The effectiveness of two oral contraceptives in suppressing plasma androstenedione, testosterone, LH, and FSH, and in stimulating plasma testosterone-binding capacity in hirsute women

The attention-emotion interaction in healthy female participants on oral contraceptives during 1-week escitalopram intake

Previous findings in healthy humans suggest that selective serotonin reuptake inhibitors (SSRIs) modulate emotional processing via earlier changes in attention. However, many previous studies have provided inconsistent findings. One possible reason for such inconsistencies is that these studies did not control for the influence of either sex or sex hormone fluctuations. To address this inconsistency, we administered 20 mg escitalopram or placebo for seven consecutive days in a randomized, double-blind, placebo-controlled design to sixty healthy female participants with a minimum of 3 months oral contraceptive (OC) intake. Participants performed a modified version of an emotional flanker task before drug administration, after a single dose, after 1 week of SSRI intake, and after a 1-month wash-out period. Supported by Bayesian analyses, our results do not suggest a modulatory effect of escitalopram on behavioral measures of early attentional-emotional interaction in female individuals with regular OC use. While the specific conditions of our task may be a contributing factor, it is also possible that a practice effect in a healthy sample may mask the effects of escitalopram on the attentional-emotional interplay. Consequently, 1 week of escitalopram administration may not modulate attention toward negative emotional distractors outside the focus of attention in healthy female participants taking OCs. While further research in naturally cycling females and patient samples is needed, our results represent a valuable contribution toward the preclinical investigation of antidepressant treatment.

Interventions for hirsutism (excluding laser and photoepilation therapy alone)

BACKGROUND

Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective.

OBJECTIVES

To assess the effects of interventions (except laser and light-based therapies alone) for hirsutism.

SEARCH METHODS

We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism.

DATA COLLECTION AND ANALYSIS

Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses.

MAIN RESULTS

We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty-eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow-up above 40%.Primary outcomes, 'participant-reported improvement of hirsutism' and 'change in health-related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin-releasing hormone (GnRH) analogues)).Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one-third of studies.The quality of evidence was moderate to very low for most outcomes.There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman-Gallwey scores. The mean difference (MD) was -1.84 (95% confidence interval (CI) -3.86 to 0.18).There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman-Gallwey scores more effectively than placebo (MD -7.60, 95% CI -10.53 to -4.67 and MD -7.20, 95% CI -10.15 to -4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87).Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman-Gallwey scores (MD -7.69, 95% CI -10.12 to -5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD -1.90, 95% CI -5.01 to 1.21 and MD 0.49, 95% CI -1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI -0.58 to 3.56 and MD 0.40, 95% CI -1.18 to 1.98) (low quality evidence).Although there was very low quality evidence of a difference in reduction of Ferriman-Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD -5.73, 95% CI -6.87 to -4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached.Metformin demonstrated no benefit over placebo in reduction of Ferriman-Gallwey scores (MD 0.05, 95% CI -1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements.We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman-Gallwey scores.Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman-Gallwey scores (low quality evidence). Ferriman-Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD -6.30, 95% CI -9.83 to -2.77) (very low quality evidence). Data showing reductions in Ferriman-Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%).Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman-Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs.

AUTHORS' CONCLUSIONS

Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision-making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects.Further research should consist of well-designed, rigorously reported, head-to-head trials examining OCPs combined with antiandrogens or 5α-reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α-reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment.

Retrospective, observational study on the effects and tolerability of flutamide in a large population of patients with acne and seborrhea over a 15-year period

The long-term effects and tolerability of flutamide (Flu) in women with acne and seborrhea were evaluated. Over the 15-year period, which spans from January 1991 to January 2006, a total of 230 Caucasian women with acne, 211 of which also with seborrhea, received yearly reducing doses (250, 125, and 62.5 mg/day) of Flu alone or combined with oral contraceptive for a period varying from 3 to 6 years and more. Clinical and endocrine evaluations were performed half-yearly and yearly, respectively, in the first 3 years of the study, and yearly in the following years. Liver function evaluations were performed quarterly. Both the groups of patients under Flu therapy showed a similar, marked decrease in acne and seborrhea scores after 6 months of treatment compared with basal values. The maximum drug effect was observed after 1 year, and it was maintained during the following years of treatment. Androgens were strongly suppressed during treatment. During the first year of treatment with 250 mg/day, 4.8% of patients interrupted the study due to hepatic disorders. During the following years on the 125 and 62.5 mg/day doses, no transaminase elevation was observed. The study supports very low-dose Flu as a first-line therapy for women with acne and seborrhea.

Does St. John's wort interfere with the antiandrogenic effect of oral contraceptive pills?

BACKGROUND

St. John's wort (SJW), a commonly used herbal remedy, has been shown to compromise the efficacy of drugs, including oral contraceptive pills (OCPs), by inducing cytochrome P-450. We investigated whether the simultaneous use of SJW with OCPs resulted in elevated serum androgen levels with implications of impaired OCP treatment of hirsutism and acne.

MATERIALS AND METHODS

Fifteen healthy women were treated with the low-dose OC Loestrin 1/20trade mark for 2 months and then additionally with SJW for 2 months. Androgen and sex hormone-binding globulin (SHBG) levels were measured in serum by immunoassay methods; free testosterone (fT) was calculated. Results were analyzed using the Wilcoxon signed-rank test.

