecule drugs to treat prostate cancer is of great significance. In recent years, many small-molecule drugs have been proven to have therapeutic effects on prostate cancer. The purpose of this review is to give a comprehensive look at the clinical uses and synthetic methods of various significant small-molecule drugs that have been approved to treat prostate cancer, to facilitate the development of more powerful and innovative drugs for the effective control of prostate cancer.

Prodrug approaches for the development of a long-acting drug delivery systems

Long-acting formulations are designed to reduce dosing frequency and simplify dosing schedules by providing an extended duration of action. One approach to obtain long-acting formulations is to combine long-acting prodrugs (LA-prodrug) with existing or emerging drug delivery technologies (DDS). The design criteria for long-acting prodrugs are distinct from conventional prodrug strategies that alter absorption, distribution, metabolism, and excretion (ADME) parameters. Our review focuses on long-acting prodrug delivery systems (LA-prodrug DDS), which is a subcategory of long-acting formulations where prodrug design enables DDS formulation to achieve an extended duration of action that is greater than the parent drug. Here, we define LA-prodrugs as the conjugation of an active pharmaceutical ingredient (API) to a promoiety group via a cleavable covalent linker, where both the promoiety and linker are selected to enable formulation and administration from a drug delivery system (DDS) to achieve an extended duration of action. These LA-prodrug DDS results in an extended interval where the API is within a therapeutic range without necessarily altering ADME as is typical of conventional prodrugs. The conversion of the LA-prodrug to the API is dependent on linker cleavage, which can occur before or after release from the DDS. The requirement for linker cleavage provides an additional tool to prolong release from these LA-prodrug DDS. In addition, the physicochemical properties of drugs can be tuned by promoiety selection for a particular DDS. Conjugation with promoieties that are carriers or amenable to assembly into carriers can also provide access to formulations designed for extending duration of action. LA-prodrugs have been applied to a wide variety of drug delivery strategies and are categorized in this review by promoiety size and complexity. Small molecule promoieties (typically MW < 1000 Da) have been used to improve encapsulation or partitioning as well as broaden APIs for use with traditional long-acting formulations such as solid drug dispersions. Macromolecular promoieties (typically MW > 1000 Da) have been applied to hydrogels, nanoparticles, micelles, dendrimers, and polymerized prodrug monomers. The resulting LA-prodrug DDS enable extended duration of action for active pharmaceuticals across a wide range of applications, with target release timescales spanning days to years.

Discovery of thiohydantoin based antagonists of androgen receptor with efficient degradation for the treatment of prostate cancer

Prostate cancer (PC) is one of the most prevalent cancers in men worldwide, and androgen receptor (AR) is a well-validated drug target for the treatment of PC. However, PC often exhibits resistance to AR antagonists over time. Thus, it is urgent to identify novel and effective drugs for PC treatment. A series of novel thiohydantoin based AR antagonists with efficient degradation against AR were designed, synthesized, and evaluated. Based on our previous SAR and further structural optimization, a tool molecule 26h was discovered with dual mechanisms including improved antagonistic activity and potent degradation (AR-fl and AR-V7). Moreover, 26h can also effectively block AR nuclear translocation and inhibit AR/AR-V7 heterodimerization, thereby inhibiting downstream gene transcription. Importantly, 26h displayed potent robust efficacy in LNCaP (TGI: 70.70%) and 22Rv1 (TGI: 78.89%) xenograft models. This provides new design strategies and advantageous potential compounds for the treatment of prostate cancer.

Progesterone and contraceptive progestin actions on the brain: A systematic review of animal studies and comparison to human neuroimaging studies

In this review we systematically summarize the effects of progesterone and synthetic progestins on neurogenesis, synaptogenesis, myelination and six neurotransmitter systems. Several parallels between progesterone and older generation progestin actions emerged, suggesting actions via progesterone receptors. However, existing results suggest a general lack of knowledge regarding the effects of currently used progestins in hormonal contraception regarding these cellular and molecular brain parameters. Human neuroimaging studies were reviewed with a focus on randomized placebo-controlled trials and cross-sectional studies controlling for progestin type. The prefrontal cortex, amygdala, salience network and hippocampus were identified as regions of interest for future preclinical studies. This review proposes a series of experiments to elucidate the cellular and molecular actions of contraceptive progestins in these areas and link these actions to behavioral markers of emotional and cognitive functioning. Emotional effects of contraceptive progestins appear to be related to 1) alterations in the serotonergic system, 2) direct/indirect modulations of inhibitory GABA-ergic signalling via effects on the allopregnanolone content of the brain, which differ between androgenic and anti-androgenic progestins. Cognitive effects of combined oral contraceptives appear to depend on the ethinylestradiol dose.

Modeling hormonal contraception in female rats: A framework for studies in behavioral neurobiology

Research on hormonal contraceptives (HC) in animal models is lacking, and as a result, so is our understanding of the impact of HC on the brain and behavior. Here, we provide a review of the pharmacology of HC, as well as the methodology and best practices for designing a model of HC in female rats. We outline specific methodological considerations regarding dosing, route of administration, exposure time/timing, and selecting a control group. We also provide a framework outlining important levels of analysis for thinking about the impact of HC on behavioral and neurobiological outcomes. The purpose of this review is to equip researchers with foundational knowledge, and some basic elements of experimental design for future studies investigating the impact of HC on the brain and behavior of female rats.

