From the Guidelines
Antiandrogens for compulsive sexual behavior should be prescribed only under close medical supervision, typically starting with oral medroxyprogesterone acetate (MPA) at 50-100mg daily or cyproterone acetate (CCA) at 50-100mg daily where available, as supported by the most recent evidence 1.
Key Considerations
- For more severe cases, depot MPA injections of 300-400mg intramuscularly every 1-3 months may be used.
- Treatment duration typically ranges from 6-24 months, with regular monitoring of liver function, testosterone levels, and bone density.
- These medications work by reducing testosterone levels or blocking testosterone receptors, thereby decreasing sexual drive and compulsive behaviors.
- Side effects can include weight gain, fatigue, depression, and potential liver toxicity.
Treatment Approach
- Before starting antiandrogens, patients should undergo comprehensive psychiatric evaluation.
- Antiandrogens should be used as part of a broader treatment approach including psychotherapy, cognitive-behavioral interventions, and possibly SSRIs.
- Treatment should be individualized based on symptom severity, comorbidities, and response, with the lowest effective dose used to minimize side effects while achieving behavioral control, as suggested by recent studies 1.
Monitoring and Follow-up
- Regular monitoring of liver function, testosterone levels, and bone density is crucial during treatment.
- Patients should be followed clinically and started on treatment once symptoms of compulsive sexual behavior present.
- The decision to stop or continue treatment must be weighed on individual risks, family history, personal feelings, and relevance of symptoms, as recommended by recent guidelines 1.
From the Research
Dosing Antiandrogens for Compulsive Sexual Behavior
- The dosing of antiandrogens for compulsive sexual behavior is a complex issue, and there is no one-size-fits-all approach 2, 3, 4.
- Antiandrogens such as cyproterone acetate and medroxyprogesterone acetate are effective in reducing testosterone secretion and/or antagonizing the action of testosterone at the level of the receptor, but they are only effective in relatively high doses and have a substantial number of severe side effects 2.
- Long-acting gonadotropin-releasing hormone (GnRH) agonist analogues are the most potent antiandrogens and selectively abolish testosterone secretion in a totally reversible fashion, with the fewest side effects 2.
- GnRH analogue treatment constitutes the most promising treatment for sex offenders at high risk of sexual violence, such as pedophiles or serial rapists 5.
- The treatment recommendations for paraphilias include cognitive-behavioral psychotherapy, serotoninergic monotherapies (selective serotonin reuptake inhibitors [SSRIs] or tricyclic antidepressants), and antiandrogenic therapies (progestogens, GnRH agonists, or estrogens) 4.
- The choice of treatment depends on the specific paraphilia, the risk of reoffending, and the presence of comorbid psychiatric disorders 4, 5.
- In general, a combination of psychotherapy and pharmacotherapy is recommended, with the goal of reducing paraphilic behavior and preventing sexual violence 4, 5.
Specific Antiandrogens and Their Dosage
- Cyproterone acetate: oral administration, dosage not specified 2, 4.
- Medroxyprogesterone acetate: intramuscular (IM) administration, dosage not specified 2, 4.
- GnRH agonists (e.g., leuprolide, triptorelin): parenteral administration, dosage not specified 2, 4, 5.
- Estrogens: oral or parenteral administration, dosage not specified, used as second- or third-line agents 4.
Important Considerations
- Informed consent is necessary in all cases of antiandrogen treatment 5.
- Treatment should be part of a comprehensive plan including psychotherapy and behavior therapy 5.
- The development of more specific, effective, and better-tolerated medications for paraphilic and nonparaphilic sexual disorders is needed 4.