RESULTS

There were no statistically significant differences in androgen levels after the addition of SJW in women using Loestrin 1/20trade mark. However, there were decreases in total testosterone and fT levels (10.7% and 15.8%, respectively) along with a small increase in SHBG levels (7.0%).

CONCLUSIONS

In women using OCPs and SJW simultaneously, it appears that SJW does not interfere with the antiandrogenic properties of OCPs.

Efficacy of second versus third generation oral contraceptives in the treatment of hirsutism

OBJECTIVE

To compare second versus third generation combination oral contraceptives (OCs) in the treatment of hirsutism.

METHODS

Women with hirsutism, as defined by a minimum Ferriman-Gallwey score of 10, were randomized in a double-blind fashion to receive an OC containing either ethinyl estradiol/desogestrel or ethinyl estradiol/levonorgestrel for 9 months of treatment. Ferriman-Gallwey scores, androgen levels and sex hormone-binding globulin were measured at baseline and every 3 months for the duration of the study. Hormones were measured in duplicate by radioimmunoassay.

RESULTS

Of the 47 women enrolled, 24 were randomized to ethinyl estradiol/desogestrel and 23 were randomized to ethinyl estradiol/levonorgestrel. Mean sex hormone-binding globulin increased significantly in subjects using the desogestrel-containing contraceptive compared with the levonorgestrel-containing contraceptive. Ten subjects completed the 9 months of treatment in the levonorgestrel group and 11 completed the study in the desogestrel group. Mean free testosterone and 3alpha-androstanediol glucuronide decreased significantly in the group receiving ethinyl estradiol/desogestrel but not in the ethinyl estradiol/levonorgestrel group. Mean Ferriman-Gallwey scores decreased significantly in both treatment groups. Improvement in mean Ferriman-Gallwey score was 35.7 +/- 38.1% (p < 0.001) for the ethinyl estradiol/desogestrel arm and 33.4 +/- 27.3% (p < 0.001) for the ethinyl estradiol/levonorgestrel arm. There were no statistically significant differences found in the improvement of Ferriman-Gallwey scores between the two treatment arms, although the power to detect a difference was limited by the small sample size.

CONCLUSIONS

Treatment of hirsute women with third generation OCs containing desogestrel results in a significant increase in sex hormone-binding globulin and decrease in free testosterone and 3alpha-androstanediol glucuronide. Both second and third generation OCs were clinically effective in treating hirsutism.

Anti-androgens for the treatment of hirsutism

Many alternatives exist for treating hirsutism. Based on an analysis of scientific literature and on the experiences of the author, the most common anti-androgen agents are discussed in this review. Androgen receptor blockers (cyproterone acetate, flutamide and spironolactone), 5 alpha-reductase inhibitors (finasteride) and androgen-suppressing agents (gonadotrophin-releasing hormone [GnRH] agonists, oestroprogestins, corticosteroids and insulin-sensitising agents) are evaluated and compared. The importance of diagnosis in choosing the most appropriate anti-androgen treatment is also discussed.

A risk-benefit assessment of pharmacological therapies for hirsutism

In recent years, many new therapeutic regimens for hirsutism have been introduced. This has considerably enlarged the different choices of the physician but at the same time has produced considerable confusion and uncertainty as to what is the best possible therapy for the single patient or for the different pathologies of this condition. This review presents data on the characteristics, adverse effects and effective dosage for the more commonly used drugs for hirsutism. In most patients, low doses of antiandrogens (cyproterone acetate, flutamide or spironolactone) are used with few adverse effects and good results in terms of improvement of the hirsutism. Patients with severe hyperandrogenic hirsutism may require larger doses of antiandrogens. In only a few patients, therapy with agents that primarily reduce androgen secretion (mostly a gonadotropin releasing hormone agonist) is needed. In responsive patients, dexamethasone may be used at low doses (associated with an antiandrogen) to prolong the length of the remission. Finally, agents that inhibit 5alpha-reductase activity (finasteride) may be used as alternative to low dose antiandrogen therapy but the results are often less satisfactory.

Prospective randomized study comparing the long-acting gonadotropin-releasing hormone agonist triptorelin, flutamide, and cyproterone acetate, used in combination with an oral contraceptive, in the treatment of hirsutism

OBJECTIVE

To compare triptorelin, cyproterone acetate (CPA), and flutamide, in combination with an oral contraceptive, in the treatment of hirsutism.

DESIGN

Prospective randomized study.

SETTING(S)

Tertiary care hospital.

PATIENT(S)

Thirty-nine hirsute women with idiopathic or functional ovarian hyperandrogenism.

INTERVENTION(S)

Patients were randomly assigned to receive triptorelin (3.75 mg IM every 28 days), CPA (100 mg/d orally on days 1-10 of the menstrual cycle), or flutamide (250 mg orally twice daily). All the patients also received a triphasic oral contraceptive.

MAIN OUTCOME MEASURE(S)

Before and after 3 and 9 months of treatment, the Ferriman-Gallwey score, hepatic function, and gonadal and adrenal steroid profiles were evaluated.

RESULTS

Thirty-three patients completed the 9-month study period. The Ferriman-Gallwey score decreased in all the groups. In the patients treated with CPA or flutamide, a decrease in the hirsutism score was noted as soon as after 3 months of treatment. This decrease was more pronounced after 9 months of treatment, especially in the patients who received flutamide, who had lower hirsutism scores compared with the other treatment groups. None of the patients had abnormal liver function test results. There was a mild increase in serum lipid concentrations, mostly in the group treated with triptorelin.

