PROS-1-Male Hormonal Contraceptive Regimens on Prostate Tissue

The investigators propose to examine the in vivo responses to hormonal manipulation at the molecular level directly in the tissue of interest (prostate). As in the investigators' previous, pilot study, the investigators will use the novel approach of procuring tissue specimens from normal, healthy men who might be chose to use a male hormonal contraceptive regimen were it available. The investigators will employ state of the art techniques such as laser capture microdissection (LCM) and cDNA microarrays to determine the tissue-specific consequences of male hormonal contraceptive regimens on the prostate. The results will help guide the design, safety monitoring, and selection of male hormonal contraceptive agents and provide valuable insights into prostate human prostate biology.

The investigators will test the hypothesis that exogenous T administration that results in increased circulating T and dihydrotestosterone (DHT) levels will increase intraprostatic concentrations of T and its metabolite DHT.

The investigators will test the hypothesis that the addition of a potent 5α-reductase inhibitor, dutasteride, or the progestin, Depomedoxyprogesterone (IM DMPA), to T administration in young and middle aged men will decrease intraprostatic DHT and increase intraprostatic T concentrations compared to T alone.

The investigators will test the hypothesis that the addition of a 5α-reductase inhibitor dutasteride or the progestin IM DMPA to exogenous T, by reducing intraprostatic DHT, will decrease prostate epithelial proliferation, assessed by Ki-67 labeling index (Ki-67LI), and increase apoptosis, assessed by caspase-3 expression, and decrease androgen-regulated protein expression such as prostate specific antigen (PSA).

The investigators will test the hypothesis that the addition of a 5α-reductase inhibitor or the progestin IM DMPA to exogenous T, by modifying the intraprostatic hormonal milieu, will alter prostate epithelial gene expression. Specifically, the investigators expect that the addition of the 5α-reductase inhibitor dutasteride or the progestin IM DMPA to exogenous T, will result in decreased expression of androgen-regulated genes such as PSA.

The purpose of this research study is to understand the effects of testosterone on the prostate. This knowledge will be used to help in the development of a safe male hormonal contraception.

We will be administering three drugs in this study: Testim (testosterone (T) gel), dutasteride (which affects testosterone break down) and Depomedoxyprogesterone (DMPA, a progestin). We want to see their effects on levels of hormones in the blood and prostate. In addition, we will be examining the effects of these drugs on the expression of genes within the prostate. DMPA suppresses LH and FSH, which are hormones made by the pituitary gland, thus blocking the signal from the brain that causes the testes to make testosterone. Prolonged (> 1 month) low levels of LH and FSH cause decreased sperm production in normal men. However, men may experience some side effects from the low levels of testosterone caused by DMPA; adding testosterone to DMPA eliminates these side effects while more effectively blocking LH and FSH release and sperm production. This combination of drugs is a promising male contraceptive regimen. However, the effect of these drugs on the prostate is not known. Some studies suggest that testosterone administration may promote prostate growth. Dutasteride blocks the conversion of testosterone to dihydrotestosterone and is used to treat men with enlarged prostates. Dutasteride shrinks the prostate. It is possible that combining testosterone and dutasteride may be an effective part of a male hormonal contraceptive regime. Therefore, further studies examining the effect of testosterone, DMPA and dutasteride on the prostate are needed.

• Drug: Testosterone gel
  Testosterone gel 10 g
  Other Name: Testim
• Drug: Dutasteride
  dutasteride 0.5 mg orally
  Other Name: Avodart
• Drug: Depo-Medroxyprogesterone (DMPA)
  300 mg DMPA injection on Day 0 IM (into the muscle)
  Other Name: Depo-Provera
• Other: Placebo Testosterone gel
  Place gel applied daily for 12 weeks
• Other: Placebo dutasteride
  placebo pill for 12 weeks
• Other: Placebo DMPA
  placebo DMPA injection Once

• Placebo Comparator: 1
  Placebo gel + Placebo pill + placebo injection
  Interventions:

