This study was designed to compile the reasons and specific indications for the prescription of Cyproterone Acetate combined with Ethinyl Estradiol by Health Care Providers. The primary objective of the study was to characterize the prescribing behaviors for Cyproterone Acetate combined with Ethinyl Estradiol in 5 European countries (Austria, Czech Republic, France, the Netherlands, and Spain), including:

• prescription indications for Cyproterone Acetate combined with Ethinyl Estradiol
• use of Cyproterone Acetate combined with Ethinyl Estradiol in accordance with the updated label
• concomitant use of Cyproterone Acetate combined with Ethinyl Estradiol and combined hormonal contraceptives
• second line treatment with Cyproterone Acetate combined with Ethinyl Estradiol for the indication acne

Cyproterone acetate (CPA) 2mg, in combination with ethinyl estradiol (EE) 35mcg, is a medicinal product currently indicated for the treatment of moderate to severe acne in women of reproductive age. Due to the combination with ethinyl estradiol and the dosing, the preparations also act as effective contraceptives.

In 2012, the French health authority conducted a national review of Cyproterone Acetate combined with Ethinyl Estradiol and highlighted serious thromboembolic events and extensive off-label use of these medicines as a contraceptive only. This triggered an Urgent Union Procedure at the beginning of 2013. The European Medicines Agency's Pharmacovigilance Risk Assessment Committee (PRAC) concluded that the benefits of Cyproterone Acetate combined with Ethinyl Estradiol (cyproterone acetate 2mg / ethinyl estradiol 35mcg) outweigh the risks, providing that several measures are taken to minimize the risk of thromboembolism. These medicines should be used solely for the treatment of moderate to severe acne related to androgen sensitivity and/or hirsutism in women of reproductive age. Since Cyproterone Acetate combined with Ethinyl Estradiol acts as a hormonal contraceptive, women should not take these medicines in combination with hormonal contraceptives. As one of the risk minimization measures, the Market Authorization Holders were required to conduct a number of studies including this drug utilization survey.

This study was a multi-national, cross sectional, prospective, non-interventional, drug utilization study conducted in 5 countries. Study participants were recruited by a network of health care professionals. Physicians collected information from study participants based on questionnaires. This was a one-time survey with no follow-up.

Bayer initiated this study and supported it by an unconditional grant to ZEG. Bayer was not actively involved in the study conduct.

Prolongation of recruitment:

At the beginning of May 2016 the recruitment was finished in 4 of the 5 European countries in which the study was conducted (Austria, Czech Republic, The Netherlands, and Spain). At that point in time, only few patients were enrolled in France because of a delayed recruitment start. Therefore, it was agreed to extend the recruitment phase in France until 31st October 2016, in order to ensure that information on the use of Cyproterone Acetate (combined with Ethinyl Estradiol) would be collected from all participating countries.

Inclusion Criteria:

• Women who are prescribed Cyproterone Acetate combined with Ethinyl Estradiol during the study period
• Women who are willing to participate in the drug utilization study

Exclusion Criteria:

• Women who are not willing to sign the informed consent
• Women with a language barrier

Women who are prescribed Cyproterone Acetate combined with Ethinyl Estradiol during the study period

Adverse events were not monitored in this study, which was a non-interventional observational cross sectional study on drug utilization patterns that exclusively obtained information at the time point of prescription. There were no questions that could generate adverse events (AEs) and no follow-up questionnaires.

Since this was a drug utilization study, exclusively obtaining information at the time of prescription, no adverse events were reported.

The data cannot indicate a difference in prescribing habits between participating and non-participating physicians. The information about previous treatments of acne is likely to be incomplete because of recall bias.