Aust NZ J Obstet Gynaecol 1992; 3 2 4: 346

Danazol in the Treatment of Menorrhagia: The Effect of a 1 Month Induction Dose (200 mg) and 2 Month’s Maintenance Therapy (200 mg, 100 mg, 50 mg or placebo) Jillian A. Need:,’ Kevin L. Forbes:s6 Louise Milazzo3+’and Elaine M c K e n ~ i e ~ , ~ Royal Brisbane Hospital’, and Departments of Obstetrics and Gynaecology, Flinders Medical Centres and University of Queensland6

Summary: This paper highlights the difficulties of recruiting subjects to objective menstrual blood loss (MBL) studies. Such difficulties may explain the relative paucity of such studies in the literature. Eleven women with objectively assessed evidence of menorrhagia were treated for 1 mpnth with an induction dose of 200 mg of danazol (Danocrine). Subsequently the women were randomly assigned to receive 50,100 or 200 mg of danazol or placebo for 2 months of maintenance dosing. Follow-up with objective assessment of MBL was continued for 3 months after cessation of maintenance dosing. Danazol200 mg as an induction dose significantly reduced MBL. The maintenance dose of 200 mg during the following 2 months produced a further decrease in MBL and in some cases amenorrhoea. The lower maintenance dosages of 50 mg and 100 mg were associated with a variable response. The study was unable to determine whether any beneficial effect of the maintenance dosages of danazol could be maintained following cessation of therapy since the study numbers had become too small, It appears, however, that there is unlikely to be any persisting benefit once therapy has ceased. Evaluation of treatment regimens of menorrhagia by objective measurement of menstrual blood loss (MBL) is infrequently reported, presumably because of the difficulty in accurate collection and measurement of menstrual blood loss. Nevertheless there are a variety of treatment regimens, including danazol, that have reported efficacy in reducing menstrual blood loss at doses lower than employed for treating endometriosis. Danazol dosages of 200 mg daily have repeatedly been shown to result in a decrease in mean menstrual blood loss after 1 month, with a further fall after 2 months of therapy (1-5). Even 100 mg danazol daily has been shown to reduce menstrual blood loss after 1 month’s treatment (5). The mechanism of action of danazol in producing a reduction in MBL is probably due to a combination of several factors. Danazol is an impeded androgen, some of its metabolites are androgenic (6) and it is associated with a marked reduction in the levels of the binding capacity of sex hormone binding globulin (SHBG) and thus an increase in the free fraction of 1. Senior Lecturer. 3. Research Assistant. 4. Registered Nurse. Address for correspondence: Dr. Jillian A. Need, Department of Obstetrics and Gynaecology, Flinders Medical Centre, Bedford Park, South Australia, 5042.

testosterone in women on danazol. Initially the rate of decrease in the SHBG binding capacity is dose dependent on danazol; however, during long-term therapy similar levels of SHBG binding capacity were maintained with doses varying from 50 to 400 mg daily (7). Thus, if the mechanism of danazol in reducing MBL is at least in part due to the resultant increase in free fraction of testosterone and its antagonism of the growth promoting effect of oestradiol then an initial high dose for 1 month followed by a decreased maintenance dose would be expected to be feasible for continued therapeutic efficacy while minimizing side-effects. The present study was designed to examine the effect of an initial daily dose of 200 mg of danazol followed by 2 months maintenance dosage varying from 50 mg to 200 mg or placebo, in women with proven menorrhagia. The obiectives of the study were 4-fold: To determine if an induciion dose of 200 mg of danazol daily for one cycle would significantly reduce menstrual blood flow in women with menorrhagia. To determine if after an ‘induction period’, a reduction in menstrual blood flow could be maintained, or further reduced, by a ‘maintenance dose’ of danazol for 2 cycles. To determine if a reduction in menstrua1 blood flow could be sustained after cessation of the maintenance dose for a period of 3 months.

341

JILLIAN A. NEEDET AL

4. To determine which, if any, maintenance dose of danazol is most efficacious for this reduction.

METHODS Subject selection Subjects were recruited from clinic populations and from local newspaper advertising to the Obstetrics and Gynaecology departments of 2 Australian Hospitals (Flinders Medical Centre, South Australia and The Royal Brisbane Hospital, Queensland). Subjects included in the study were aged 18-45 years, had a history of regular menstrual cycles (21-36 days) and of ‘unexplained’ excess menstrual blood loss. Objective measurement of menstrual blood loss over 2 cycles was required to exceed a mean of 80 ml. Informed consent was given by all subjects. They agreed to participate in the study extending over 9 cycles, demanding 18 clinic visits including peripheral venous blood collections. They agreed to collect and deliver sanitary protection to the study centre after each period and to comply with medication ingestion and documentation of drug usage and menstrual loss. Study exclusion criteria are listed in table 1. Table 1. Study Exclusion Criteria ~~