CONCLUSION(S)

Triptorelin, CPA, and flutamide are effective drugs for the treatment of hirsutism. Flutamide results in a greater reduction in the hirsutism score, but CPA also offers satisfactory results at a much lower cost. Triptorelin has no advantages over flutamide and CPA, and is the most expensive of the three drugs tested.

Hormonal contraception and ovarian pathology

Despite sporadic ovarian follicle development, hormonal contraception consistently and uniformly prevents steroidogenesis and ovulation. For their suppressive activity on ovarian androgen production, oral contraceptives remain the treatment of choice for acne and hirsutism in most hyperandrogenic women. Inhibition of the synthesis of endometrial estrogen receptors explains the effectiveness of hormonal contraception in the therapy of dysfunctional uterine bleeding and in the treatment of pain associated with pelvic endometriosis. Through the inhibition of ovarian cyclicity, the contraceptive pill lowers the incidence of functional ovarian cysts, benign breast disease, dysmenorrhea and premenstrual syndrome and shows a consistent and long-lasting protection against ovarian and endometrial cancer.

Comparison of four different treatment regimes in hirsutism related to polycystic ovary syndrome

Polycystic ovary syndrome is the most common endocrinological problem associated with hirsutism. The objective of this study was to compare four different treatment modalities for hirsutism related to this syndrome. Pelvic ultrasonography was performed on all patients who were referred to our Reproductive Endocrinology Outpatient Clinic because of complaints of hirsutism. After exclusion of hyperandrogenism caused by endocrine abnormalities other than polycystic ovary syndrome, 141 patients were included in the study. Patients were divided into four groups in regard to the drug chosen for treatment. Group 1 (n = 48) received low-dose combined oral contraceptive. Group 2 (n = 65) was treated with cyproterone acetate 100 mg daily for the first 10 days of a 21-day cycle with an oral contraceptive containing 2 mg cyproterone acetate, Group 3 (n = 12) with spironolactone (100-200 mg daily) and Group 4 (n = 16) with ketoconazole (400 mg daily). All patients were followed frequently with respect to side-effects, hirsutism scoring, and lipid and hormonal levels. All four drug regimens were effective in the treatment of hirsutism related to polycystic ovary syndrome, but the most effective seemed to be ketoconazole. The decrement level in hirsutism scoring was the largest in the ketoconazole group, followed by the cyproterone, oral contraceptive and spironolactone groups (34.6 +/- 2.2%, 20.1 +/- 2.7%, 18.1 +/- 2.7% and 12.8 +/- 3.7%, respectively, p < 0.05). Although high-density lipoprotein-cholesterol levels increased in all groups, this increment was smaller in Group 4 than in Groups 1 and 2 (5.1 +/- 2.8%, 34.1 +/- 5.5% and 29.1 +/- 4.9%, respectively, p < 0.05), but not statistically different from that in Group 3 (22.3 +/- 5.9%). The free testosterone levels decreased after treatment in all groups, but the decrement ratios did not differ significantly among groups, although the decrease in free testosterone levels with treatment seemed to be higher in the ketoconazole group than in Groups 1, 2 and 3 (57.0 +/- 2.5%, 22.7 +/- 10.2%, 26.7 +/- 6.5% and 9.5 +/- 19.9%, respectively). In conclusion, ketoconazole seems to be an excellent alternative to more-recognized therapies, but its effect on lipoprotein profile requires further study, because the hyperandrogenism, and the other problems related to hyperandrogenism besides hirsutism, should also be treated.

Pituitary function is altered during the same cycle in women with polycystic ovary syndrome treated with continuous or cyclic oral contraceptives or a gonadotropin-releasing hormone agonist

OBJECTIVE

To determine if continuous oral contraceptive (OC) therapy was superior to a cyclic regimen in achieving persistent pituitary suppression of LH in patients with polycystic ovary syndrome (PCOS).

DESIGN

Fourteen women (ages 16 to 41 years) with PCOS received one of three treatment groups: continuous OC therapy (30 micrograms ethinyl E2 plus 150 micrograms desogestrel), cyclic OC therapy, or monthly injections of a GnRH agonist (GnRH-a, leuprolide acetate depot 3.75 mg) for 3 months. Basal hormone levels were obtained before initiating therapy, on days 15 to 17 of the 3rd month of treatment (study 1) and again on days 26 to 28 of the 3rd month (study 2). A GnRH stimulation test was also performed during study 1 and study 2.

RESULTS

After 3 months of treatment, LH levels were decreased significantly in all groups with less effective suppression observed in the cyclic OC group compared with the continuous OC or GnRH-a groups. A significant rise in LH was found only in the cyclic OC group after 5 to 7 days of placebo treatment (study 1 versus study 2). An increase in T was also observed in the cyclic OC group during study 2, whereas the continuous OC and GnRH-a groups showed continued inhibition of T levels. Although there was no significant difference in LH area under the curve (AUC) measurements after GnRH stimulation in study 1 versus study 2, the LH AUC was significantly greater in both studies in the cyclic OC group compared with the continuous OC or GnRH-a groups.