  • Other: Placebo Testosterone gel
  • Other: Placebo dutasteride
  • Other: Placebo DMPA
• Active Comparator: 2
  Testosterone 1% transdermal gel 10 g + placebo pill + placebo injection
  Intervention: Drug: Testosterone gel
• Active Comparator: 3
  Testosterone 1% transdermal gel 10 g + dutasteride 0.5 mg Orally + placebo injection
  Interventions:

  • Drug: Testosterone gel
  • Drug: Dutasteride
• Active Comparator: 4
  Testosterone 1% transdermal gel 10 g + placebo pill + DMPA 300 mg injection (IM)
  Interventions:

  • Drug: Testosterone gel
  • Drug: Depo-Medroxyprogesterone (DMPA)
  • Other: Placebo dutasteride

• Amory JK, Page ST, Bremner WJ. Drug insight: Recent advances in male hormonal contraception. Nat Clin Pract Endocrinol Metab. 2006 Jan;2(1):32-41. Review.
• Brady BM, Amory JK, Perheentupa A, Zitzmann M, Hay CJ, Apter D, Anderson RA, Bremner WJ, Pollanen P, Nieschlag E, Wu FC, Kersemaekers WM. A multicentre study investigating subcutaneous etonogestrel implants with injectable testosterone decanoate as a potential long-acting male contraceptive. Hum Reprod. 2006 Jan;21(1):285-94. Epub 2005 Sep 19.
• Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol. 2004 Apr;190(4 Suppl):S5-22. Review.
• Jacobsen SJ, Girman CJ, Lieber MM. Natural history of benign prostatic hyperplasia. Urology. 2001 Dec;58(6 Suppl 1):5-16; discussion 16. Review.
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• Wilson JD, George FW. The Physiology of Reproduction. Raven Press, 1994
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• Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, Lieber MM, Cespedes RD, Atkins JN, Lippman SM, Carlin SM, Ryan A, Szczepanek CM, Crowley JJ, Coltman CA Jr. The influence of finasteride on the development of prostate cancer. N Engl J Med. 2003 Jul 17;349(3):215-24. Epub 2003 Jun 24.
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• Page ST, Lin DW, Mostaghel EA, Hess DL, True LD, Amory JK, Nelson PS, Matsumoto AM, Bremner WJ. Persistent intraprostatic androgen concentrations after medical castration in healthy men. J Clin Endocrinol Metab. 2006 Oct;91(10):3850-6. Epub 2006 Aug 1.
• Page ST, Amory JK, Anawalt BD, Irwig MS, Brockenbrough AT, Matsumoto AM, Bremner WJ. TESTOSTERONE GEL COMBINED WITH DEPOMEDROXYPROGESTERONE ACETATE IS AN EFFECTIVE MALE HORMONAL CONTRACEPTIVE REGIMEN AND IS NOT ENHANCED BY THE ADDITION OF A GnRH ANTAGONIST. J Clin Endocrinol Metab. 2006 Aug 29; [Epub ahead of print]

Inclusion Criteria:

• Men in good health, and without a history of chronic androgen therapy or known history of gonadal or prostate abnormalities.

  • PSA ≤ 2.
  • Age 25-55 years
  • Ability to understand the study,study procedures and provide consent
  • Normal serum total T, LH, FSH, urine analyses, and sperm count > or equal to 15million/ml
  • International Prostate Symptom Score (IPSS) < 10
  • Normal seminal fluid analysis (>20 million sperm/ml)
  • Agree not to donate blood during the treatment and recovery periods

Exclusion Criteria:

• A history or evidence of prostate or breast cancer
• History of invasive therapy for BPH
• History of acute urinary retention
• Current or past treatment with a 5α-reductase inhibitor
• History of anti/androgenic drugs or drugs that interfere with steroid metabolism within past 3 months
• Severe systemic illness (renal, liver, cardiac, lung disease, cancer, poorly controlled diabetes)
• Known untreated obstructive sleep apnea
• Hematocrit > 52%
• Skin disease that might interfere with T gel absorption
• Hypersensitivity to any of the drugs used in the study
• History of a bleeding disorder or anticoagulation
• History of drug or alcohol abuse within 12 months
• History of infertility or desire for fertility within 12 months, or current pregnant partner
• A first-degree relative (i.e. father, brother) with a history of prostate cancer
• Abnormal digital rectal examination or prostate ultrasound