> 1 cm, endometrial polyps, endometrial hyperplasia, adenomyosis, pelvic inflammatory disease, ovarian cysts, endometriosis or cancer. History of pelvic cancer. Concurrent diseases which would interfere with the conduct or analysis of the study. History of cardiovascular, haematological, hepatic or renal disease; pituitary or endocrine disease; thrombophlebitis; jaundice during pregnancy; alcohol or drug abuse. Current pregnancy or lactation. Use of intrauterine device up to 2 months prior to study commencement. Surgical curettage of the uterus within 60 days of study commencement. Use of danazol, gestrinone, androgens, oestrogens, progestogens (including oral contraception), LHRH analogues any time within 6 months of study commencement. Participation in any other drug trial within 4 months of study commencement. Use of any medication which could interfere with pituitary or gonadal function (i.e. phenothiazines) or liver function (i.e Dilantin, barbituates, phenothiazines). Failure to respond to a prior and proper course of danazol. Any emotional, psychological or other impediment which would interefere with the patients ability to adhere to protocol requirements and give informed consent. Obiective menstrual blood loss measurement of less than 80 ml.

1. Presence of uterine myomas

2.

3.

4. 5. 6. 7.

8.

9. 10. 11.

12.

A complete physical examination was performed at the beginning and end of the study including a pelvic examination and a cervical smear test. Laboratory investigations included a complete blood picture, urinalysis and micro-urine if indicated, liver function tests, urea and electrolytes, blood sugar level and pregnancy test.

Study design The study was divided into 4 phases. After the initial assessments and an open induction phase, the subjects were randomized into a double blind, placebo controlled parallel group design: Phase I: Pretreatment phase - baseline evaluations of laboratory tests and menstrual blood loss (MBL). The MBL assessments were carried out over 2 cycles (table 2, P1 and P2). Phase 11: Induction phase - An open phase with all patients receiving danazol 100 mg b.d. (200 mg daily) for 1 cycle or for 36 days, whichever was the shorter time. Medication was started at the beginning of period 3 (P3 table 2) and thus P4 (table 2 ) represents the menses in which the effect of this ‘induction’ dose of danazol was observed. Phase 111: Maintenance phase - Double blind, placebo controlled randomized, parallel group design in which patients received danazol(200 mg, 100 mg or 50 mg) or placebo for 2 consecutive cycles (or 2 x 36 day cycles, whichever is shorter). MBL was measured for P5 and P6 (table 2). Phase I V Posttreatment evaluation - MBL was measured for 3 cycles following cessation of medication (P7-P9, table 2). Table 2. Study Design Scheme Phase 1

Phase I1

Phase 111

Phase IV

Qualify

Maintenance Phase: Danazol 0-200 mg or placebo daily

Follow-up

study

Induction Phase: Danazol200 mg daily

PI P2

P3 P4

P5 P6

P I P8 P9

for

Assessment of efficacy and adverse effects Subjects kept diaries of blood loss over each cycle for the length of the trial. A clinical evaluation at each visit included assessments of dysmenorrhoea, dyspareunia and premenstrual pain. Haematology assessments were recorded at every visit and laboratory parameters including liver function tests were performed at regular intervals. In addition, questions referring to potential drug side-effects, particularly androgen excess, were asked of the subject at each visit. The primary efficacy measure in this study however, was the objective assessment of menstrual blood loss. Subjects collected all sanitary protection used during each menses and actual menstrual blood loss was measured after the method of Hallberg and Nilsson (8) and Newton, Barnard and Collins (9) modified for use with an ELISA spectrophotometer as follows. Assay of menstrual blood loss Tampons and or sanitary pads which had been supplied to the participants were placed in a Cryovac plastic bag. No more than 8 items per bag were assayed at a

AUST.AND N.Z. JOURNAL OF OBSTETRICS AND GYNAECOLOGY

348

FO 1

EOl

arlin

;:

mfd" li pbcabo

n. r. rrfi

I

U

I

N

PHASES OF THE TRlAL

"1

EO 1

E06

W

--5 5

2.

-2-

Em b u l l -

-p=!

? i b - T 1Y)

W

h 2 d

B B

I

N

I, f1

n.

'I

0

.

FWASES OF THE TRIAL

60mg tdlo-

-

5'"

I I

N N

PHASES OF THE TRLAL

WHASE; OF THE TRW

F03

EO4

:I

100 m(l dmuol

3. E" -

;ilL

followup

so

I

8

HASES OF THE

PHASES OF THE TRw

withdrawn N

mik

F06

F02

"I

E02

XD

followup

4.

2-

z-

2 -am

=Ep

80

lso

IW

)

ulln

rm W

b.rllm

mmo

-I

21W -_

d-d

d-'l 2

~ 200 ~ mgd

y.

l

withbarm 0

1

U

.

PHASES OF THE

N

mwL

I

2Oom dmad

W

U

8

PHASES OF THE TRIAL

N

0

'

I

fl. D

n. B

PHASES OF THE

ma

N

Figure 1. Individual subject menstrual blood loss (MBL) measurements during each of 4 phases of the trial. Maintenance phase doses: 1. placebo, 2. 50 mg danazol, 3. 100 mg danazol, 4. 200 mg danazol.

