Androgens, Anti-androgens, and Anabolic Steroids

Question 1

What are the effects of androgens? (2)

Answer 1

1. Masculinization

2. Anabolism

Question 2

What are the indications of androgens?

Answer 2

1. Replacement therapy in castrated adults and in those who are hypogonadal due to either pituitary or testicular disease
2. Treatment of impotence and impaired spermatogenesis ONLY if these are due to hypogonadism

Question 3

Is androgen therapy useful in treating patients with impotence?

Answer 3

NO, unless the impotence is due to hypogonadism

They should not be given until hypogonadism has been properly investigated

Question 4

True or false: androgen therapy in males with hypogonadism leads to normal fertility

Answer 4

False; When given to patients with hypopituitarism they can lead to normal sexual development and potency but not to fertility. If fertility is desired, the usual treatment is with gonadotrophins or pulsatile gonadotrophin-releasing hormone which will stimulate spermatogenesis as well as androgen production.

Question 5

What is the preferred route of administration for testosterone replacement therapy?

Answer 5

Intramuscular injection

Question 6

What is cyproterone acetate?

Answer 6

An anti-androgen

Question 7

What are the indications of cyproterone acetate? (4)

Answer 7

1. Severe hypersexuality
2. Sexual deviation
3. Metastatic prostate cancer refractory to gonadorelin analogue therapy
4. Acne and hirsutism in women

Question 8

Does the use of cyproterone acetate work as a male contraceptive?

Answer 8

NO, although it does inhibit spermatogenesis and produces reversible infertility; abnormal sperm forms are produced

Fully informed consent is recommended and an initial spermatogram

Question 9

What is the main risks associated with cyproterone acetate therapy? (2)

Answer 9

1. Hepatic tumors in animal studies

2. Meningioma

Question 10

What are the two 5 alpha-reductase inhibitors listed on the BNF?

Answer 10

1. Finasteride

2. Dutasteride

Question 11

What is the mechanism of action of 5 alpha-reductase inhibitors?

Answer 11

5 alpha-reductase normally converts testosterone to DHEA. DHEA is responsible for external male sexual development including prostate growth and hair loss in males, thus inhibition of 5 alpha-reductase is useful in treating prostatic enlargement and male-pattern baldness (not as helpful as alpha blockers eg doxazosin in the acute setting due to delayed enzymatic effect)

Question 12

What are the side effects of 5 alpha-reductase therapy? (3)

Answer 12

1. Depression and suicidal thoughts
2. Sexual dysfunction
3. Breast abnormalities (cases of male breast cancer have been reported)

Question 13

What are the monitoring requirements for 5 alpha-reductase therapy?

Answer 13

Patients should be regularly evaluated for prostate cancer

Question 14

What information should be given to patients and carers taking 5 alpha-reductase inhibitors? (3)

Answer 14

1. Drug is excreted in semen and use of condom is recommended if sexual partner is pregnant or likely to become pregnant
2. Women of childbearing potential should avoid handling leaking or damaged capsules
3. Cases of male breast cancer have been reported; patients or their carers should be told to promptly report any changes in breast tissue such as lumps, pain, or nipple discharge

Question 15

5 alpha-reductase inhibitors should be prescribed with caution in which patients?

Answer 15

Patients with obstructive uropathy

Question 16

Can finasteride be prescribed in primary care for the treatment of androgenic alopecia in men?

Answer 16

Not in the NHS

Question 17

What are the medical indications of anabolic steroids? (2)

Answer 17

1. Some aplastic anemias
2. Osteoporosis in women (no longer advocated for this purpose)

• The protein-building properties of anabolic steroids have not proved beneficial in the clinical setting. Their use as body builders or tonics is unjustified; some athletes abuse them.

Question 18

What are the main contraindications of cyproterone acetate? (10)

Answer 18

1. Dubin-Johnson syndrome
2. Thromboembolic disease
3. Malignant disease (except carcinoma of the prostate)
4. Meningioma
5. Previous or existing liver tumors (not due to metastasis from carcinoma of the prostate)
6. Rotor syndrome
7. Wasting diseases (except for inoperable carcinoma of the prostate)
8. Severe depression
9. Severe diabetes with vascular changes
10. Sickle cell anemia

Question 19

What are the side effects of cyproterone acetate?

Answer 19

1. Depressed mood
2. Dyspnea
3. Fatigue
4. Gynecomastia (rarely, glactorrhea)
5. Hepatic disorders
6. Hot flush
7. Hyperhidrosis
8. Nipple pain
9. Restlessness
10. Weight changes

Question 20

What are the monitoring requirements for patients taking cyproterone acetate?

Answer 20

Monitor blood counts initially and throughout treatment

Monitor adrenocortical function regularly

Monitor hepatic function regularly

Question 21

What advice should be given to patients and carers taking cyproterone acetate?

Answer 21

Fatigue and lassitude may impair performance of skilled tasks like driving