Medroxyprogesterone acetate is the primary hormonal agent that has been used in the United States, since initially reported by Heller et al.(56> Its effect results from the acceleration of testosterone-A-reductase in the liver which accelerates testosterone metabolism and thereby reduces testosterone levels. Medroxyprogesterone acetate also reduces plasma testosterone through the pituitary axis. It is not an antiandrogen. Significant side-effects have included liver damage, fatigue, weight gain, hot and cold flushes, headaches, gallbladder disease, diabetes, and thrombophlebitis. Historically, the dose was 300 to 400 mg of the injectable form of medroxyprogesterone acetate, but in recent years lower doses have been found to be equally effective without causing so many side-effects that the medication is discontinued by the paraphiliac. An alternative to injectable medroxyprogesterone acetate can be administered orally. Generally doses of less than 200 mg daily by mouth are effective at helping the paraphiliac gain control over his behaviour.
More recently studies have been reported using luteinizing hormone-releasing hormone (LHRH) agonists, which initially accelerate the production of testosterone through the hypothalamic-pituitary axis but then exhaust the axis and result in a dramatic reduction in testosterone to castrated levels. Since these drugs initially cause an acceleration of testosterone production, the non-steroidal antiandrogen flutamide is usually concomitantly administered at a dose of 250 mg three times daily for the first month of LHRH agonist use. After that, flutamide can be discontinued. The LHRH agonists have the advantage of not being true steroids, but polypeptides, and therefore do not cause many of the steroidal effects while still resulting in a dramatic reduction of testosterone and increased control over paraphilic urges.
Since it was reported that SSRIs were effective in managing the treatment of exhibitionism, a number of authors have report their effectiveness in the treatment not only of other paraphiliacs, but also of those with hypersexuality. (5Z,58> The exact mechanism of action of the SSRIs is not completely understood, but it is suspected that their effectiveness results from a reduction of sexual drive and of the obsessive ruminations that accompany paraphiliacs' behaviour. The most extensively investigated SSRI has been sertraline, with the mean dose being 130 mg daily. Fluvoxamine, fluoxetine, and paroxetine have all been found to be effective in treating both the paraphilias and males with non-paraphilic hypersexuality.
The main limitation of ciproterone acetate, medroxyprogesterone acetate, the LHRH agonists, and SSRIs is that they are only effective during clinical administration; to date, there is insufficient evidence to suggest persistent effectiveness following discontinuation of the medication. The SSRIs show great promise because of their greater ease of administration, lower cost, and lower side-effect profiles. These medications are traditionally prescribed as an adjunct to cognitive-behavioural treatment.
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