RESEARCH Use of high dose cyproterone acetate and risk of intracranial BMJ: first published as 10.1136/bmj.n37 on 3 February 2021. Downloaded from meningioma in women: cohort study Alain Weill,1,2 Pierre Nguyen,2,3 Moujahed Labidi,4 Benjamin Cadier,1 Thibault Passeri,4 Lise Duranteau,5 Anne-Laure Bernat,4 Isabelle Yoldjian,3 Sylvie Fontanel,6 Sébastien Froelich,4 Joël Coste1,7 1Department of Public Health ABSTRACT meningiomas in the control group (during 439 949 Studies, French National Health OBJECTIVE person years of follow-up) were treated by surgery or Insurance, Paris, France radiotherapy. The incidence of meningioma in the two 2 To assess the risk of meningioma associated with EPI-PHARE Scientific Interest groups was 23.8 and 4.5 per 100 000 person years, Group, Saint-Denis, France use of high dose cyproterone acetate, a progestogen respectively (crude relative risk 5.2, 95% confidence 3French National Agency for the indicated for clinical hyperandrogenism. interval 3.2 to 8.6; adjusted hazard ratio 6.6, 95% Safety of Medicines and Health DESIGN Products (ANSM), Saint-Denis, confidence interval 4.0 to 11.1). The adjusted Observational cohort study. France hazard ratio for a cumulative dose of cyproterone 4 Department of Neurosurgery, SETTING acetate of more than 60 g was 21.7 (10.8 to 43.5). Lariboisière Hospital, AP-HP, Data from SNDS, the French administrative healthcare University of Paris, Paris, France After discontinuation of cyproterone acetate for one database, between 2007 and 2015. 5Gynaecology Unit and Reference year, the risk of meningioma in the exposed group Center for Rare Diseases of PARTICIPANTS was 1.8-fold higher (1.0 to 3.2) than in the control Genital Development, AP-HP, 253 777 girls and women aged 7-70 years living in group. In a complementary analysis, 463 women with University Paris Saclay, Bicêtre meningioma were observed among 123 997 already Hospital, Le Kremlin-Bicêtre, France who started cyproterone acetate between France 2007 and 2014. Participants had at least one using cyproterone acetate in 2006 (risk of 383 per 6Grand Est Regional Health reimbursement for high dose cyproterone acetate 100 000 person years in the group with the highest Authority, Nancy, France and no history of meningioma or benign brain exposure in terms of cumulative dose). Meningiomas 7Biostatistics and Epidemiology tumour, or long term disease status. Participants located in the anterior skull base and middle skull Unit, Cochin Hospital, AP-HP, were considered to be exposed when they had base, particularly the medial third of the middle skull Paris, France received a cumulative dose of at least 3 g during base, involving the spheno-orbital region, appeared Correspondence to: A Weill EPI-PHARE the first six months (139 222 participants) and very to be specific to cyproterone acetate. An additional Scientific Interest Group, slightly exposed (control group) when they had analysis of transgender participants showed a high http://www.bmj.com/ 42 Bd de la Libération, received a cumulative dose of less than 3 g (114 555 risk of meningioma (three per 14 460 person years; 93200 Saint-Denis, France 20.7 per 100 000 person years). [email protected] participants). 10 876 transgender participants (male (ORCID 0000-0001-8687-9092) to female) were included in an additional analysis. CONCLUSIONS Additional material is published MAIN OUTCOME MEASURE A strong dose-effect relation was observed between online only. To view please visit use of cyproterone acetate and risk of intracranial the journal online. Surgery (resection or decompression) or radiotherapy for one or more intracranial meningiomas. meningiomas. A noticeable reduction in risk was Cite this as: BMJ 2021;372:n37 observed after discontinuation of treatment. http://dx.doi.org/10.1136/bmj.n37 RESULTS on 1 October 2021 by guest. Protected copyright. Accepted: 3 December 2020 Overall, 69 meningiomas in the exposed group (during 289 544 person years of follow-up) and 20 Introduction Cyproterone acetate is a synthetic progestogen with a potent antiandrogen action. The drug has WHAT IS ALREADY KNOWN ON THIS TOPIC been approved in European countries by national Cyproterone acetate is a synthetic progestogen with strong antiandrogen and marketing authorisation procedures since the 1970s and is available on prescription under various trade antigonadotrophin effects names and dose strengths (1, 2, 10, 50, and 100 Since 2007, several case series of intracranial meningiomas have described mg). The indications for cyproterone acetate also vary patients who developed one or more meningiomas after using cyproterone considerably from one country to another. Cyproterone acetate at doses of 25-100 mg daily for 5-30 years acetate is indicated in men (50 or 100 mg) with The presence of progesterone receptors on meningiomas supports the biological inoperable prostate cancer and paraphilias. In women, plausibility of an association the 50 mg dose is indicated for various disorders WHAT THIS STUDY