The consequences of living longer-Effects of an experimentally extended velvet antler phase on the histomorphology of antler bone in fallow deer (Dama dama)

Antlers are periodically regenerated paired cranial appendages of male deer (both sexes in reindeer) that constitute the fastest-growing bones in the animal kingdom. The annual antler cycle of male deer is linked to testicular activity and largely controlled by seasonal fluctuations of testosterone concentrations in their blood. We studied the effects of an experimental doubling (to eight months) of the velvet antler phase, during which the antlers are covered by skin (velvet), on the histomorphology of antler bone in three adult fallow bucks. Extension of the velvet antler phase in the experimental animals had been caused by administration of the antiandrogen cyproterone acetate (CPA). The distal portions of the antlers from two of the CPA-treated bucks exhibited partial sequestration of the antler cortex, with the separation plane typically located along the border between cortex and spongiosa. It is hypothesized that this was caused by cortical necrosis due to severe ischemia during later stages of the extended velvet antler phase. In places, new cancellous bone had been deposited on the resorption surface of the spongiosa, indicating a regeneration process. Normal fallow deer antlers ("controls") from this and a previous study, that is, antlers with a timespan of about four months between onset of new antler growth and velvet shedding, exhibited no or only minor bone remodeling and still contained remnants of calcified cartilage in their distal portions. In contrast, the antlers of the three CPA-treated bucks showed evidence (secondary osteons and resorption cavities) of marked bone remodeling along their entire length and lacked remnants of calcified cartilage. Our results underscore that the typical histological features of antler bone reflect its short-lived nature. Antlers are not mechanically loaded during the velvet stage, and it is presently unclear what triggered remodeling activity in the antlers whose lifespan had been experimentally extended.

Exploration and Biological Evaluation of Basic Heteromonocyclic Propanamide Derivatives as SARDs for the Treatment of Enzalutamide-Resistant Prostate Cancer

A series of propanamide derivatives were designed, synthesized, and pharmacologically characterized as selective androgen receptor degraders (SARDs) and pan-antagonists that exert a broad-scope androgen receptor (AR) antagonism. Incorporating different basic heteromonocyclic B-ring structural elements in the common A-ring-linkage-B-ring nonsteroidal antiandrogen general pharmacophore contributed to a novel scaffold of small molecules with SARD and pan-antagonist activities even compared to our recently published AF-1 binding SARDs such as UT-69 (11), UT-155 (12), and UT-34 (13). Compound 26f exhibited inhibitory and degradation effects in vitro in a wide array of wtAR, point mutant, and truncation mutant-driven prostate cancers (PCs). Further, 26f inhibited tumor cell growth in a xenograft model composed of enzalutamide-resistant (EnzR) LNCaP cells. These results demonstrate an advancement toward the development of novel SARDs and pan-antagonists with efficacy against EnzR prostate cancers.

Influence of circulating testosterone concentration on sperm cryoresistance: The ibex as an experimental model

BACKGROUND

Recent studies have noted that the circulating testosterone concentration may affect the ability of spermatozoa to survive cryopreservation. However, few attempts to confirm such a relationship have been made. Wild ruminant species have very marked seasonal changes in their reproductive function and strong annual changes in their plasma testosterone concentration.

OBJECTIVES

The present work examines the influence of induced changes in testosterone secretion on sperm variables following conventional slow freezing and ultra-rapid freezing, using the Iberian ibex as an experimental model.

MATERIALS AND METHODS

In a first experiment, testosterone levels were reduced in the middle of the rutting season (December) using the antiandrogen cyproterone acetate (CA). In a second experiment, testosterone levels were increased at the end of the rutting season (January) via the use of the androgen testosterone propionate (TP).

RESULTS

During December, the testosterone concentration was found to be higher in the blood and seminal plasma of untreated males than in those of CA-treated males (p < 0.001 and p < 0.05, respectively). Compared with controls, the TP-treated animals had higher blood plasma testosterone concentrations but lower seminal plasma testosterone concentrations during January (p < 0.01 and p < 0.001, respectively). The seminal vesicles of the TP-treated males were larger than those of untreated males (p < 0.05). When CA was administered, sperm viability improved compared with controls (p < 0.05), irrespective of the freezing protocol followed. For the ultra-rapid freezing procedure, the cryoresistance ratio for motility decreased when TP was administered (p < 0.05). The values for fresh sperm morphometric variables decreased during the 50 days after the end of CA treatment (p < 0.001) and increased over the same time after the end of TP treatment (p < 0.001).

DISCUSSION AND CONCLUSION

The circulating testosterone concentration appears to influence sperm cryoresistance. This may explain the seasonal changes seen in sperm freezability in some species, independent of fresh sperm quality.

Medicinal Use of Testosterone and Related Steroids Revisited

Testosterone derivatives and related compounds (such as anabolic-androgenic steroids—AAS) are frequently misused by athletes (both professional and amateur) wishing to promote muscle development and strength or to cover AAS misuse. Even though these agents are vastly regarded as abusive material, they have important pharmacological activities that cannot be easily replaced by other drugs and have therapeutic potential in a range of conditions (e.g., wasting syndromes, severe burns, muscle and bone injuries, anemia, hereditary angioedema). Testosterone and related steroids have been in some countries treated as controlled substances, which may affect the availability of these agents for patients who need them for therapeutic reasons in a given country. Although these agents are currently regarded as rather older generation drugs and their use may lead to serious side-effects, they still have medicinal value as androgenic, anabolic, and even anti-androgenic agents. This review summarizes and revisits the medicinal use of compounds based on the structure and biological activity of testosterone, with examples of specific compounds. Additionally, some of the newer androgenic-anabolic compounds are discussed such as selective androgen receptor modulators, the efficacy/adverse-effect profiles of which have not been sufficiently established and which may pose a greater risk than conventional androgenic-anabolic agents.

Modeling the synergistic properties of drugs in hormonal treatment for prostate cancer

Prostate cancer is one of the most prevalent cancers in men, with increasing incidence worldwide. This public health concern has inspired considerable effort to study various aspects of prostate cancer treatment using dynamical models, especially in clinical settings. The standard of care for metastatic prostate cancer is hormonal therapy, which reduces the production of androgen that fuels the growth of prostate tumor cells prior to treatment resistance. Existing population models often use patients' prostate-specific antigen levels as a biomarker for model validation and for finding optimal treatment schedules; however, the synergistic effects of drugs used in hormonal therapy have not been well-examined. This paper describes the first mathematical model that explicitly incorporates the synergistic effects of two drugs used to inhibit androgen production in hormonal therapy. The drugs are cyproterone acetate, representing the drug family of anti-androgens that affect luteinizing hormones, and leuprolide acetate, representing the drug family of gonadotropin-releasing hormone analogs. By fitting the model to clinical data, we show that the proposed model can capture the dynamics of serum androgen levels during intermittent hormonal therapy better than previously published models. Our results highlight the importance of considering the synergistic effects of drugs in cancer treatment, thus suggesting that the dynamics of the drugs should be taken into account in optimal treatment studies, particularly for adaptive therapy. Otherwise, an unrealistic treatment schedule may be prescribed and render the treatment less effective. Furthermore, the drug dynamics allow our model to explain the delay in the relapse of androgen the moment a patient is taken off treatment, which supports that this delay is due to the residual effects of the drugs.

