Early metformin therapy (age 8-12 years) in girls with precocious pubarche to reduce hirsutism, androgen excess, and oligomenorrhea in adolescence

CONTEXT

Girls with a combined history of low(-normal) birth weight (LBW) and precocious pubarche (PP) are at high risk to develop polycystic ovary syndrome (PCOS).

OBJECTIVE

The objective of the study was to compare the capacity of early vs. late metformin treatment to prevent adolescent PCOS.

DESIGN

This was a randomized, open-label study over 7 yr.

SETTING

The study was conducted at a university hospital.

PATIENTS

Thirty-eight LBW-PP girls were followed up from the mean age 8 until age 15 yr.

INTERVENTION

Early metformin (study yr 1-4; age 8-12 yr) vs. late metformin (yr 6; age 13-14 yr).

MAIN OUTCOME MEASURES

Measures included height; weight; hirsutism score; menstrual cycle; endocrine-metabolic screening (fasting; follicular phase); C-reactive protein; body composition (absorptiometry); abdominal fat partitioning (magnetic resonance imaging); ovarian morphology (ultrasound); PCOS (National Institutes of Health and Androgen Excess Society definitions) after yr 7 (all girls thus untreated for at least 1 yr).

RESULTS

None of the girls dropped out of the study. At age 15 yr, early-metformin girls were taller (4 cm), were in a less proinflammatory state, and had less central fat due to reductions in visceral and hepatic fat. Hirsutism, androgen excess, oligomenorrhea, and PCOS were between 2- and 8-fold more prevalent in late- than early-treated girls. Abdominal adiposity was the first variable to diverge (at age 8-10 yr) between girls without vs. with PCOS at age 15 yr.

CONCLUSIONS

In LBW-PP girls, early metformin therapy was found to prevent or delay the development of hirsutism, androgen excess, oligomenorrhea, and PCOS more effectively than late metformin. The time window of late childhood and early puberty may be more critical for the development, and thus for the prevention, of adolescent PCOS than the first years beyond menarche.

Nonclassic congenital adrenal hyperplasia

PURPOSE OF REVIEW

Late-onset or nonclassic congenital adrenal hyperplasia (NCAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive disorders. Reported prevalence ranges from 1 in 30 to 1 in 1000. Affected individuals typically present due to signs and symptoms of androgen excess. The purpose of this review is to provide current information regarding the pathophysiology, molecular genetics, and management of this common disorder.

RECENT FINDINGS

Subfertility and the consequences of elevated progesterone concentrations have been increasingly documented for women with NCAH. Although testicular adrenal rest tumors (TARTs) are more common in men with classical congenital adrenal hyperplasia, oligospermia and TARTs have been described in men with NCAH. The phenotypic spectrum of defects in other components of the steroidogenic pathway such as P450 oxidoreductase and steroidogenic acute regulatory protein has been expanded to include milder forms.

SUMMARY

Treatment needs to be directed toward the symptoms. Goals of treatment include normal linear growth velocity, normal rate of skeletal maturation, 'on-time' puberty, regular menstrual cycles, prevention of or limited progression of hirsutism and acne, and fertility. Treatment needs to be individualized and should not be initiated merely to decrease abnormally elevated hormone concentrations.

Oral contraceptive containing desogestrel in the maintenance of the remission of hirsutism: monthly versus bimonthly treatment

A treatment to keep hirsutism in remission while minimizing lipid disturbances was attempted in 20 formerly hirsute patients with hirsutism scores already greatly reduced after oral contraceptives (OCs) treatment. After OCs discontinuation for one to three months, they were thereafter treated for two years as follows: 9 patients received ethinyl estradiol (30 micrograms/day) plus desogestrel (150 micrograms/day) in three-week cycles every month (monthly); 6 patients received the same formulation during three-week cycles every other month (bimonthly); 5 patients received no treatment. In the untreated patients, abnormal hirsutism scores reappeared within 12-18 months; the levels of testosterone and free testosterone, initially high following discontinuation of OCs, remained elevated. Monthly treatment kept hirsutism in remission, and testosterone and free testosterone levels decreased. Bimonthly treatment was equally effective keeping hirsutism in remission, although testosterone levels did not decrease. Bimonthly treatment was not better than monthly treatment in relation to changes in plasma lipids (cholesterol, HDL-cholesterol, triglycerides).

17-Hydroxysteroid dehydrogenase type 5 gene polymorphism (-71A/G HSD17B5 SNP) and treatment with oral contraceptive pills in PCOS women without metabolic comorbidities

We studied (1) the effects of oral contraceptive pills (OCPs) on hirsutism, hormonal and metabolic variables in 49 polycystic ovary syndrome patients without metabolic comorbidities and (2) the effect of 17-hydroxysteroid dehydrogenase type 5 gene polymorphism (-71A/G HSD17B5 SNP) on the response to OCP treatment. Mean age was 21.9 ± 6.5 years. Patients received monophasic OCP (20 μg ethinyl estradiol plus 75 μg gestodene), 21/28 days per cycle, during 6 months; 32 patients with severe hirsutism also received spironolactone 100 mg. The frequencies of HSD17B5 genotypes were: AA = 0.49 (55.1%), AG = 0.42 (30.6%) and GG = 0.09 (14.3%). After 6 months, body mass index and waist circumference remained unchanged regardless of the presence of allele G. A slight reduction (p < 0.05) was noted in systolic blood pressure (p < 0.05) and luteinizing hormone levels, whereas a slight increase (p < 0.05) was noted in lipids. Total testosterone and hirsutism score declined, while sex hormone binding globulin increased after OCP treatment (p < 0.05). None of these changes were associated with genotype. Insulin and homeostasis model assessment remained unchanged after treatment and did not vary according to the presence of allele G. OCP seems to ameliorate androgenic symptoms without compromising metabolic parameters. The -71A/G SNP of HSD17B5 gene did not contribute to the improvements observed.