CONCLUSIONS

Increased LH secretion during the week of placebo in the cyclic OC group was associated with a concomitant increase in T. The striking rise in LH secretion after GnRH stimulation in the cyclic OC group may represent increased pituitary sensitivity in patients receiving cyclic OCs regardless of the phase of the treatment cycle, perhaps secondary to increased pituitary stores of LH in these women.

Clinical and hormonal effects of gonadotropin-releasing hormone agonist plus an oral contraceptive in severely hirsute patients with polycystic ovary disease

OBJECTIVE

To evaluate the therapeutic effects of a GnRH agonist (GnRH-a), leuprolide acetate (LA) plus a pill containing ethinyl E2 plus cyproterone acetate (CPA) in a group of women with severe hirsutism who were unresponsive to oral contraceptive (OC) therapy.

DESIGN

Twenty-four patients suffering from severe hirsutism secondary to polycystic ovary disease (PCOD) were treated for 12 months with 3.75 mg IM LA every 28 days in association with 0.035 mg/d ethinyl E2 plus 2 mg/d CPA (Diane; Schering, Berlin, Germany) for 21 d/mo.

SETTING

Patients were recruited in the Institute of Obstetrics and Gynecology, St. Bambino Hospital, University of Catania, Catania, Italy. Hormonal assays were performed in the Hormone Laboratories of St. Bambino Hospital, University of Catania, Catania, Italy.

MAIN OUTCOME MEASURES

Every 3 months the hirsutism score was evaluated. Mean serum concentrations of LH, FSH, E2, total and free T, androstenedione (A), sex hormone-binding globulin (SHBG), and DHEAS were determined. Every 6 months a vaginal ultrasound examination was performed.

RESULTS

In all patients after 6 and 12 months of treatment with LA plus OC, the hirsutism score improved significantly. Serum levels of LH, FSH, E2, total and free T, A, and DHEAS decreased significantly, whereas SHBG showed a marked increase. A significant reduction in the ovarian size was observed.

CONCLUSION

Gonadotropin-releasing hormone agonist, associated with a pill containing CPA, reduced the hirsutism in severely affected women with PCOD who are unresponsive to OC treatment alone.

Treatment of hirsutism with flutamide and a low-dosage oral contraceptive in polycystic ovarian disease patients

OBJECTIVE

To evaluate the clinical and hormonal response of the antiandrogen flutamide (Eulexin, Schering Plough, Milan, SA, Italy) associated with a low dosage oral contraceptive (OC) in a group of hirsute women who were unresponsive to OC treatment.

DESIGN

Twenty-two polycystic ovarian disease (PCOD) patients with hirsutism were treated with flutamide (250 mg twice/d) in association with ethinyl-E2 (0.030 mg/d) plus desogestrel (0.150 mg/d) (Practil 21; Organon, Rome, Italy) for 21 d/mo.

SETTING

Patients were recruited in the Institute of Obstetrical and Gynaecological Pathology, St. Bambino Hospital, University of Catania, Italy. Hormonal assays were performed in the Hormone Laboratories of St. Bambino Hospital, University of Catania, Catania, Italy.

MAIN OUTCOME MEASURE

Every 2 months the hirsutism score was evaluated using the Ferriman-Gallwey hair density index. Mean plasma concentrations of LH, FSH, E2, total T, dihydrotestosterone (DHT), androstenedione (A), sex hormone-binding globulin, DHEAS were determined.

RESULTS

After 8 months treatment with flutamide and low dosage OC, the Ferriman-Gallwey score improved in all patients, mean values decreasing from 25.4 +/- 3.96 to 14.6 +/- 1.92. Plasma levels of total T and E2 were unchanged, whereas LH, FSH, A, and DHT values decreased significantly. Sex hormone-binding globulin levels showed a marked increase.

CONCLUSION

Flutamide, associated with low dosage OC, favorably influence the hirsutism in PCOD women who are unresponsive to OC treatment alone.

Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II

In the May 1993 issue of the Journal we reviewed the basic science of androgen biology in women. We now discuss the evaluation of suspected hyperandrogenism and the therapeutic modalities available.

Selective venous catheterization in the evaluation of hyperandrogenism

Retrograde bilateral ovarian-adrenal vein catheterization was carried out in 16 patients with plasma testosterone levels exceeding 1.4 ng/ml (4.85 nmol/l). While pelvic ultrasonography and computerized axial tomographic scan failed to locate the androgen-producing ovarian tumors, catheterization led to a diagnosis of occult ovarian tumor in 5 patients, based on the observation of an abnormally-high and unilateral ovarian-peripheral vein testosterone gradient, which was subsequently confirmed histopathologically. In one case, unilateral elevation of the adrenal-peripheral vein testosterone gradient was found, complementing the ultrasonographic finding of an adrenal mass and confirming the diagnosis of a virilizing adrenal tumor. In the other 10 patients, gradient analysis ruled out an androgen-producing tumor, leading to the identification of nontumoral hyperandrogeny, such as a severe form of the polycystic ovary syndrome in the 6 premenopausal patients and of ovarian stromal and hilus cell hyperplasia in the 4 menopausal patients. In conclusion, appropriate indication of selective catheterization may considerably reduce the need for exploratory surgery and may help in selecting the adequate surgical approach.