Meningiomas and cyproterone acetate: a retrospective, monocentric cohort of 388 patients treated by surgery or radiotherapy for intracranial meningioma

PURPOSE

Meningiomas are the most common intracranial tumors, accounting for 20-30% of central nervous system tumors. Recently, the European Medicines Agency issued an alert on cyproterone acetate (CPA) based on the results of a study that found an increased risk of meningioma 7 to 20 times higher when a patient is on CPA. The primary objective of this study was to determine the prevalence of CPA exposure in patients who had one or more intracranial meningiomas treated surgically or with radiation therapy. The secondary objectives were to establish a description of the patients who had intracranial meningioma in Nantes and to establish whether there was a difference in the intrinsic and tumoral characteristics of patients exposed to CPA compared with patients who had no hormonal exposure and patients who had been exposed to other hormones.

METHODS

Monocentric, retrospective study including all patients treated by surgery or radiotherapy for intracranial meningioma from 2014 to 2017 excluding those with a history of exposure to ionizing radiation or neurofibromatosis type 2.

RESULTS

388 patients were included, 277 were treated by surgery and 111 by radiotherapy. 3.9% of the patients had a history or current use of CPA, 16.2% were taking other hormonal treatment. Compared with the group without hormonal exposure, the CPA-exposed group had significantly an earlier onset of meningiomas at 48.9 vs. 61.9 years (p = 0.0005) and had more multiple meningiomas, 26.7% vs. 6.1% (p = 0.0115).

CONCLUSIONS

In our study, patients with a history or current use of CPA had significantly more meningiomas and were significantly younger at the onset.

Fate and behavior of progestogens in activated sludge treatment: Kinetics and transformation products

Previous studies have shown the high ecotoxicological potential of progestogens (PGs) on the reproductive system of aquatic organisms. Yet the ubiquitous presence of several PGs in wastewater treatment plant (WWTP) effluents indicates an incomplete removal during treatment. To investigate the fate and behavior of PGs during biological wastewater treatment, nine commonly used PGs were incubated in aerobic lab-scale degradation experiments with activated sludge taken from a municipal WWTP. The degradation kinetics revealed a fast removal after 48 h for most of the compounds. Cyproterone acetate and dienogest were the most recalcitrant of the analyzed steroids with half-lives of 8.65 h and 4.55 h, respectively. Thus, only moderate removals of these PGs can be predicted in full-scale WWTPs. Moreover, numerous transformation products (TPs) were detected via high-resolution mass spectrometry. Hydrogenation or dehydrogenation of ring A and non-selective hydroxylations of 17α-hydroxyprogesterone derivatives (medroxyprogesterone acetate, chlormadinone acetate, cyproterone acetate) as well as for 19-nortestosterone derivatives (dienogest, norethisterone acetate, etonogestrel) were observed as major transformation reactions. Seven of the identified TPs were confirmed by reference standards. The biodegradation of cyproterone acetate revealed an almost quantitative transformation to 3α‑hydroxy cyproterone acetate which is reported to be genotoxic. In a comparative evaluation of the TPs formed and the steroid structure, it was observed that molecular structure played a role in the inhibition of several transformation reactions, explaining the increased recalcitrance of these compounds. In addition, aromatization of the steroid ring A was identified for the 19-nortestosterone derivatives leading to the formation of estrogen-like TPs. For instance, the degradation of norethisterone acetate led to the formation of 17α-ethinylestradiol, a well-known and very potent synthetic estrogen. The evidence of the conversion of progestogenic to estrogenic compounds and the formation of potentially hazardous TPs indicates the need of a more comprehensive environmental risk assessment for synthetic steroids. Two of the newly identified TPs (3α-hydroxy cyproterone acetate and ∆9,11-dehydro-17α-cyanomethyl estradiol) were detected in WWTP effluents for the first time.

Electrochemical study and simultaneous voltammetric determination of contraceptives ethinylestradiol and cyproterone acetate using silver nanoparticles solid amalgam electrode and cationic surfactant

In this work we propose the voltammetric analysis of contraceptive hormones ethinylestradiol (EE) and cyproterone acetate (CPA) using solid amalgam electrode fabricated with silver nanoparticles. To the best of our knowledge, this is the first report describing the simultaneous determination of these two compounds and also the first report of the use of amalgam electrode for analysis of EE and CPA. The voltammetric behavior of both substances was investigated by their reduction. An irreversible electrochemical process involving two protons and two electrons was found for each compound. The analytical assays were carried out using staircase voltammetry (SCV). Due to this, aiming to improve the analytical sensitivity, the cationic surfactant cetyltrimethylammonium bromide was also used. The instrumental and experimental parameters were studied and optimized to achieve the best conditions for the analysis. Under the optimum conditions, the voltammetric signals of EE and CPA showed dependence on the concentration range from 6.4 × 10^-7 to 7.8 × 10^-6 mol L^-1 and from 1.0 × 10^-6 to 1.0 × 10^-5 mol L^-1, respectively. The limits of detection obtained were 1.03 × 10^-7 mol L^-1 for EE and 2.99 × 10^-7 mol L^-1 for CPA. The analytical usefulness of the method was evaluated through its application on the simultaneous determination of EE and CPA in pharmaceutical formulations and urine samples. The two analytes were successfully quantified in these samples with good precision and the values found presented satisfactory concordance with the reference values, suggesting acceptable analytical efficiency for the approach described here.

