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Paraphilias.comSexual Abuse: A Journal of Research and Treatment ( C 2006)DOI: 10.1007/s11194-006-9012-5 Prescription of Medroxyprogesterone Acetate
to a Patient with Pedophilia, Resulting in Cushing’s
Syndrome and Adrenal Insufficiency
Richard B. Krueger,Wylie Hembree,and Michael Hill
This article provides a case report of a patient with pedophilia who was treatedover a 4-year period with medroxyprogesterone acetate (MPA) at a dose of 300mg/day and as a consequence developed Cushing’s Syndrome and adrenal insuf-ficiency, for which he was treated and from which he recovered. He also reporteda hypersexual reaction to his own past cessation of MPA. Gonadotropin-releasinghormone agonists, which have a more benign side-effect profile than MPA, aresuggested as an alternative to MPA. KEY WORDS: medroxyprogesterone acetate; LRHR agonists; leuprolide acetate; antiandrogens;
sex offenders; paraphilia; Cushing’s syndrome; adrenal insufficiency; hypersexual behavior.
Medroxyprogesterone acetate (MPA) has been used for years to treat patients with paraphilias (Rosler & Witztum, and shares some of the pharmacologicalproperties of glucocorticoids (Dux et al., Use of MPA in doses comparableto those used to treat individuals with paraphilias has been reported as beingassociated with Cushing’s Syndrome and adrenal insufficiency in patients withcancer (Dux et al., Malik, Wakelin, Dean, Cove, & Wood, and adrenalsuppression has been reported in patients treated with MPA for premature puberty(Sadeghi-Nejad, Kaplan, & Grumbach, To our knowledge we offer the first 1Department of Psychiatry, Columbia University, College of Physicians and Surgeons, and Medical Director, Sexual Behavior Clinic, New York State Psychiatric Institute, Unit #45, 1051 RiversideDrive, New York, NY, 10032.
2Departments of Medicine and Obstetrics-Gynecology, Columbia University Medical Center, New 3New York State Office of Mental Health, Central New York Psychiatric Center, Marcy, NY, 13403.
4To whom correspondence should be addressed at Department of Psychiatry, Columbia University, Col- lege of Physicians and Surgeons, and Medical Director, Sexual Behavior Clinic, New York State Psy-chiatric Institute, Unit #45, 1051 Riverside Drive, New York, NY, 10032; e-mail: firstname.lastname@example.org.
1079-0632/06 C 2006 Springer Science+Business Media, Inc.
Krueger, Hembree, and Hill
case report of MPA-induced Cushing’s Syndrome and adrenal insufficiency in apatient treated with this agent for pedophilia.
Consultation to evaluate the appropriateness of antiandrogen treatment was requested at a state correctional facility on a 30-year-old male who had a longhistory of pedophilic behavior and, as an outpatient, had been treated with medrox-yprogesterone acetate (MPA) for three years. Treatment had curtailed his sexualurges, but development of mild gynecomastia and obesity led him to discontinuehis medication. Over the ensuing several weeks he developed progressive hyper-sexual behavior, described as more intense than he had previously experiencedand characterized by compulsive use of commercial telephone sex lines for 12or more hours per evening, with 5 or 6 ejaculations per 12-hour period, whichpersisted for many weeks. These calls were discovered, he was arrested for felonytheft, and, while in jail, his MPA was reinstituted at a dose of 300 mg/day andcontinued for the year prior to the consultation.
Physical examination was notable for obesity (body mass index 36 kg/m2), truncal fat distribution, a mild buffalo hump, marked gynecomastia, and abdominalstria. Laboratory assessment was notable for 3 fasting AM cortisols less than1.0 µg/dl (normal range = 4–25 µg/dl). After IV cosyntropin (0.25 mg) cortisolincreased only to 6.3 µg/dl at 60 min (normal is at least 7.0 µg/dl). Testosteronewas <20 ng/dl (normal: 286–1511 ng/dl). He was treated with hydrocortisone,after which both MPA and hydrocortisone were tapered. Baseline AM cortisollevels were 12.9 and 11.2 µg/dl at 1 and 6 months, respectively, after cessation ofmedication and testosterone level was 465 ng/dl two years later.
Three aspects of this case are noteworthy. First, clinicians should be aware of these possible side effects of MPA treatment. Second, effective alternativeantiandrogen treatment of paraphiliacs is available with gonadotropin-releasinghormone agonists. Although expensive, these agents offer considerable advantagesin terms of their side effect profile over progestational agents (Rosler & Witztum,Third, recent literature has focused on hypersexual behavior as a clinicalproblem (Stein et al., which is illustrated by the apparent hypersexualreaction to cessation of MPA reported by this patient.
Dux, S., Bishara, J., Marom, D., Blum, I., & Pitlik, S. (1998). Medroxyprogesterone acetate-induced secondary adrenal insufficiency. Annals of Pharmacotherapy, 32, 134.
Malik, K. J., Wakelin, K., Dean, S., Cove, D. H., & Wood, P. J. (1996). Cushing’s syndrome and hypothalamic-pituitary adrenal axis suppression induced by medroxyprogesterone acetate. Annalsof Clinical Biochemistry, 33, 187–189.
Rosler, A., & Witztum, E. (2000). Pharmacotherapy of paraphilias in the next millennium. Behavioral Sciences and the Law, 18, 43–56.
Sadeghi-Nejad, A., Kaplan, S. L., & Grumbach, M. M. (1971). The effect of medroxyprogesterone acetate on adrenocortical function in children with precocious puberty. Journal of Pediatrics, 78,616–624.
Stein, D. J., Black, D. W., Shapira, N. A., & Spitzer, R. L. (2001). Hypersexual disorder and preoccu- pation with Internet pornography. American Journal of Psychiatry, 158, 1590–1594.
(The first 15 minutes of the examination are for reading the paper only.)------------------------------------------------------------------------------------------------------------Answer all questions in Part I and five questions from Part II, choosing three questions from Section A and two questions from Section B. All workings, including rough work, should be done on the separate an