Potential utility of gonadotropin-releasing hormone agonists in the management of ovarian hyperandrogenism

Gonadotropin-releasing hormone agonists are potent suppressors of ovarian androgen biosynthesis even in the face of severe hyperandrogenism (e.g., hyperinsulinemia, hyperthecosis). Gonadotropin-releasing hormone agonists are clinically useful in the context of hirsutism. The use of Gn-RH-a in the context of hirsutism is not duration-limited in that the induced hypoestrogenism and its consequent complications are likely to be effectively managed by the concurrent provision of estrogen replacement therapy.

Treatment with dexamethasone of androgen excess in adolescent patients

Fourteen hirsute girls, ages 12 to 22 years (mean +/- SD: 17.2 +/- 2.6 years), in whom 21-hydroxylase deficiency was excluded by a 1-hour intravenous alpha 1-24 corticotropin test, were evaluated by a 4-day dexamethasone test and then treated with a bedtime dose of dexamethasone (0.5 mg in 10 patients, 0.25 mg in four) for 0.6 to 3.4 years (1.3 +/- 0.8 years). Hirsutism decreased in four patients, did not change in nine, and increased in one. Of the 10 patients with irregular menses, only three developed regular cycles while taking dexamethasone. During long-term dexamethasone therapy, serum levels of testosterone decreased from 102 +/- 22 to 72 +/- 27 ng/dL, free testosterone from 35 +/- 11 to 19 +/- 8 pg/mL, and dehydroepiandrosterone sulfate from 396 +/- 138 to 171 +/- 101 micrograms/dL. Although free testosterone decreased to less than 15 pg/mL in eight of 14 patients with the suppression test, only four patients had free testosterone levels less than 15 pg/mL during therapy. Two of the 14 patients have had no recurrence of hirsutism or increase in serum androgens after 28 and 29 months, respectively, after dexamethasone therapy was discontinued. Oral contraceptives were given to nine patients inadequately responsive to bedtime dexamethasone therapy. The mean percent decrease of testosterone and free testosterone levels during oral contraceptive therapy was significantly greater than during long-term treatment with dexamethasone, and hirsutism lessened in all. We conclude that a single bedtime dose of dexamethasone is satisfactory only in patients who maintain serum free testosterone values less than 15 pg/mL without side effects. For other patients, either another glucocorticoid or, in most cases, ovulation suppression should be prescribed for adolescents with progressive hirsutism and elevated androgen levels.

Exercise and Serum Androgens in Women

In brief: Little information exists about the role of androgens in women relative to exercise, particularly resistance exercise. This study examines (1) the effect of a ten-week hydraulic resistance exercise program on serum androgen levels, strength, and lean body weight and (2) the relationship of serum androgen levels to strength and lean body weight before and after the ten-week program. Thirteen experimental and five control subjects, all college women, participated. Training did not result in significant increases in androgen hormones, although there were significant gains in strength. In addition, no significant correlations were observed between testosterone, androstenedione, or sex hormone-binding globulin and pretraining and delta values of strength or lean body weight (r <.49).

Increased adrenocortical responsiveness to exogenous ACTH in oral contraceptive users

To evaluate the effects of changing steroid milieu on adrenocortical function, basal levels and responses of cortisol, 17-hydroxyprogesterone (17PO), androstenedione (A), dehydroepiandrosterone (DHEA), and testosterone to exogenous synthetic ACTH were investigated in six normal women during the early follicular (EF) and midluteal (ML) phases of the menstrual cycle and in five women on an oral contraceptive (OC) agent (35 micrograms ethinyl estradiol and 1 mg ethynodiol diacetate, Demulen). Baseline serum steroid and cortisol binding globulin (CBG) levels were measured on days 3-7 and 21-23 of the menstrual cycle in the normal subjects and on days 3-7 of OC treatment cycles. ACTH stimulation (10 micrograms m-2 i.v. bolus) was performed following dexamethasone suppression (0.5 mg p.o. q 6 h X 4). Basal levels of cortisol and CBG as well as cortisol responses to ACTH were increased in OC users relative to normal women tested during both the EF and ML phases of the cycle. In addition, 17PO levels were increased during the ML phase both before and following dexamethasone suppression compared to levels present in the EF phase and in OC users, no doubt because of increased ovarian steroidogenesis.

The effect of an oral contraceptive containing ethinylestradiol and desogestrel on hair growth and hormonal parameters of hirsute women

A group of 22 hirsute women was treated with a combination of 0.030 mg of ethinylestradiol and 0.150 mg of desogestrel (EE-DG) for 6 or 12 months. After 6 months the hair growth was decreased in 17 patients. There was a significant decrease in testosterone/sex hormone binding globulin (T/SHBG) ratio and serum dehydroepiandrosterone sulphate (DHEAS) levels. The changes in the hirsutism and the T/SHBG ratio showed correlation (rho 0.36, P less than 0.05). The patient groups with the best and the poorest clinical response differed in terms of summed changes in the T/SHBG ratio and DHEAS. These findings suggest that the therapeutic effect of the EE-DG is based on combined changes in the related hormone levels.