Disorders of Puberty: Pharmacotherapeutic Strategies for Management

During puberty, with activation of the hypothalamic pituitary axis that has been quiescent since the neonatal period, linear growth accelerates, secondary sexual characteristics develop, and adult fertility potential and bone mass are achieved, together with psychosocial and emotional maturation.Disordered pubertal onset and progress, either early or late, presents frequently for endocrine care. Where a disorder is found, due either to a central hypothalamic pituitary cause or to primary gonadal failure, pharmacotherapeutic interventions are required to alter the trajectory of disturbed pubertal onset or progress and for maintenance of adolescent and adult sex hormone status. This paper describes pharmacologic interventions used for pubertal disorders but is not intended to address the diagnostic cascade in detail.

Is There a Role for Antiandrogen Therapy for Hidradenitis Suppurativa? A Systematic Review of Published Data

BACKGROUND

Hidradenitis suppurativa/acne inversa is a disease with deep-seated chronic painful nodules, abscesses, and draining sinus tracts, which manifests on the apocrine gland-rich skin areas of the body. Observational findings demonstrate that the disease usually appears after puberty, exhibits pre-menstrual flares in women, improves in pregnancy, and worsens post-partum, which indicates a role of hormones and particularly of androgens in its pathophysiology. Because increased androgen levels in serum have not been widely reported, an end-organ androgen hypersensitivity has been postulated.

OBJECTIVE

The aim of this systematic review was to identify and present evidence for antiandrogen therapeutic options for the treatment of hidradenitis suppurativa/acne inversa.

METHODS

A literature search was conducted in different medical electronic databases using the keywords "hidradenitis", "suppurativa", "acne inversa", and "antiandrogen" on 1 December, 2018. The main therapeutic options were subsequently used as separate keywords with the disease terms in a separate search.

RESULTS

The main therapeutic options yielded were cyproterone acetate, spironolactone, finasteride, and metformin. One randomized controlled crossover trial and seven case series were identified following use of a standard extraction form for eligibility.

CONCLUSION

The existing studies do not allow a robust evidence-based recommendation for the use of antiandrogens in the treatment of hidradenitis suppurativa/acne inversa. Further randomized controlled trials are needed to define the role of hormonal treatment as an alternative or concomitant therapy together with antibiotics or biologics.

Androgen receptor modulators: a review of recent patents and reports (2012-2018)

INTRODUCTION

Androgen receptor (AR) is one of the most promising targets of drug discovery because of its importance in male reproductive systems and homeostasis of bone and muscle. Various AR-modulating agents have been developed and used clinically to treat androgen-dependent disorders, including prostate cancer, and some new-generation antiandrogens have recently been approved. Intensive studies are underway to develop various AR-modulating compounds, including conventional antagonists, tissue-specific AR modulators (SARMs), degraders, and nonconventional AR-modulating compounds that target sites other than the ligand-binding domain (LBD), such as the N-terminal domain (NTD) or the DNA-binding domain (DBD).

AREAS COVERED

The authors provide an overview of AR-modulating agents from 2012 to 2018.

EXPERT OPINION

The LBD has been the primary target for AR modulation, and important AR-modulating agents, including SARMs and recently approved antiandrogens such as enzalutamide and apalutamide, have been developed as conventional LBD antagonists. Development of LBD-targeting antiandrogens to treat prostate cancer is a kind of cat-and-mouse game between clinical agents and AR mutations, and therefore next-generation antiandrogens are still required. Development of nonconventional AR-modulating agents targeting NTD and DBD, is likely to be a promising approach to develop multiple and synergistic strategies able to overcome any kind of androgen-dependent condition.

Cardiovascular health in transgender people

This review examines the relationship between exogenous sex steroids and cardiovascular events and surrogate markers in trans (transgender) people. Data from trans populations is compared to data from postmenopausal women and hypogonadal men when appropriate. In an age-adjusted comparison with cisgender people, trans people appear to have an increased risk for myocardial infarction and death due to cardiovascular disease. It is uncertain whether hormone therapy in trans people affects their risk of stroke. In studies that followed trans people on hormone therapy, the rates of myocardial infarction and stroke were consistently higher in trans women than trans men. There is strong evidence that estrogen therapy for trans women increases their risk for venous thromboembolism over 5 fold. Extrapolating from studies of hormone therapy in postmenopausal women, transdermal estrogen likely carries a lower risk for venous thromboembolism than oral estrogen. Regarding red blood cells, testosterone therapy increases hemoglobin in trans men, and lowering testosterone in trans women has the opposite effect. Regarding blood pressure, the effects of hormone therapy on systolic blood pressure in trans women are inconsistent, with most studies showing an increase. In trans men, testosterone therapy consistently increases systolic blood pressure and may increase diastolic blood pressure. For lipids, hormone therapy may increase triglycerides in both trans women and men. In trans men, testosterone therapy also may increase LDL-cholesterol and decrease HDL-cholesterol.

Use of cyproterone acetate/ethinylestradiol in polycystic ovary syndrome: rationale and practical aspects

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a common, heterogeneous disorder characterised by hyperandrogenic skin symptoms, irregular menstruation and subfertility, increased risk of endometrial malignancy, and increased risk of preventable diseases associated with metabolic syndrome. Cyproterone acetate (CPA) 2 mg, combined with ethinylestradiol (EE) 35 μg, is indicated for the treatment of moderate to severe acne related to androgen-sensitivity (with or without seborrhea) and/or hirsutism, in women of reproductive age.

OBJECTIVES

To review the present knowledge about PCOS and summarize the role of CPA/EE in the care of patients suffering from this condition for the practitioner.

METHODS

Experts with clinical interest and experience in treating symptoms of androgen excess performed a non-systematic review to provide updated information regarding the use of CPA/EE in patients with PCOS.