Effect of metformin and spironolactone therapy on OGTT in patients with polycystic ovarian syndrome - a retrospective analysis

BACKGROUND

Metformin (an insulin sensitizer) and spironolactone (an antiandrogen) are both used for treatment of polycystic ovary syndrome. We analyzed the effect of 6 months of therapy with these drugs on body weight and glucose tolerance.

RESULTS

This was a retrospective analysis of polycystic ovarian syndrome (PCOS) cases on treatment. There were 88 patients with PCOS-42 were on metformin 1 g daily and 46 were taking spironolactone 50-75 mg daily. 21 of 42 had abnormal glucose tolerance (AGT) in the metformin group and 13 of 46 had AGT in the spironolactone group. Patients on metformin reported a greater reduction in body weight, whereas there was no change in body weight with spironolactone therapy (67.6-63.7 versus 59.6-59.2 kg). There was a significant reduction in the 1 and 2 h glucose and insulin levels with metformin therapy in those with AGT. However, fasting glucose increased in those with normal glucose tolerance. There was no change in either body weight or insulin levels with spironolactone. But, there was a significant reduction in both the 0 and 2 h glucose with spironolactone also in those with AGT.

CONCLUSION

Spironolactone and metformin had similar effect in reducing the glucose levels in PCOS patients with AGT. PCOS patients with normal glucose tolerance had higher fasting plasma glucose at the end of 6 months of metformin therapy inspite of weight reduction.

Hyperandrogenism in a postmenopausal woman: a rare case of ectopic adrenal cortical gland

Most frequent causes of androgenic manifestation are Cushing's syndrome, PCO, benign and malignant androgen-secreting non adrenal tumors and iatrogenic hirsutism. Hyperplasia or neoplasms of ectopic adrenocortical gland are rare. We report a case of a 63-year old female with hirsutism and alopecia. Laboratory data highlighted increased levels of androgens. Diagnostic imaging revealed normal morphology of adrenocortical gland and ovaries. In view of the clinical picture and suspected diagnosis of extra-adrenal cause, she underwent bilateral salpingo-oophorectomy. Histologic examination showed an ectopic adrenal gland with adenoma in the ovarian and peri-ovarian tissue. At six months of follow up, the patients has no sign of hyperandrogenism. In case of hyperandrogenism in postmenopausal women and in the absence of the adrenocortical gland abnormality, ovarian origin should be considered in the differential diagnosis.

Desogestrel+ethinylestradiol versus levonorgestrel+ethinylestradiol. Which one has better affect on acne, hirsutism, and weight change

OBJECTIVE

To compare complications of third and second generation oral contraceptive pills (OCPs).

METHODS

In a randomized clinical trial from October 2007 to October 2008, 100 healthy women of reproductive age referred to Amir Hospital Family Planning Clinic and some heath centers in Semnan, Iran were randomized in 2 equal groups. They received either a third generation OCP (150 microgram desogestrel [DSG] + 30 microgram ethinylestradiol [EE]) or a second generation type (150 microgram levonorgestrel [LNG] + 30 microgram EE). Six months later, changes of weight, acne, and hirsutism severity, as well as serum titers of sex hormone-binding globulin (SHBG) and free testosterone were compared between the 2 groups.

RESULTS

Forty-five women were evaluated in the DSG+EE OCP group, and 46 women in the LNG+EE OCP group. The BMI was significantly higher in the second group (p=0.000) after 6 months duration. Likewise, the decrement of acne and hirsutism severity was significantly higher in the DSG+EE users (p=0.000). Mean changes of serum free testosterone (p=0.967) and SHBG (p=0.916) were comparable between the 2 groups.

CONCLUSION

In comparison with the LNG+EE OCP, the DSG+EE OCP is a contraceptive pill that significantly decreases the severity of acne and hirsutism, without any significant change in weight.

Polycystic ovarian syndrome: is community care appropriate?

In recent years the complexities and heterogeneity of polycystic ovarian syndrome (PCOS) have been recognised. Most PCOS sufferers with amenorrhoea, menstrual dysfunction, hirsutism, acne and infertility can be evaluated and safely managed in primary care. It is prudent to remember that all women with PCOS are at risk of insulin resistance and the associated abnormalities of the insulin resistance syndrome--dyslipidaemia, hypertension, coronary artery disease and diabetes mellitus.

[Pharmacologic treatment for polycystic ovary syndrome]

The study an evaluation of pharmacological treatment of PCOS with regard to inhibition in increase of hirsutism, regulation of the menstrual cycle, infertility and acne. During treatment the following pharmacological agents were used; sequential estrogen-progestagens, oral contraceptives, antiandrogens, clomiphene citrate and dexamethasone. The regular menstrual non-ovulating cycles were achieved in 82%, improvement of hirsutism in 73.8% and retreat in 92.9% fertility by 76.9% of patients after conservative treatment.