ADDS of the hirsutism or hyperandrogenism spectrum in 19 European countries, including France, Spain, This study confirms a strong and dose dependent association between use Germany, Belgium, Poland, and the Netherlands. In of high dose cyproterone acetate (25 or 50 mg/day) in girls and women and other European countries, 10 mg tablets are marketed meningioma treated by surgery or radiotherapy and indicated for signs of androgenisation and certain The risk of meningioma in the group who used cyproterone acetate for 10-30 forms of hirsutism (table 1 shows approved indications years was four participants per 1000 person years in women in Europe; supplementary material S1 Meningiomas located in the anterior skull base and middle skull base appeared shows approved indications in men in Europe). to be specific to cyproterone acetate; the risk decreased after cyproterone Cyproterone acetate is also used at a low dose of 2 mg acetate was discontinued combined with 35 µg ethinylestradiol for the treatment the bmj | BMJ 2021;372:n37 | doi: 10.1136/bmj.n37 1 RESEARCH of acne related to androgen sensitivity or hirsutism in incidence of treated meningioma (event of interest) in women of reproductive age, and at a dose of 1 mg in girls and women (age 7-70 years) who used high dose BMJ: first published as 10.1136/bmj.n37 on 3 February 2021. Downloaded from combination with estradiol valerate 2 mg as hormone cyproterone acetate with the incidence in those who replacement therapy. prematurely discontinued cyproterone acetate and Since 2007, several case series of both men and were only very slightly exposed (control group). women have reported meningioma associated with The main study included a cohort of women who prolonged use (5-30 years) of high dose cyproterone started high dose cyproterone acetate between 2007 acetate (25-100 mg daily).1-11 The labelling of and 2014, with follow-up to the end of 2015. Under cyproterone acetate (10, 50, and 100 mg) was modified optimal epidemiological conditions (new incident in 2009,12 and since 2011 and 2013 the labelling users with known cumulative doses over time), we of both the brand name drug and generic drugs, tested the hypothesis of an association between respectively, indicate that meningiomas have been exposure and risk of meningioma, and evaluated a reported in people with prolonged use of cyproterone possible dose-effect relation. acetate.13 A history or presence of meningioma We also analysed a population of girls and women now also constitutes a contraindication to use of who were already using cyproterone acetate in 2006, cyproterone acetate.12 13 and followed this cohort until the end of 2015. Based Two low powered epidemiological studies on the on the hypothesis of a causal association, we used this link between cyproterone acetate and meningioma population to define the characteristics of cyproterone have been published. One of the studies reported two acetate related meningiomas and the number of men and two women with meningioma, corresponding meningiomas treated by surgery or radiotherapy that to a relative risk of 11.4 (95% confidence interval 4.3 were attributable to cyproterone acetate use. This to 30.8).14 The other study found an excess risk in men cohort comprised women who had continually used (four men with meningioma) with an odds ratio of 3.3 cyproterone acetate for a long period (more than (1.0 to 10.6), but concluded that low dose cyproterone eight years), although left censoring of data occurred acetate was not associated with an increased risk of because only cumulative doses since 2006 are known meningioma in women.15 with certainty. We conducted a further analysis on We evaluated the real life impact of prolonged use of a population of transgender participants (male to high dose cyproterone acetate on risk of meningioma female) who started high dose cyproterone acetate in girls and women. Our secondary objectives were between 2007 and 2017, with follow-up until the end to evaluate the dose-effect relation, define the course of 2018. http://www.bmj.com/ of the risk of meningioma after discontinuation of cyproterone acetate, identify specific features of Data source cyproterone acetate related meningiomas, measure SNDS covers the entire population of France—67 the effective discontinuation rate for cyproterone million residents. Each person is identified by a acetate after treatment for meningioma, and estimate unique, anonymous number. Since 2006, SNDS has the number of meningiomas treated by surgery recorded information on all outpatient care (including or radiotherapy that were attributable to use of drugs, imaging, and laboratory tests) and inpatient cyproterone acetate in France. In an additional care (including diagnoses and procedures performed, on 1 October 2021 by guest. Protected copyright. analysis, we evaluated the real life impact of prolonged coded according to the common classification of use of high dose cyproterone acetate on risk of medical procedures—CCAM).