RESULTS

Polycystic ovary-related hyperandrogenic skin symptoms are effectively treated by CPA/EE, reducing not only the symptoms but also their negative impact on quality of life and mental health. Proven additional benefits for these patients include the treatment of menstrual irregularities and reduction in endometrial cancer risk. Possible benefits include preservation of fertility. Treatment increases the risk for venous thromboembolic complications. The nature of other metabolic and cardiovascular long-term effects i.e., whether positive or negative, are still to be investigated.

CONCLUSIONS

Cyproterone acetate/ethinylestradiol provides effective treatment for PCO-related hyperandrogenic skin symptoms. This efficacy and additional benefits related to menstrual irregularities and endometrial cancer risk, have to be weighed against the risk of venous thromboembolic complications based on an individual benefit/risk evaluation.

The use of cyproterone acetate/ethinyl estradiol in hyperandrogenic skin symptoms - a review

INTRODUCTION

Hyperandrogenism affects approximately 10-20% of women of reproductive age. Hyperandrogenic skin symptoms such as hirsutism, acne, seborrhea and alopecia are associated with significant quality of life and psychological impairment. Women with abnormalities in androgen metabolism may have accompanying anovulation and/or polycystic ovary syndrome (PCOS), both of which have reproductive and metabolic implications if left untreated. Cyproterone acetate (CPA), combined with ethinylestradiol (EE), is indicated for the treatment of moderate to severe acne related to androgen-sensitivity (with or without seborrhea) and/or hirsutism, in women of reproductive age.

OBJECTIVE

To review the data on the efficacy and safety of CPA 2 mg/EE 35 μg for the treatment of hyperandrogenic skin symptoms in women.

METHODS

A non-systematic narrative review based on a literature search of the PubMed database.

RESULTS

Seventy-eight studies were identified. The majority of sufficiently powered studies show a high efficacy of CPA 2 mg/EE 35 μg in the treatment of severe acne and hirsutism. Studies show that therapeutic response in women with hirsutism requires a long-term approach and that hyperandrogenic skin symptoms in patients with PCOS are efficiently treated. Additional benefits include cycle control and, in some women, improvement in mood and perception of body image. Safety and tolerability data are summarized by the pharmacovigilance risk assessment committee (PRAC) of the European Medicine's Agency's (EMA).

CONCLUSIONS

This review provides a comprehensive overview about the efficacy of CPA 2 mg/EE 35 μg in the treatment of hyperandrogenic skin symptoms, thus allowing both health care professionals and women to balance the risks and benefits of treatment based on evidence.

Design, synthesis and biological profiling of aryl piperazine based scaffolds for the management of androgen sensitive prostatic disorders

Twenty-six piperazine derivatives were synthesized and findings revealed that compound9ais promising candidate for management of prostatic disorders.

Effects of the anti-androgen cyproterone acetate (CPA) on oocyte meiotic maturation in rainbow trout (Oncorhynchus mykiss)

In the present study, we aimed at characterizing the effect of cyproterone acetate (CPA), an anti-androgenic compound, on oocyte meiotic maturation in a freshwater teleost fish species, the rainbow trout (Oncorhynchus mykiss). Fully-grown post-vitellogenic ovarian follicles were incubated in vitro with CPA, luteinizing hormone (Lh) or a combination of CPA and Lh. Incubations were also performed using a combination of Lh and testosterone (T). The occurrence of oocyte maturation (i.e., resumption of the meiotic process) was assessed by monitoring germinal vesicle breakdown (GVBD) after a 72h in vitro incubation. The effect of CPA on the production of 17,20β-dihydroxy-4-pregnen-3-one (17,20βP), the natural maturation-inducing steroid (MIS), was quantified by radioimmunoassay. Our results show that CPA dramatically inhibits Lh-induced oocyte maturation and MIS synthesis. We also observed a synergistic effect of Lh and T on oocyte maturation in highly competent oocytes (i.e., able to resume meiosis after stimulation by low doses of Lh). Our results also show that a combination of CPA and Lh inhibits phosphorylation of extracellular signal-regulated kinase (Erk), kinases that are associated with oocyte maturation in many species. As a whole, our results indicate that CPA has a potential to alter meiotic maturation in rainbow trout. Further analyses are, however, needed to determine the mechanisms by which this anti-androgen interferes with the meiotic process. Furthermore, the present study provides a framework for better understanding of the ecological consequences of exposure to anti-androgens and resulting meiotic maturation abnormalities observed in trout.

Role of testosterone and photoperiod on seasonal changes in horn growth and sperm variables in the Iberian ibex: a model for polygynous wild bovids

This work examines the effect of testosterone secretion and photoperiod on seasonal changes in horn growth and sperm variables in the Iberian ibex (Capra pyrenaica), here used as a model for polygynous wild bovids. The hypothesis that high levels of testosterone provide an endocrine signal that inhibits horn growth in autumn was tested by assessing the effect of cyproterone acetate (CA), an anti-androgen, administered in October - coinciding with the period of natural increases in plasma testosterone concentrations - under different photoperiodic conditions (natural photoperiod and artificial long days). The persistence of horn growth during autumn in all ibexes held under the long-day photoperiodic conditions clearly shows that horn growth regulation in the mating season is primarily modulated by day length and not by a fall in testosterone concentration. A retrospectively designed second experiment involving testosterone propionate (TP) administration in April (when horns are growing) was then undertaken to confirm that high levels of testosterone do not inhibit horn growth. Overall, the results strongly suggest that the rise in testosterone secretion during the autumn mating season does not act as an endocrine signal for the arrest of horn growth, although the rate of horn growth before the mating season may be related to springtime testosterone levels. A direct relationship was seen between the rate of horn growth and the incidence of sperm abnormalities. Neither CA treatment in October nor TP administration in April affected the studied sperm variables. By contrast, CA treatment plus artificial long days in autumn had a negative effect on sperm motility and sperm morphology.