The effect of age, weight-related parameters and hormonal contraceptives on andrological assays

Serum levels of dehydroepiandrosterone-sulfate (DHEA-S), testosterone (T), sex hormone binding globulin (SHBG), T/SHBG ratio and the calculated free T were evaluated in healthy female blood donors. The influence of age and weight-related parameters were studied together with the effects of 9 different oral contraceptives. A gradual decrease with age of DHEA-S, T, T/SHBG and free T levels were observed. The Quetelet index showed a significant negative correlation with the androgen levels except for the T/SHBG ratio. In the females using contraceptives, DHEA-S levels were only significantly decreased in the group using Depo-provera. Most contraceptive users had slightly lowered T levels. Marvelon and Ministat induced an increase in the SHBG levels. Androstenedione (A) levels were studied for some of the contraceptives (Ministat, Marvelon, Lyndiol, Depoprovera); levels were found to be significantly lower than in normal premenopausal women. A highly significant correlation was demonstrated between DHEA-S and the T, T/SHBG and free T levels in the serum of 106 normal women.

The treatment of hirsutism with a combination of desogestrel and ethinyl oestradiol

Some available oral contraceptive agents are unsuitable for the treatment of hirsutism since, although they suppress endogenous gonadotrophins and so ovarian androgen production, they contain a progestogen which is itself androgenic. The combination of 30 micrograms ethinyl oestradiol (EE2) and 150 micrograms desogestrel (Marvelon) does not suffer from this drawback. We have therefore assessed its value in 15 hirsute women treated for one year. Mean +/- SE androgen-dependent hair growth, assessed photographically fell from 0.31 +/- 0.01 to 0.23 +/- 0.01 mm/d at 1 year (P less than 0.001). Ten of the fifteen patients reported definite subjective improvement. Treatment was associated with a marked rise in SHBG concentration identical to that seen with 30 micrograms EE2 alone. By four months there were significant falls in serum levels of androstenedione and LH throughout the cycle, but not for testosterone, dihydrotestosterone or 5 alpha-androstane 3 alpha, beta 17 -diol. Calculated free testosterone levels were significantly suppressed. All the biochemical changes were maintained after seven months of treatment. We conclude that this preparation is a suitable oral contraceptive for the treatment of hirsute women.

Effect of D-thyroxine on serum sex hormone binding globulin (SHBG), testosterone, and pituitary-thyroid function in euthyroid subjects

Concentrations of serum sex hormone binding globulin (SHBG) and free testosterone (T) were examined in 10 euthyroid subjects (5 men and 5 women) before, during and after 30 days of the daily ingestion of 1 or 4 mg D-thyroxine (D-T4), the thyroxine analog that has only 1-15% of the calorigenic effect of L-thyroxine (L-T4). No changes in serum L-T4 or triiodothyronine (T3), serum cholesterol, SHBG, T, progesterone, estradiol-17 beta, or free T concentrations were observed in response to the 1 mg dose, but there was a slight elevation in the free thyroxine index (FTI) and a significant (p less than 0.02) suppression of the thyrotropin (TSH) response to thyrotropin releasing hormone (TRH). The 4 mg dose of D-T4 induced an increase in SHBG levels in all but one man. There was a significant negative correlation between the SHBG and percent free T (p less than 0.05) although the mass of free T did not change. As a group, the women responded with a greater increase in SHBG and decrease in percent free T than the men. Serum cholesterol decreased (p less than 0.01), all serum thyroid hormone values measured by RIA were increased (p less than 0.01), and the TSH response to TRH was completely suppressed. Despite these changes, the subjects remained clinically euthyroid. Concentrations of testosterone, progesterone and estradiol-17 beta remained unchanged. Serum luteinizing hormone (LH), which was evaluated in the men only, also did not change during the daily administration of 4 mg D-T4.

Ovarian function is effectively inhibited by a low-dose triphasic oral contraceptive containing ethinylestradiol and levonorgestrel

For various metabolic and clinical reasons, it has been strongly advocated to reduce the dose of both the estrogen and progestogen components of oral contraceptives (OCs). In this study, we compared after 6 months of treatment, the action on various hormonal parameters of a standard-dose combined OC containing ethinylestradiol (EE) 0.050 mg and levonorgestrel (LNg) 0.250 mg and a low-dose triphasic combination containing a 59% reduced amount of the same steroids. Hormonal measurements in the last 3 days of OC intake indicated that basal levels of FSH and LH were less inhibited by the low-dose preparation, while PRL levels were unchanged. However, gonadal function was effectively inhibited by both high and low dose OCs, as demonstrated by equally low levels of E2, E1, P and 17-P. Consequently, no residual gonadal function could be anticipated from the observed low steroid concentrations. These results corroborated other studies (reviewed in this paper) in which serial hormonal measurements also revealed a complete lack of follicular maturation during low-dose triphasic OC treatment. Moreover, inhibition of circulating levels of A, DHEA, DHEAS, free T and DHT was similarly obtained with both preparations. Collectively, these data indicate that ovarian function is as effectively inhibited by a low-dose triphasic preparation as by a higher, standard-dose OC containing the same steroids.

