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Effect of gestational sex steroid exposure on limb development and endochondral ossification in the pregnant C57Bl/6J mouse: I. Medroxyprogesterone acetate.

Although data supporting the teratogenic potential of intrauterine progestin exposure is lacking, concern persists among some individuals within the scientific community that these drugs have the potential for nongenital teratogenesis, especially with regard to limb reduction defects. Our laboratory has been interested in the ontogeny of steroid receptors in the developing embryo and in the role of steroid-receptor interactions in limb development, particularly the process of endochondral ossification. Since limb reduction defects can be produced from abnormal processes that are operative during organogenesis or during midgestation (vascular disruption) we have designed an animal study whereby embryos were exposed to sex steroids throughout organogenesis and fetal development. The present study assesses the effects of medroxyprogesterone acetate (MPA) on intrauterine endochrondral bone development specifically, as well as overall embryo-fetal development. Primagravid C57Bl/6J mice were treated via subdermal pellets which deliver MPA at dosages of 5.0, 50.0, and 500.0 mg/kg/day on gestational days 7 through 19. These doses were 25-, 250-, and 2,500-fold higher on a mg/kg basis than the human dose equivalent (HDE). No increases in nongenital malformations were noted at any evaluated MPA dosage level. At 25 X the HDE, MPA did not influence endochondral bone development as evidenced by a lack of significant effects on assessed bone growth parameters. In the 250- and 2,500-fold HDE dosage groups, MPA was shown to exert an embryotoxic effect inducing 48 and 100% resorptions respectively. Mean embryo weights/litter were significantly reduced by MPA exposure at 250 X the HDE. Intrauterine exposure to 250 X the MPA HDE induced reductions in humeral and femoral diaphyseal length in proportion to a reduction in overall growth. The data demonstrate that MPA, administered at dosages of up to several orders of magnitude in excess of the HDE and which permitted embryo survival, did not induce increases in the frequency of nongenital teratogenesis at any dose or gestational stage. Importantly, limb reduction defects were not noted even in instances where the dosage of MPA induced an inhibition of endochondral bone growth.

Animals↗

In vitro functions of lymphocytes during high-dose medroxyprogesterone acetate (MPA) treatment.

The number and function of T and B lymphocytes were studied in endometrial cancer patients during 3 months' treatment with high-dose medroxyprogesterone acetate (MPA). No significant changes were observed in the proportions of T and B cells or in the function of B cells during MPA treatment. At 3 months, lymphocyte blastogenic responsiveness to mitogens was slightly reduced both in patients treated with standard therapy alone (intracavitary radium and surgery) and in patients receiving additional MPA therapy. These results indicate that other factors than progesterone are responsible for the suppression of lymphocyte blastogenesis induced by mitogens during high-dose progestin treatment.

Antibody Formation↗

Pharmacokinetic approach to the selection of dose schedules for medroxyprogesterone acetate in clinical oncology.

The pharmacokinetic and bioavailability properties of medroxyprogesterone acetate (MPA) after single PO and IM doses in man were used as a basis to predict, on a theoretical pharmacokinetic basis, the blood level profile of the drug during repeated dose administration with various dosage schedules. Because of the unusually long-lasting depot effect of IM MPA, a different build-up process of blood levels is expected during repeated IM or PO administration, and this should be taken into account when dose schedules for use in clinical oncology are selected. As regards the IM route, dose schedules based on 4 weeks' treatment with daily injections of 500-1,000 mg followed by a maintenance therapy with 1,000 mg/week are suggested, since they permit rapid achievement and maintenance of relatively high plasma levels. A similar plasma level profile can be obtained with oral MPA provided that daily doses twice as large as the IM doses are given during the first month of treatment and continued during the maintenance period. The serum levels observed in 25 patients with advanced breast cancer treated with MPA given IM or PO according to various dose schedules and recent literature data are very close to the serum level profiles predicted on a theoretical pharmacokinetic basis.

Biological Availability↗

Medroxyprogesterone acetate (MAP) and tamoxifen (TMX) plasma levels after simultaneous treatment with 'low' TMX and 'high' MAP doses.