Recent developments in antiandrogens and selective androgen receptor modulators

The androgens testosterone and dihydrotestosterone play an essential role in the development and maintenance of primary and secondary male characteristics. Androgens bind to a specific androgen receptor (AR), a ligand-dependent transcription factor which controls the expression of a large number of downstream target genes. The AR is an essential player in early and late prostate cancer, and may also be involved in some forms of breast cancer. It also represents a drug target for the treatment of hypogonadism. Recent studies furthermore indicate that targeting the AR in pathologies such as frailty syndrome, cachexia or polycystic ovary syndrome may have clinical benefit. Numerous AR ligands with very different pharmacological properties have been identified in the last 40 years and helped to treat several of these diseases. However, progress still needs to be made in order to find compounds with an improved profile with regard to efficacy, differentiation and side-effects. This will only be achieved through a better understanding of the mechanisms involved in normal and aberrant AR signaling.

Pharmacology and clinical use of sex steroid hormone receptor modulators

Sex steroid receptors are ligand-triggered transcription factors. Oestrogen, progesterone and androgen receptors form, together with the glucocorticoid and mineralocorticoid receptors, a subgroup of the superfamily of nuclear receptors. They share a common mode of action, namely translating a hormone-i.e. a small-molecule signal-from outside to changes in gene expression and cell fate, and thereby represent "natural" pharmacological targets.For pharmacological therapy, these receptors have originally been addressed by hormones and synthetic hormone analogues in order to overcome pathologies related to deficiencies in the natural ligands. Another major use for female sex hormone receptor modulators is oral contraception, i.e. birth control.On the other side, blocking the activity of sex steroid receptors has become an established way to treat hormone-dependent malignancies, such as breast and prostate cancer.In this review, we will discuss how the experience gained from the classical pharmacology of these receptors and their molecular similarities led to new options for the treatment of gender-specific diseases and highlight recent progress in medicinal chemistry of sex hormone-modulating drugs.

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.

La contraception des adolescentes en France en 2007

The two main objectives of adolescence contraception are the eviction of involuntary pregnancies and the prevention of sexually transmitted infections. In France, in spite of our rich contraceptive arsenal and a widely spread information, the rate of voluntary termination of pregnancy keeps growing among the teenagers population--and this, probably because the gap between theoretical effectiveness and practice of contraception is particularly wide among the young people. Every contraceptive means can be used by teenagers; the best option being, it seems, the "double DUTCH", which consists of concomitant use of condoms and hormonal contraception. Most often, the consultation for contraception is the first gynaecological consultation. That is the reason why it is usually stressful for teenagers who dread undergoing a gynaecological examination. If this examination is not necessary for most of young patients, it is essential to create a trustful relationship and to make explicit the several contraceptive methods. During this consultation it is interesting to look for common teenage troubles like addiction to smoking and eating disorders. For any prescription of hormonal contraception, it is important to explain the benefits and the possible side effects, to stress the observance and to tell the teenager about the recommendations in case of forgetting. Concerning condom - the only efficient way of preventing sexually transmitted infections--, it is useful to talk about it in concrete and straightforward terms, to show its handling and to inform about risks of tearing. With this state of mind, an emergency contraception can be prescribed straightaway in order to make its use easier. Also, without any moralizing speech, the need for maturity must be emphasized as well as taking care of one's body with the aim of avoiding a premature pregnancy or any sexually transmitted infection. This consultation must be coupled with a close follow-up, availability and mutual confidence which are the main elements vouching for a good observance and consequently an efficient contraception.

Drugs, their targets and the nature and number of drug targets

What is a drug target? And how many such targets are there? Here, we consider the nature of drug targets, and by classifying known drug substances on the basis of the discussed principles we provide an estimation of the total number of current drug targets.

Sex steroids in the female zebrafish (Danio rerio). Effects of cyproterone acetate and leachate-contaminated sediment extract

In Molnbyggen, a leachate-contaminated lake in Sweden, effects on the reproductive system of perch included a decreased frequency of sexually mature female perch, reduced gonadosomatic index and decreased plasma levels of androstenedione and testosterone, but the contaminants responsible for these effects have not yet been identified. A biomarker-directed fractionation approach could be used to narrow the search for the compound(s) responsible for the adverse effects in Molnbyggen female perch. Thus, it is important to develop and test a suitable biomarker, which can be used in this type of approach. We evaluated if decreased concentrations of sex steroids could work as an in vivo end-point in female zebrafish fed an organic extract of bottom sediments from Molnbyggen. The responsiveness of zebrafish to endocrine alteration was evaluated using a positive control substance, cyproterone acetate (CA), which is known to inhibit steroid biosynthesis. After the 21-day exposure period the concentrations of testosterone (T) and estradiol (E2) were successfully determined by HRGC/HRMS in whole-body homogenates of individual fish. Median T concentrations were 1.7pmol/g fish in controls and were decreased after exposure both to CA (0.55pmol/g fish) and Molnbyggen sediment extract (1.2-1.3pmol/g fish). Median E2 concentrations were 5.3pmol/g fish in controls and were decreased after CA exposure (2.3pmol/g fish) and after exposure to Molnbyggen sediment extract (4.0-4.5pmol/g fish). This suggests that sex steroid concentrations in zebrafish are responsive to endocrine alteration and indicates that compounds with endocrine altering potency are present in Molnbyggen sediments.

Effect of benzothiazoline ligand and corresponding organoantimony(V) derivative on the reproductive system of male rats

Benzothiazoline HNC(6)H(4)SC(C6H5)CH:C(OH)COOCH(3) 1 prepared by the condensation reaction of aroyl pyruvate and 2-aminothiophenol has been treated with Ph(3)Sb(OPr(i))(2) to yield Ph(3)Sb[SC(6)H(4)NC(C6H5)CH:COCOOCH(3)] 2. These compounds have been characterized by elemental analyses and molecular weight determinations. The probable structures of the ligand as well as antimony complex have been tentatively proposed on the basis of IR and NMR ((1)H and (13)C) spectral evidences. Both compounds have been tested for their antifertility activity in male albino rats. The oral administration of compounds 1 and 2 at the dose level of 10 mg/rat/day significantly reduced the weights of testes, epididymides, ventral prostate, and seminal vesicles. The production of preleptotene spermatocytes was decreased by 36.57%; 57.23%, pachytene spermatocytes by 40.06%; 62.01%, and secondary spermatocytes by 52.45%; 63.22%, following the treatment of compounds 1 and 2, respectively. The marked reduction in sperm motility and density resulted in infertility by 100%. Significant (P < .01) alterations were found in biochemical parameters of reproductive organs in treated animals as compared to control group. It is concluded that all these effects may finally impair the fertility of male rats.