Sex-hormone-binding globulin in clinically hyperandrogenic women: association of plasma concentrations with body weight

The relationship of sex-hormone-binding globulin (SHBG) with actual body weight (ABW), ideal body weight (IBW), ABW as percentage of the IBW (% IBW), Quetelet index (weight/height2) and plasma concentrations of various androgens and 17 beta-estradiol (E2) were studied in 9 normal and 57 hirsute patients (group 1). In hirsute patients, plasma levels (ng/dl, mean +/- standard error of the mean [SEM]) of testosterone (T; 77 +/- 4), dihydrotestosterone (DHT; 26 +/- 2), androstenedione (delta 4A; 184 +/- 16), and SHBG (0.91 +/- 0.05 micrograms DHT/dl) but not of dehydroepiandrosterone (DHA; 608 +/- 55) and E2 (6.1 +/- 0.1) were significantly different from those in controls. A negative correlation was observed between SHBG and ABW, both in controls (P less than 0.05) and hirsute patients (P less than 0.01). The hirsute patient population was subdivided into two groups: nonobese (group 2; 60 +/- 1 kg; n = 35) and obese (group 3; 96 +/- 2 kg; n = 22). Plasma androgens, T/SHBG (an index of free T) and E2 in groups 2 and 3 (T: 75 +/- 4, 81 +/- 7; DHT: 24 +/- 2, 28 +/- 3; T/SHBG: 85 +/- 7, 105 +/- 11; delta 4A: 203 +/- 13, 155 +/- 16; DHA: 663 +/- 83, 521 +/- 49; E2: 6.1 +/- 1.0, 5.8 +/- 0.9) were similar; yet SHBG in group 3 (0.75 +/- 0.04) was significantly lower than in group 2 (1.0 +/- 0.01). Inverse correlations between SHBG and ABW, % IBW, and ABW/H2 were observed in group 2 but not in group 3. We conclude that a negative relationship exists between SHBG and the body size in nonobese women and that in hirsute patients, obesity leads to a further lowering of SHBG through mechanism(s) probably independent of androgens.

Plasma androgens, 17 beta-estradiol, and sex hormone-binding globulin in patients with hirsutism and/or clitoromegaly

Plasma androgen, 17 beta-estradiol, and sex hormone-binding globulin (SHBG) levels were measured in 11 normal subjects (group 1), 18 hirsute patients with no clitoromegaly (group 2), 13 hirsute patients with clitoromegaly (group 3), and 8 patients with clitoromegaly but no hirsutism (group 4). Significantly elevated levels of testosterone (T) and dihydrotestosterone (DHT) were found in groups 2 and 3 but not in group 4 when compared with group 1. In contrast, levels of dehydroepiandrosterone (DHEA) in groups 1 and 2 were comparable but significantly lower than those in group 3 and 4; the levels in the latter two groups were not significantly different from each other. In groups 2, 3, and 4, levels of androstenedione (delta 4A) and the factor T/SHBG were significantly elevated whereas SHBG levels were significantly suppressed when compared with those of group 1. The clitoral index correlated (P less than 0.01) with DHEA levels in group 3. It is concluded that clitoromegaly without hirsutism is associated with increased plasma levels of DHEA and delta 4A. In contrast, hirsutism without clitoromegaly is associated with elevated levels of T, DHT, and delta 4A but normal DHEA levels.

Plasma androgens and sex hormone-binding globulin in the evaluation of hirsute females

Hirsutism is usually associated with increased testosterone (T) production and metabolic clearance rates. Considerable overlap of plasma T occurs between hirsute and normal groups. Plasma levels of sex hormone-binding globulin (SHBG) and the factor T/SHBG might separate hirsute patients from normal subjects better than plasma T. A group of 39 hirsute females and 22 normal ovulatory control subjects were studied. Plasma T, androstenedione, and dehydroepiandrosterone were measured by radioimmunoassay; apparent free T (AFT) by equilibrium dialysis; and SHGBG by a method based on saturating the binding sites by labeled dihydrotestosterone. Mean levels of androgens and SHBG of the hirsute patients were significantly different from those of the normal subjects (P less than 0.01). Positive linear correlations were observed between T and AFT, T/SHBG and AFT, and T/SHBG and T; a negative correlation was observed between T/SHBG and SHBG, but no correlation was observed between SHBG and T or AFT. Thirty (77%) of the patients had elevated T/SHBG factors and 28 (72%) had suppressed SHBG levels. Only two patients (5%) had hirsutism associated with normal levels of androgens, SHBG, and T/SHBG. We conclude that SHBG and the factor T/SHBG separate the hirsute population better than any of the androgens studied.

Effect of contraceptive steroids on serum levels of sex hormone binding globulin and caeruloplasmin

Serum sex hormone binding globulin and caeruloplasmin levels were measured in women receiving 30 microgram or 50 microgram ethinyl oestradiol daily or a 'triphasic' formulation containing ethinyl oestradiol and levonorgestrel. In women taking ethinyl oestradiol alone, there was a rapid increase in the levels of both proteins, and even 10 days after the last tablet the levels were still elevated. There was no significant difference between the serum levels of the proteins in women receiving the two doses of ethinyl oestradiol, but the percentage change was significantly higher in the 50 microgram group than in the 30 microgram group. In women using the 'triphasic' formulation, levels of the proteins were significantly lower than in women taking ethinyl oestradiol alone. There was a marked variation between women in the changes produced. This marked inter-subject variation may be important in the development of side-effects in women using steroidal contraceptives.

Oligomenorrhea in adolescent girls

Forty-two patients ages 15 to 20 years (average 17.3 years) were evaluated for oligomenorrhea. Group I consisted of 19 patients with evidence of androgen excess (hirsutism, clitoromegaly, acne); and Group II included 23 patients without evidence of androgen excess. Sixteen of the 19 patients in Group I had elevated serum LH and normal FSH values. Serum total testosterone concentration was elevated in 12 patients and free T was elevated in one additional patient. In nine patients urinary 17KS excretion was elevated and dexamethasone suppressible. For the purpose of treatment, patients in Group I were divided into three subgroups: IA, polycystic ovary syndrome--12 patients; IB, adrenal block--two patients; IC, combined adrenal and ovarian hyperandrogenism--five patients. Among the 23 Group II patients, four had persistently elevated serum LH and normal FSH values, suggesting PCO; three had menopausal levels of LA and FSH; one had hyperprolactinemia and a depressed floor of the pituitary sella; and the remaining 15 patients had low to normal serum levels of LH and FSH, consistent with hypothalamic suppression. Guidelines for the diagnosis and treatment of adolescents with oligomenorrhea are discussed on the basis of these findings.

