What is the recommended dose of medroxyprogesterone (Medroxyprogesterone) given intramuscularly (IM) for an elderly patient with sexually aggressive behavior?

Management of Sexually Aggressive Behavior in Elderly Patients with Medroxyprogesterone Acetate

For elderly patients with sexually aggressive behavior, medroxyprogesterone acetate should be administered at a dose of 150 mg intramuscularly every 3 months (13 weeks) as a treatment option when first-line approaches have failed. 1

Treatment Algorithm for Sexually Aggressive Behavior in the Elderly

First-Line Approaches (Try These First)

1. Non-pharmacological interventions:

   • Behavioral modifications
   • Environmental adjustments
   • Addressing underlying causes (pain, discomfort, boredom)

2. First-line medications:

   • SSRIs (e.g., sertraline, fluoxetine)
   • If ineffective, try TCAs (e.g., imipramine)

Second-Line Treatment: Medroxyprogesterone Acetate

When first-line treatments fail and sexual aggression poses significant risk:

• Dosage: 150 mg IM every 3 months (13 weeks) 1
• Administration: Deep intramuscular injection in gluteal or deltoid muscle using strict aseptic technique 1
• Important considerations:
  • Rotate injection sites with each administration
  • Assess body habitus prior to injection to determine if a longer needle is necessary
  • Shake the vial vigorously before use to ensure uniform suspension

Evidence Base and Considerations

The use of medroxyprogesterone acetate for sexually aggressive behavior in elderly patients is supported by case reports and clinical experience, though high-quality randomized controlled trials are limited. Romanian and Serbian guidelines recommend medroxyprogesterone for treating sexual disinhibition in men 2.

Research evidence indicates that medroxyprogesterone acetate can effectively reduce inappropriate sexual behaviors, with positive responses typically occurring within 3 weeks of treatment initiation 3. A case series demonstrated successful control of inappropriate sexual behaviors in men with dementia using medroxyprogesterone acetate 4.

Monitoring and Precautions

• Contraindications: 1

  • Active thrombophlebitis or thromboembolic disorders
  • Cerebrovascular disease
  • Known or suspected breast malignancy
  • Significant liver disease
  • Undiagnosed vaginal bleeding
  • Hypersensitivity to medroxyprogesterone

• Side effects to monitor:

  • Bone mineral density loss (particularly concerning in elderly)
  • Weight changes
  • Mood alterations

Alternative Approaches

If medroxyprogesterone is contraindicated or ineffective, consider:

1. Other hormonal treatments:

   • Estrogens (oral or transdermal patch) 5, 6
   • LHRH agonists (leuprolide, triptorelin) 5

2. Combination therapy:

   • If monotherapy fails, combining medications from different classes may be reasonable 5

Important Clinical Pearls

1. Document thoroughly before initiating treatment, including specific behaviors, frequency, and impact on patient and others.

2. Obtain informed consent from the patient (if capable) or surrogate decision-maker, explaining risks and benefits.

3. Start with the lowest effective dose and monitor closely for side effects.

4. Reassess regularly to determine continued need for treatment.

5. Consider bone health: Medroxyprogesterone reduces serum estrogen levels and is associated with significant bone mineral density loss, which is particularly concerning in elderly patients 1.

The treatment of sexually aggressive behavior in elderly patients requires balancing the risks of medication against the potential harm from the behaviors themselves. While medroxyprogesterone acetate has demonstrated efficacy, its use should be considered after non-pharmacological approaches and first-line medications have proven ineffective.