N-Arylpiperazine-1-carboxamide Derivatives: a Novel Series of Orally Active Nonsteroidal Androgen Receptor Antagonists

A novel series of N-arylpiperazine-1-carboxamide derivatives was synthesized and their androgen receptor (AR) antagonist activities and in vivo antiandrogenic properties were evaluated. Reporter assays indicated that trans-2,5-dimethylpiperazine derivatives are potent AR antagonists, and in this series trans-N-4-[4-cyano-3-(trifluoromethyl)phenyl]-N-(2,4-difluorophenyl)-2,5-dimethylpiperazine-1-carboxamide (18 g, YM-175735) exhibited the most potent antiandrogenic activity. Compared to bicalutamide, YM-175735 is an approximately 4-fold stronger AR antagonist and has slightly increased antiandrogenic activity, suggesting that YM-175735 may be useful in the treatment of prostate cancer.

Novel molecular aspects of prostate carcinogenesis

Prostate adenocarcinoma is one of the most frequently diagnosed forms of cancer in the male population of the Western world. The pivotal role of androgen and its receptor in this disease has been abundantly documented and indeed, chemical castration and treatment with antiandrogens are now standard therapies. However, relapse is often observed after 18-24 months, due to the remarkable ability of prostate tumour cells to adapt to low or undetectable androgen levels. Amplification and mutations of the androgen receptor (AR) gene have been described as well as alterations in cofactor expression and crosstalk with other signalling pathways. Another recent line of research focused on the re-programming of gene expression taking place in prostate tumours. Global expression profiling of normal and cancerous prostate tissues led to the identification of tumour-distinctive patterns. Validation studies are currently underway to identify novel drug targets as well as diagnostic and outcome prediction markers.

Different steroids co-regulate long-term expansion versus terminal differentiation in primary human erythroid progenitors

Outgrowth, long-term self-renewal, and terminal maturation of human erythroid progenitors derived from umbilical cord blood in serum-free medium can be modulated by steroid hormones. Homogeneous erythroid cultures, as characterized by flow cytometry and dependence on a specific mixture of physiologic proliferation factors, were obtained within 8 days from a starting population of mature and immature mononuclear cells. Due to previous results in mouse and chicken erythroblasts, the proliferation-promoting effect of glucocorticoids was not unexpected. Surprisingly, however, androgen had a positive effect on the sustained expansion of human female but not male erythroid progenitors. Under optimal conditions, sustained proliferation of erythroid progenitors resulted in a more than 10(9)-fold expansion within 60 days. Terminal erythroid maturation was significantly improved by adding human serum and thyroid hormone (3,5,3'-triiodothyronine [T3]) to the differentiation medium. This resulted in highly synchronous differentiation of the cells toward enucleated erythrocytes within 6 days, accompanied by massive size decrease and hemoglobin accumulation to levels comparable to those in peripheral blood erythrocytes. Thus, obviously, different ligand-activated nuclear hormone receptors massively influence the decision between self-renewal and terminal maturation in the human erythroid compartment.

Synthesis and Pharmacological Evaluation of Novel Arylpiperazine Derivatives as Nonsteroidal Androgen Receptor Antagonists

The search for novel antiandrogens by high-throughput screening (HTS) of the Yamanouchi chemical library led to the discovery of the lead compound (5), which possesses an arylmorpholine moiety. Through the optimization of the lead compound (5), we have found a series of novel arylpiperazine derivatives. Among them, 4-[4-cyano-(3-trifluoromethyl)phenyl]-N-(4-fluorophenyl)piperazine-1-carboxamide (22; YM-92088) exhibited a potent AR antagonistic activity with an IC(50) value of 0.47 microM in the reporter assay, which is more potent than bicalutamide (4) which has an IC(50) value of 0.89 microM.

Cyproterone Acetate with Ethinylestradiol as a Risk Factor for Venous Thromboembolism: An Epidemiological Evaluation

OBJECTIVE

To review the incidence of venous thromboembolism (VTE) in association with combined cyproterone acetate and ethinylestradiol (CPA/EE) use, compared to the incidence of VTE in association with conventional oral contraceptive (OC) use, in women aged 14 to 49 years.

METHODS

A review consistent with the guidelines of "best evidence synthesis" was conducted on 6 peer-reviewed, controlled epidemiological studies reporting both outcome numerators and exposure denominators. Relative risks as the estimate of the association between CPA/EE and the clinical outcome of VTE were set aside in favour of absolute incidence rates, rate differences, or attributable risks.

RESULTS

The range of absolute incidence rates of VTE among CPA/EE users varied from 1.2 to 9.9 per 10 000 women-years (WYs). All other marketed conventional OCs were the reference. In 6 studies conducted in 3 European countries, CPA/EE exhibited an attributable risk in women not higher than 0.04% when compared to approved conventional OCs. Except for 1 study exhibiting a small statistically significant benefit, there was no difference between the incidence rates of VTE among CPA/EE users and those among conventional OC users. VTE as an adverse event for CPA/EE was either rare or very rare, according to the criteria set by the World Health Organization/ Council for International Organizations of Medical Sciences. No deaths were reported in the studies reviewed.

CONCLUSIONS

The evidence in the worldwide literature does not demonstrate an excess of health-threatening harm for CPA/EE. A best-evidence synthesis, using sound epidemiological methods, showed clearly that the risks of VTE among CPA/EE users do not exceed the risks of VTE among conventional OC users.