Plasma levels of medroxyprogesterone acetate (MAP), tamoxifen (TMX) and its major metabolites, 4-hydroxy TMX and desmethyl TMX, were determined in five patients with advanced breast cancer following simultaneous MAP (2,000 mg/day) and TMX (20 mg/day) oral therapy. The interindividual variance in MAP plasma levels was wide; the mean plasma levels of both drugs were nearly identical, despite the large difference in the administered doses.

Antineoplastic Combined Chemotherapy Protocols↗

Medroxyprogesterone acetate bioavailability after high-dose intraperitoneal administration in advanced cancer.

Administration of medroxyprogesterone acetate IP in advanced cancer with peritoneal metastases and ascitic effusion generates considerably higher drug plasma levels than those observed after PO or IM treatment. Comparison of areas under the time-concentration curves (AUC) with reference to the three administration routes indicates that after oral administration only 0.2%-17.4% (mean 5.7%; SD 3.77; 40 patients) of the administered dose is absorbed; after IM treatment a daily absorption of 0.7%-7.7% (mean 2.5%; SD 1.66; 30 patients) of the administered dose per injection site was computed.

Antineoplastic Agents↗

Medroxyprogesterone acetate plasma pharmacokinetics after intravenous administration in rabbits.

Medroxyprogesterone acetate (MAP) plasma pharmacokinetics was followed up in a total of 30 New Zealand rabbits after i.v. administration (0.1, 0.5, and 1.0 mg/kg) of either an aqueous suspension or a homogeneous solution of the drug in dimethylsulphoxide (DMSO). A well-defined triphasic decay of MAP plasma levels was noticeable in the animals treated with DMSO solutions. A delayed concentration peak was often present when aqueous suspensions were used, so if is not feasible to fit the experiment with simple polyexponential equations. Model-independent pharmacokinetic analysis (statistical moment theory) revealed a significant dependence of plasma clearance and mean residence time on the dose administered in both conditions.

Animals↗

Medroxyprogesterone acetate (MAP) plasma levels after simultaneous oral and intramuscular administration in cancer patients.

After simultaneous administration of medroxyprogesterone acetate (MAP) 1,000 mg PO and 1,000 mg IM to ten cancer patients, we observed mean plasma MAP profiles that could be exactly superimposed on the two absorption/decay curves obtained after administration of single doses IM or PO. Treatment with MAP given simultaneously by the IM and PO routes may be effective in overcoming the drawbacks of both routes, and can also more reliably guarantee plasma levels in the therapeutic range.

Administration, Oral↗

Treatment of advanced renal cell cancer with recombinant interferon alpha as a single agent and in combination with medroxyprogesterone acetate. A randomized multicenter trial.

The response rates in metastatic renal cell cancer (RCC) after chemotherapy, hormonal treatment, or immunotherapy rarely exceed 15%. Recently, interferon alpha (IFN alpha) was used for treatment of this disease in several studies which also demonstrated response rates of 15%. In order to test whether IFN therapy combined with hormones would result in higher response rates we compared single agent IFN therapy with a combined therapy of rIFN alpha 2C plus medroxyprogesterone acetate (MPA) in a randomized multicenter trial. The rIFN alpha 2C (2MU) was given s.c. 5 times per week for 8-12 weeks and subsequently once weekly until week 48. In the combined treatment, 750 mg MPA was given p.o. daily until week 48 in addition to the IFN as described. The overall response rate in 93 evaluable patients was 5.4% corresponding to 2 complete and 3 partial responses. Median survival was 7 months in both treatment groups. These data confirm the ineffectivity of low IFN doses for treatment of RCC. The low response rate is not increased by addition of MPA to IFN. The analysis of other IFN studies suggests that not only IFN doses but also IFN sources may influence response rates in metastatic RCC.

Antineoplastic Combined Chemotherapy Protocols↗

Medroxyprogesterone acetate: steady-state pharmacokinetics bioequivalence of two oral formulations.

Two micronized oral formulations of medroxyprogesterone acetate (MPA) (Farlutal and Clinovir) were compared in order to evaluate their relative bioavailability. Sixteen female patients with metastatic breast cancer were entered in a randomized cross-over study on 500-mg MPA tablets repeatedly administered (twice daily for 20 days). At the steady state, similar mean +/- SD serum levels of MPA were obtained (131 +/- 44 ng/ml for Farlutal and 136 +/- 45 ng/ml for Clinovir) and the two formulations proved to be bioequivalent (confidence interval at a significance level of 0.95 = 93%-107%).