Ovarian hyperandrogenism with normal and abnormal histologic findings of the ovaries

Thirty-one patients with clinical features of polycystic ovary syndrome (PCO) were studied to determine the correlation between biochemical and histologic findings. The biochemical features investigated were the effects of adrenocortical and ovarian suppression by dexamethasone and oral contraceptives (Ovulen) on plasma free androgens. Four patients showed a histologic picture consistent with PCO (Group A), and five had histologically normal ovaries (Group B). The remaining 22 patients had no tissue available for histologic examination (Group C). The baseline values of plasma free testosterone (FTel) were higher and those of testosterone-binding globulin (TeBG) were lower (p less than 0.05) in Group A than in Group B, although plasma total testosterone (T) and the free 17beta-hydroxysteroid androgen index (FHSl) were similar in the two groups. During dexamethasone administration in all study groups, T and FTel fell slightly (17.7% to 33.8%), and FHSl levels decreased moderately (36% to 46.6%); in no case did both indices of free androgen levels fall to the normal range for dexamethasone-suppressed women. However, no change was noted in TeBG in all three groups. On the other hand, Ovulen treatment suppressed T and free androgens to normal in all groups, and raised TeBG more than 350% from the baseline. These data suggest a decrease in androgen production. The effects of dexamethasone and Ovulen on all three groups were similar in percent changes. As Group B patients resemble those of Group A biochemically and clinically, except for possibly being less hyperandrogenic, the concept of ovarian hyperandrogenism should be expanded to include patients with no anatomic ovarian abnormality, particularly in milder cases.

Comparative studies of the ethynyl estrogens used in oral contraceptives: effects with and without progestational agents on plasma androstenedione, testosterone, and testosterone binding in humans, baboons, and beagles

The effects of ethynylestradiol or mestranol given in cyclic fashion, with and without a progestational compound (norethindrone acetate, dl-norgestrel, or megestrol acetate), on plasma androgens and their binding were examined in adult women, female baboons, and beagles. The two estrogens are equivalent in their effect, and there were essentially no dose-related differences over the range examined. In human subjects, the estrogens increased total testosterone and testosterone binding, and decreased free testosterone. In baboons, estrogen produced a transient decrease in total testosterone and an increase in binding. The levels of progestational agents used did not affect total testosterone in humans, as is commonly observed with commercial agents, but did decrease it in baboons. Percentage binding was decreased in both species by the 19-nor compounds, but not by megestrol. Androstenedione levels were unaffected in human subjects, but effects of both estrogens and progestins were seen in baboons. Because of the very low levels of androgens in female beagles, this species did not lend itself well to a study of this kind. However, an increase in testosterone binding was induced by estrogen even in the absence of testosterone/estrogen-binding globulin.

Free testosterone concentration in serum: elevation is the hallmark of hirsutism

A simple, reliable procedure for quantitating the concentration of free (not protein bound and thus biologically active) testosterone in serum has been applied to normal and hirsute patients. Each of 32 hirsute women studied had a significantly elevated level of free testosterone (that is, more than two standard deviations above the mean of that found in normal women), although half of them had a total serum testosterone level within normal limits. Suppression of free testosterone to within normal limits could be accomplished by dexamethasone alone in 47 per cent of the hirsute group. In the remainder of the hirsute group, suppression of free testosterone to within normal limits could be accomplished by addition of Enovid-E. Use of free serum testosterone concentration is clearly superior to the use of total serum testosterone concentration for the identification and rational therapy of simple hirsutism.

Changed levels of endogenous sex steroids in women on oral contraceptives

Serum and urinary levels of unconjugated testosterone, dihydrotestosterone, and oestradiol were measured by specific radioimmunoassays in 10 healthy women in the early follicular phase of their menstrual cycle and in nine healthy women taking oral contraceptives. The contraceptive group had testosterone levels 1-3 times higher and dihydrotestosterone levels two times higher than those in the controls. Serum oestradiol levels in the contraceptive group were much lower than those in the controls and similar to levels in postmenopausal women. The contraceptive group had about twice the urinary excretion of unconjugated (free) testosterone and dihydrotestosterone of the controls, but their excretion of unconjugated oestradiol was 2-7 times lower. The great increase in serum and urinary androgen concentrations, as well as the suppression of oestradiol, may be related to the antiovulatory effect of oral contraceptives.

Response of the binding capacity of plasma testosterone-estradiol-binding globulin to norethindrone, 2 mg., and mestranol, 0.1 mg., in polycystic ovarian disease

The binding capacity of plasma testosterone-estradiol-binding globulin (TeBG) and testosterone (T) levels were measured in four women with proved polycystic ovaries and three women with a clinical diagnosis of polycystic ovarian disease before, during, and after administration of norethindrone, 2 mg., and mestranol, 0.1 mg. (N + M)...