JILLIAN A. NEEDET AL

time. A known volume of 5 % sodium hydroxide (NaOH) (up to 2,000 ml) was added to the bag which was then placed into a Stomacher Lab-Blender (model 3500) for about 15 minutes until extraction was complete. At the same time, 10 ml of 5 % NaOH was added to 0.1 ml of peripheral blood from the same subject for comparison. After centrifugation at 1,000 rpm for 1 minute, quadruplicate 200 p1 samples of this solution were aliquoted into the wells of an ELISA tray. An aliquot of the sanitary protection homogenate was removed from the bag and centrifuged at 1,000rpm for 1 minute to clear the supernatant. Quadruplicate samples of 200 p1 of this solution were also aliquoted into the wells of an ELISA tray. After 30 minutes the optical density of each peripheral blood sample followed by the corresponding menstrual sample was determined at 570 nm by a Micro ELISA Auto Reader MR580 (Dynatech). The volume of menstrual blood (MBL) was calculated from the formula:ODS7,of menstrual eluate x Volume* MBL (ml) = OD,,, of venous blood x 100 (Volume*

= volume

of 5% NaOH)

Reproducibility of the assay was determined with repeated analysis of 8 tampons containing 10 ml of blood each (total 80 ml) and 8 sanitary pads containing 20 ml of blood each (160 ml in total). In the tampons the interassay coefficient of variation was 5.62% (n = 18) and the intraassay coefficient of variation was 3.62% (mean of 5 experiments with 5 to 8 measurements each). In the pads, the interassay coefficient of variation was 6.9% (n = 7) and the intraassay variation was 4.1% (mean of 3 experiments with 3 to 8 measures in each).

RESULTS Subjects Due to stringent and extensive selection criteria and the distasteful nature of the expectations of the proto-

349

col, recruitment was extremely difficult. One centre for example screened more than 150 people to include 5 eligible subjects in the study. A large number of subjects were screened out because of recent curettage or hormonal therapy, others were unwilling to comply with sanitary protection collection, had MBL measurements which did not meet the criterion of greater than 80 ml or otherwise failed to pass all the exclusion criteria. Six subjects commenced the study from the second centre thus bringing the total number of study participants to 11. They were all Caucasian women and had a mean age of 37.9 years (range 29 to 45 years). They had parities of between 1 and 5, generally regular cycles and mean heights and weights of 162.7 cm (range 152.5 to 183) and 64.3 kg (range 53.8 to 88.6) respectively. Figure 1 illustrates the MBL for each of the study subjects during the 4 phases of the trial.

Phase I: quaiifying period The mean MBL of 2 baseline cycles for the subjects included in the study ranged from 79.3 ml to 647.8 ml (table 3). Variability between the first and second measurement was in some cases considerable. The second baseline measure varied from the first measurement by a mean of 17.5% (range 2.5% to 45.8%). There was no consistency in the direction of the change. Phase IL induction phase Mean MBL for the group dropped from 206.87 k 184.5 ml to 73.95 k 126.37ml following one month of treatment with 200 mg of danazol daily. The mean reduction in MBL for the group was 73.2% (range 37.3 to 100%); 9 out of the 11 women had MBL well below 80 ml (table 3). Three women were amenorrhoeic following this first month of treatment. Analyses of the matched pairs using the Wilcoxon signed rank test indicated the reduction was statistically significant (p = 0.002; 1 tailed).

Table 3. Effect of Danazol Treatment on MBL Patient number F06 E03 FO 1 F04 EO5 E01 F03 E04 E02 F05 F02

Danazol group 0 0

0 50 50 50 100 100 200 200 200

Baseline MBL

Induction MBL

Maintenance MBL

Follow-up 1

Follow-up 2

Follow-up 3

408 88 102 91 107 272 648 99 301 81 79

219 49 17

316 70 34

53 44

-

33

73 47

41 247

56 225

76 275

86 182

54 283

92 239

0 41 O* 406 O* 37 34 11

38 20 1 557 20 6 9 0

0

Danazol group: Treatment group during maintenance phase Baseline M B L Mean of 2 pretreatment menses MBL Induction MBL: MBL following 1 month treatment with 200 mg danazol Maintenance MBL: Mean of MBL after 1 and 2 months of maintenance dose treatment Follow-up 1: MBL 1 month after danazol withdrawal Follow-up 2: MBL 2 months after danazol withdrawal Follow-up 3: MBL 3 months after danazol withdrawal * at 36 days n o menses; maintenance dosing was postponed until menses of 13 ml (47 days) and 146 ml (76 days) respectively

350

AUST.AND N.Z. JOURNAL

OF OBSTETRICS AND

Prior to treatment the women had a period every 26.8 k 2.5 days lasting 6.8 k 1.7 days. In the 8 women who were not amenorrhoeic, the period following one month of danazol treatment occurred after 27.5 3.8 days and lasted 6.0 f 1.2 days; this difference was not statistically different (cycle length: t = 0.893, 7 d.f.; p