Administration, Oral↗

Plasma concentrations of medroxyprogesterone acetate and megesterol acetate during long-term follow-up in patients treated for metastatic breast cancer.

A total of 32 patients with metastatic breast cancer responding with at least disease stabilization to treatment with two commercially available preparations of medroxyprogesterone acetate (MPA) or one preparation of megestrol acetate (MA) were followed for their plasma concentrations. The MPA and MA were measured by HPLC. MPA from Upjohn and Farmitalia was given to 12 patients (median age, 61 years; median follow-up, 20 weeks) and 8 patients (54 years, 16 weeks), respectively, on a schedule of 1000 mg daily i.m. for 10 days followed by 200 mg t.i.d.p.o. for the remainder of the treatment course. The peak concentrations (means, 163 vs 97 ng/ml), the time to peak levels (medians, 3 vs 10 weeks), and the areas under the concentration curves from time 0 to 24 weeks (means, 2400 vs 1868 ng/ml X weeks) were significantly different in the respective treatment groups (t-test; significance level, 0.05). MA from Bristol-Myers was administered orally in one daily dose of 160 mg throughout the treatment course in 12 patients (median age, 51 years; median follow-up, 20 weeks). A mean MA peak concentration of 218 ng/ml was reached after a median of 7 days. Plateau plasma levels were higher for MA than MPA.

Aged↗

Lack of correlations between plasma concentration of medroxyprogesterone acetate, hypothalamic-pituitary function, and tumour response in patients with advanced breast cancer.

Plasma medroxyprogesterone acetate (MPA) concentrations were measured in 61 patients with advanced breast cancer, after 3 weeks' treatment using 200 mg PO 8-hourly, to determine whether the previously reported wide interpatient variations correlated with tumour response or toxicity. Seventeen patients (28%) responded to the drug, and their mean plasma MPA concentration was 97 ng/ml +/- 68 SD, compared with 115 ng/ml +/- 87 SD for the patients whose disease progressed. Side-effects attributed to MPA were seen in 18 patients, who had a mean drug concentration of 113 ng/ml +/- 104 SD. This was not significantly higher than that of the patients who did not experience drug toxicity. Because of a suggestion that some of the antitumour activity of the drug could be mediated via an effect on the hypothalamic-pituitary axis, we also measured plasma FSH, LH, and prolactin concentrations after the 3-week treatment with MPA, but found no correlations with either drug concentration or tumour response. These results indicate that with the present treatment schedule the monitoring of plasma MPA concentrations has no role in routine practice and suggest that the inherent sensitivity of the tumour to progesterone is probably the major determinant of response.

Adult↗

Potentiation of medroxyprogesterone acetate antineoplastic activity by histidine in rat mammary tumours.

The antitumour activity of arginine, histidine and medroxyprogesterone acetate (MPA) was studied in female rats with dimethylbenzanthracene (DMBA)-induced mammary adenocarcinomas. After 15 days of treatment, regression was observed in 4 of 19 (21%), 3 of 18 (16.7%) and 22 of 59 (37.3%) tumours taken from rats given arginine, histidine or MPA, respectively. A total of 17 rats with tumours that had been non-responsive to MPA were then treated with MPA plus histidine for 15 more days; the growth of 3 lesions (17.6%) was arrested, and 5 tumours (29.4%) regressed markedly. The antineoplastic activity of MPA was found to be related to the oestrogen-(ER) and progesterone-receptor (PgR) concentrations measured in the tumours before the start of treatment, whereas that of arginine and histidine appeared to be independent of receptor status. A significant reduction in serum prolactin (PRL) levels occurred in rats that were responsive to MPA alone or to MPA plus histidine. In tumours taken from the same rats, the PRL receptor content was also significantly increased in comparison with that in non-responsive tumours. In contrast, serum PRL levels increased significantly in rats with tumours that were non-responsive to MPA, whereas no change in serum PRL or PRL receptor levels was observed in rats treated with arginine or histidine. Histidine showed the ability to increase the number of ERs and PgRs in responsive tumours; this could have been responsible for the unexpected potentiation of MPA antineoplastic activity. In contrast, the levels of ER and PgR in uteri taken from the same rats were not modified. Furthermore, the addition in vitro of histidine to cytosols obtained from tumours of control animals did not influence ER and PgR concentrations. These results suggest that the effect of histidine on ER and PgR levels is probably specific for tumour tissue and is not due to a direct activity.

