Low-dose flutamide (125 mg/day) as maintenance therapy in the treatment of hirsutism

Retrospective observational study on the effects and tolerability of flutamide in a large population of patients with various kinds of hirsutism over a 15-year period

OBJECTIVE

The aim of the study was to evaluate the long-term effects and tolerability of flutamide (Flu) in hirsute women. To the best of our knowledge, this study represents the largest report, concerning the population studied and the duration of treatment, to evaluate Flu use in hirsutism treatment.

DESIGN, PATIENTS AND METHODS

Over a 15-year period spanning from January 1991 to January 2006, a total of 414 premenopausal women with hirsutism of different aetiopathogeneses received yearly reducing doses (250, 125 and 62.5 mg/day) of Flu alone or in combination with oral contraceptives for a period varying from at least 3 to 8 years and more. Clinical and endocrine evaluations were assessed half-yearly and yearly respectively in the first 3 years of the study, and yearly in the following years. Liver function evaluations were assessed quarterly.

RESULTS

Both the groups of patients under Flu therapy showed a marked decrease in hirsutism scores after 12 months compared with basal values. The maximum drug effect was observed after 2 years, and it was maintained during the following years of treatment. Androgens were strongly suppressed during treatment. During the first year of treatment, 6.0% of patients abandoned the study due to hepatic disorders related to the drug. During the following years with the lowest treatment regimen, none of the patients abandoned the study due to hepatic discomfort.

CONCLUSIONS

Flu is a satisfactory therapeutic regimen for any form of hirsutism in the long run. Moreover, the use of very low doses of Flu is associated with minimal side-effects and high compliance.

Polycystic ovary syndrome in adolescents: current and future treatment options

Polycystic ovary syndrome (PCOS) is a very common disorder affecting 5-10% of women of reproductive age. The pivotal endocrine abnormalities of this syndrome are insulin resistance and ovarian and, to a lesser degree, adrenal hypersensitivity to hormonal stimulation. PCOS may manifest itself as early as the first decade of life by premature pubarche or menarche. Oligoamenorrhea in the first postpubarchal years, although very common, may be an early symptom of PCOS, especially in overweight girls with hirsutism or acne. Girls with low birth weight as well as a family history of diabetes mellitus or premature cardiovascular disease are at high risk for developing PCOS. Circulating bioavailable testosterone levels are usually elevated, while total testosterone may be normal due to low levels of sex hormone-binding globulin. The typical sonographic appearance of PCOS ovaries consists of high ovarian volume (>10 mL) and the presence of 12 or more follicles in each ovary measuring 2-9 mm in diameter. However, this finding is not specific, since it may occur in >20% of healthy girls. The therapeutic goals in adolescents with PCOS is first to restore bodyweight and menses and to reduce the signs of hyperandrogenism. The reduction of bodyweight in this young age group may require the collaboration of the pediatrician, dietitian, and psychotherapist. The adolescent should be urged to adopt a healthy lifestyle with the aim to maintain a normal body mass index throughout adolescence and adult life. The choice of medical therapy depends on the clinical presentation. Oral contraceptives are a good option when acne and hirsutism are the principal complaints. Adolescents with isolated cycle irregularity may be placed on a cyclical progestin regimen to induce withdrawal bleeding. Metformin, by decreasing insulin resistance, alleviates many of the hormonal disturbances and restores menses in a considerable proportion of patients. It may be used alone or in combination with oral contraceptives. Independently of medical treatment, restoration and maintenance of bodyweight within normal range is of paramount importance.

Guidance for the management of hirsutism

Approximately 80% of women are affected by the presence of excessive hair growth in a 'male-like' pattern. Excessive facial hair in particular can be a source of distress to such women and can lead to psychological problems such as anxiety, depression and a reduced quality of life.Current cosmetic methods of hair removal include shaving, depilatories, waxing, plucking, laser, intense pulsed light (IPL) and electrolysis.A topical treatment cream such as eflornithine 11.5% can slow hair growth and thus reduce the frequency of the need for hair removal. This treatment can be used effectively in conjunction with hair removal methods.

Absence of hepatotoxicity after long-term, low-dose flutamide in hyperandrogenic girls and young women

BACKGROUND

Flutamide is a pure non-steroidal anti-androgen that may be hepatotoxic, when given in high-dose (750 mg/d). Low- to ultralow-doses (250-62.5 mg/day) have been recently explored in patients with Polycystic Ovary Syndrome (PCOS), and these lower doses were found to confer benefit on multiple PCOS markers. There is a need for evidence on the potential hepatotoxicity of low- and ultralow-dose flutamide therapy.

METHODS

We assessed circulating levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) as markers of hepatotoxicity in a total of 190 hyperandrogenic girls and young women receiving low- or ultralow-dose flutamide because of established (n = 150) or incipient (n = 40) PCOS without obesity. Assessments were performed before start of flutamide, after 3 months, and subsequently at least twice yearly.

RESULTS

AST and ALT results were normal at baseline, and they remained so on flutamide treatment, including between 3 months and last assessment, which was after a mean time of 19 months on low- or ultralow-dose flutamide (range 3-54 months). None of the AST or ALT levels at any time during flutamide treatment was > or = 45 U/L.

CONCLUSION

We found no evidence for hepatotoxicity in 190 hyperandrogenic girls or young women receiving low- or ultralow-dose flutamide for up to 54 months. These results may represent a first step in a long process whereby the status of low- and ultralow-dose flutamide may gradually evolve from 'absence of evidence on toxicity' towards 'evidence of absence of hepatic toxicity'. Ultralow-dose flutamide may become a key component within future therapies for hyperandrogenic states in girls and young women.

Medical treatment regimens of hirsutism

Hirsutism, which is a common clinical problem in women of reproductive age, is characterized by excessive growth of terminal hair in the androgen-sensitive skin regions. It is the result of either androgen excess or increased sensitivity of the hair follicles to normal levels of androgens. The management, which includes cosmetic measures and medical treatment, is far from satisfactory. Anti-androgen drugs play a key role in the treatment of hirsutism, but they have some side-effects which may result in cessation of the drug. On the other hand, anti-androgen treatment often needs to be continued for a long time. So, safe, inexpensive, and effective anti-androgen drugs are needed. Recently low-dose anti-androgen drugs have been shown to be effective in the maintenance of treatment. On the other hand, cyproterone acetate plus ethyniloestradiol and spironolactone, cyproterone acetate plus ethyniloestradiol and finasteride, and spironolactone and finasteride combinations have been used successfully in decreasing the hirsutism score. There are also some promising data regarding the effects of insulin sensitizers in the treatment of hirsutism, particularly in patients with polycystic ovarian syndrome. In the present review, the main features of anti-androgen drugs, new combined treatments, and insulin sensitizers in the treatment of hirsutism are discussed.

Therapeutic androgen receptor ligands

In the past several years, the concept of tissue-selective nuclear receptor ligands has emerged. This concept has come to fruition with estrogens, with the successful marketing of drugs such as raloxifene. The discovery of raloxifene and other selective estrogen receptor modulators (SERMs) has raised the possibility of generating selective compounds for other pathways, including androgens (that is, selective androgen receptor modulators, or SARMs).