Bioassay of steroid hormone agonist and antagonist activities of anti-androgens on mammary gland, seminal vesicles and spleen of male mice

Young intact and adult castrated outbred C3H/Di male mice were used to characterize steroid hormone agonist and antagonist activities of anti-androgens by bioassay. Animals were injected subcutaneously with flutamide (Flut), chlormadinone acetate (CMA), cyproterone acetate (CA) or Casodex (Cas) alone or simultaneously with oestradiol (E), E plus progesterone (Prog) or norethindrone acetate (NA; a steroid exhibiting progestational and oestrogenic activities) and testosterone (T) for 15 days. Mammary gland growth was not affected with anti-androgen alone. However, all anti-androgens decreased seminal vesicle weights in intact males. In E (0.01 microg day(-1))-treated intact males, mammary growth was stimulated by CMA (progestational activity) and inhibited by CA. The inhibitory effect of CA on mammary growth (glucocorticoid activity) was overcome with high dose of E (0.1 microg day(-1)). When seminal vesicles weights were decreased with a moderate dose of E (0.01 microg day(-1)) anti-androgens injected simultaneously acted synergistically with E and decreased seminal vesicles weights more than E alone. However, in animals overloaded with E (0.1 microg day(-1)), anti-androgen CA was unable to decrease seminal vesicles weights. E (0.01 or 0.05 microg day(-1)) or E + Prog (500 or 1000 microg day(-1)) or NA (12.5 to 50 microg day(-1)) stimulated mammary growth was inhibited by T at doses 20-200 microg day(-1) and these effects were decreased or abolished by simultaneous application of Flut, CMA or Cas in both young intact and adult castrated males. In the same animals, the seminal vesicles weights were increased by T and decreased by anti-androgens. The effects of higher doses of T (300 microg day(-1)) were not inhibited by anti-androgens both in the mammary gland and seminal vesicles. Spleen weights were not consistently affected with Flut, CMA or Cas, but decreased with CA by dose dependent manner. These results demonstrated that anti-androgenic activities could be detected not only on seminal vesicle but also on the mammary gland. Our model system also detected a glucocorticoid activity of CA and progestational activity of CMA.

Glucocorticoid receptor antagonism by cyproterone acetate and RU486

The steroid compound cyproterone acetate was identified in a high-throughput screen for glucocorticoid receptor (GR) binding compounds. Cyproterone (Schering AG) is clinically used as an antiandrogen for inoperable prostate cancer, virilizing syndromes in women, and the inhibition of sex drive in men. Despite its progestin properties, cyproterone shares a similar pharmacological profile with the antiprogestin mifepristone (RU486; Roussel Uclaf SA). The binding affinities of cyproterone and RU486 for the GR and progesterone receptor were similar (K(d), 15-70 nM). Both compounds were characterized as competitive antagonists of dexamethasone without intrinsic transactivating properties in rat hepatocytes (K(i), 10-30 nM). In osteosarcoma cells, RU486 revealed a higher potency than cyproterone acetate to prevent responses to dexamethasone-induced GR transactivation and NF kappa B transrepression. Upon administration to Sprague-Dawley rats, both compounds were found to be orally bioavailable and to inhibit transactivation of liver GR. Molecular docking of cyproterone acetate and RU486 into the homology model for the GR ligand binding domain illustrated overlapping steroid scaffolds in the binding pocket. However, in contrast to RU486, cyproterone lacks a bulky side chain at position C11 beta that has been proposed to trigger active antagonism of nuclear receptors by displacing the C-terminal helix of the ligand-binding domain, thereby affecting activation function 2. Cyproterone may therefore inhibit transactivation of the GR by a molecular mechanism recently described as passive antagonism. New therapeutic profiles may result from compounds designed to selectively stabilize the inactive and active conformations of certain nuclear receptors.

Effects of sex steroid hormones on regional fat depots as assessed by magnetic resonance imaging in transsexuals

We investigated prospectively the effect of sex steroids on regional fat depots and thigh muscle mass in adult transsexuals. Ethinyl estradiol in combination with cyproterone acetate, a progestational antiandrogen, was given to 20 male-to-female (M-F) transsexuals, and parenteral testosterone esters were given to 17 female-to-male (F-M) transsexuals. Before and after 12 mo of cross-sex hormone administration, several anthropometric measurements (weight, skinfolds, body circumferences, and bioimpedance) were performed, and transverse magnetic resonance images were obtained at the level of the abdomen, hip, and thigh to quantify fat depots (subcutaneous and visceral) and muscle areas. We observed that treatment with ethinyl estradiol in M-F transsexuals induced a significant increase in all subcutaneous fat depots, with a lesser but proportional and significant increase in the visceral fat depot and a decrease in thigh muscle area. Testosterone administration in F-M transsexuals markedly increased thigh muscle area, reduced subcutaneous fat deposition at all levels measured, but slightly increased the visceral fat area. We conclude that sex steroid hormones are important determinants of the sex-specific localization of body fat.

Effect of vitamin A deficiency on the expression of low affinity glucocorticoid binding site activity and glucocorticoid-dependent induction of CYP3A2 in rat liver

Maintenance of rats on a vitamin A-deficient diet resulting in undetectable levels of plasma retinol and significant reductions in relative testes weight compared to age-matched controls leads to the loss of liver membrane-bound low affinity glucocorticoid binding site (LAGS) activity without any effects on the levels of constitutively expressed CYP3A2 protein. Subsequent daily administration of retinol acetate to vitamin A-deficient rats results in the re-expression of LAGS activity to control levels by 7 days. To determine any role for the LAGS in the modulation of CYP3A2 expression by glucocorticoids, a single dose of dexamethasone 21-phosphate was administered to vitamin A-deficient rats and vitamin A-deficient rats induced to re-express LAGS by daily retinol acetate treatment. Retinol acetate administration alone induces CYP3A2 protein to apparent maximal levels since dexamethasone 21-phosphate does not further increase the induction response. However, CYP3A2 remains inducible to dexamethasone 21-phosphate in vitamin A-deficient rats. These data suggest that vitamin A status affects the expression of LAGS and CYP3A2 but that glucocorticoids regulate the induction of CYP3A2 by a mechanism(s) independent of their interaction with the LAGS.