Animals↗

Medroxyprogesterone acetate, nocturnal penile tumescence, laboratory arousal, and sexual acting out in a male with schizophrenia.

This study reports the effects of the antilibidinal drug, medroxyprogesterone acetate (MPA) on nocturnal penile tumescence (NPT) during sleep, tumescence responses to provocative audiotapes during wakefulness in the laboratory, and sexual behaviors in the hospital environment, in a conduct-disordered sexually aggressive male, who had not responded to previous treatment. NPT, laboratory tumescence, and sexual behaviors in the hospital environment were all decreased. Testosterone levels declined by 73% within 2 weeks of starting the drug and prolactin levels increased by 300% across the treatment period. The effects on NPT and laboratory arousal were still partially in evidence 2 months after the drug had been stopped, although testosterone levels had returned to predrug levels. Some differences between the NPT and daytime test data are discussed in terms of the probable importance of testosterone to erotic fantasy. NPT may be a useful addition to present methods for examining the effects of drugs used to suppress socially unacceptable sexual behaviors.

Adult↗

Medroxyprogesterone acetate enhances spontaneous mammary tumorigenesis and uterine adenomyosis in mice.

Based on our previous findings that medroxyprogesterone acetate (MPA) significantly suppressed the formation of preneoplastic mammary hyperplastic alveolar nodules in mice, and that this suppression persisted for some time, we studied the effects of different schedules of MPA treatment on spontaneous mammary tumorigenesis and uterine adenomyosis in SHN virgin mice. Mice received a subcutaneous pellet of MPA every 2 months: I) during the limited period of 1-3 months of age; II) throughout the experiment beginning at 6-8 months of age; and III) throughout the experiment beginning at 2-3 months of age. All treatments significantly enhanced mammary tumorigenesis with little difference in the effects among treatments. The progression of uterine adenomyosis was also stimulated in Experiments I and III, but not in Experiment II. These results are in good accord with our previous observations with progesterone, indicating that MPA has progesterone-like effects on mammary and uterine lesions of mice.

Animals↗

Oral high-dose medroxyprogesterone acetate (MAP) in treatment of advanced breast cancer. A preliminary report of clinical and experimental studies.

Medroxyprogesterone acetate (MAP) in the treatment of advanced breast cancer has been regarded as a minor agent according to the previous reports when used at low doses (less than 500 mg/day). High doses of more than 500 mg which have come into use since 1973 give a response rate of over 40%, but sometimes cause gluteal abscess or induration because of daily intramuscular injections. In order to administer easily and to avoid the side effect, we have attempted to use oral administration in a daily dose of 1200 mg (400 mg X 3). Of those 20 patients treated with oral high-dose MAP, 1 showed complete response, 6 showed partial response, 7 no change, and 6 progressive disease. As for site of lesion, 4 out of 6 (67%) in skin and 4 out of 16 (25%) in bone responded. Neither severe side effects nor abnormal laboratory data were seen. Then, we examined the blood levels of MAP in vivo by RIA in 9 patients. The blood level of MAP reached 39-250 ng/ml in 3 days and was maintained at least over 50 ng/ml for 1 or 2 months of continuous administration. Subsequently, we examined the effects of MAP on binding to ER in vitro. The inhibition of binding of estradiol-17 beta to ER was about 60% at 10(-5) M MAP. The blood level of 50 ng/ml in vivo corresponds to about 1.3 X 10(-5) M.

Administration, Oral↗

Androgen and glucocorticoid receptor-mediated inhibition of cell proliferation by medroxyprogesterone acetate in ZR-75-1 human breast cancer cells.

Medroxyprogesterone acetate (MPA) is a synthetic progestin, currently used in the adjuvant treatment of advanced breast cancer, which induces remission rates (30-40%) comparable to those obtained with other types of endocrine therapies. Since, in addition to its progestin-like action, MPA exhibits androgen- and glucocorticoid-like activities in other tissues, the present study was designed to assess the relative contribution of the different steroid receptor systems in the direct action of MPA on breast cancer cell growth, using the ZR-75-1 human mammary carcinoma cell line as an in vitro model. Unlike pure progestins, MPA potently inhibited the proliferation of ZR-75-1 cells in a concentration-dependent manner either in the presence or in the absence of estrogens, and the addition of insulin had only marginal effects on its growth-inhibitory activity. On the other hand, both hydroxyflutamide (OHF, a non-steroidal monospecific antiandrogen) and RU486 (a potent antiglucocorticoid and antiprogestin also endowed with antiandrogenic activity) competitively reversed MPA antiproliferative effects. MPA further decreased the growth of ZR-75-1 cells co-incubated with maximally inhibitory concentrations of either 5 alpha-dihydrotestosterone (DHT) or dexamethasone (DEX), although at about 300-fold higher MPA concentrations with DHT-treated than with DEX-treated ZR-75-1 cells, thus demonstrating a highly predominant androgenic effect. However, MPA had no effect on the growth of ZR-75-1 cells co-incubated with DHT and DEX simultaneously, thus supporting the predominant role of androgen and glucocorticoid receptors in MPA action. A 12-day preincubation of ZR-75-1 cells with increasing concentrations of MPA (10(-12) to 3 x 10(-6)M) decreased the specific uptake of [3H]estradiol (E2) by intact cell monolayers to the same extent as 10 nM DHT, an effect which was competitively blocked by the addition of OHF (3 microM). MPA action on ZR-75-1 cell growth also significantly differed from that of progestins in being additive to the inhibition of E2-stimulated growth by the steroidal antiestrogen ICI164384. The present data indicate that the main action of MPA on ZR-75-1 human breast cancer cell growth is due to its androgen receptor-mediated inhibitory action, while its glucocorticoid-like activity could play an additional role at high concentrations.

Breast Neoplasms↗

Transforming growth factor-beta activities in 'in vivo' lines of hormone-dependent and independent mammary adenocarcinomas induced by medroxyprogesterone acetate in BALB/c mice.

We have determined the presence of transforming growth factor-beta (TGF-beta)-like polypeptides in mammary adenocarcinomas induced by medroxyprogesterone acetate (MPA) in BALB/c mice. In hormone-dependent tumors (HD) from nontreated and MPA-treated mice a high molecular weight (43 kDa) transforming activity was purified by Bio-Gel P-60 chromatography. This TGF was able to confer the neoplastic phenotype on NRK-49F cells without the addition of epidermal growth factor (EGF), though its activity was potentiated by EGF. It did not compete for binding to the EGF receptor, had no mitogenic activity on monolayer cultures of NRK fibroblasts, and was a potent inhibitor of DNA synthesis induced in these cells by EGF and insulin. In HD and hormone-independent tumors (HI) another TGF with a Mr of 13 kDa was isolated. This transforming activity showed the same biological properties as 43 kDa TGF, with the exception that in the absence of EGF it did not stimulate soft agar growth of NRK-49F cells. The synthesis of both factors in 'in vivo' HD tumors seems to be under MPA control, since it is much lower in HD tumors from MPA-treated mice. Further purification of the 13 and 43 kDa TGFs by hydrophobic interaction HPLC demonstrated that each one eluted in a different position, and that their elution profile differed from the TGF-beta from human platelets. The biological activity of the 13 and 43 kDa TGFs was not neutralized by a specific anti-TGF-beta antibody.

Adenocarcinoma↗

Inhibition by medroxyprogesterone acetate of precancerous mammary hyperplastic alveolar nodule formation in mice.

The effects of medroxyprogesterone acetate (MPA) on precancerous mammary hyperplastic alveolar nodule (HAN) formation in mice were studied as a possible step to evaluate the anticarcinogenic role of MPA in mammary tumors. One month of subcutaneous pellet implantation of MPA to 6-7 month-old SHN breeding mice resulted in marked decrease and increase in the numbers of HAN and ghosts (the remnants of regressed HAN), respectively. The number of HAN still tended to be smaller in the experimental mice than in the control even 1 month after removal of MPA pellets which had been implanted for 2 months. Serum prolactin level at autopsy was apparently decreased and prolonged estrous vaginal smears observed in the control were replaced by diestrus in the experimental mice. All results indicate that MPA can lastingly inhibit HAN formation in mice, and suggest that MPA acts on mammary glands both directly and indirectly through its antiestrogenic effect.

Animals↗