The time has come to simplify the evaluation of the hirsute patient

Testosterone in Women: Measurement and Therapeutic Use

Androgens, both in excessive and depleted states, have been implicated in female reproductive health disorders. As such, serum testosterone measurements are frequently ordered by physicians in cases of sexual dysfunction and in women presenting with hirsutism. Commercially available androgen assays have significant limitations in the female population. Furthermore, the measurements themselves are not always informative in patient diagnosis, treatment, or prognosis. This article reviews the limitations of serum androgen measurements in women suspected to have elevated or reduced androgen action. Finally, we consider when therapeutic use of androgen replacement may be appropriate for women with sexual interest/arousal disorders.

Endocrine and reproductive effects of polycystic ovarian syndrome

Management strategies for overweight and obese women with polycystic ovarian syndrome (PCOS) who desire fertility should include weight loss. Even a small reduction in body weight can improve ovulatory function and pregnancy rate and reduce adverse obstetric outcomes. New data suggest that letrozole should be considered as the new first-line medical treatment of anovulatory infertility in PCOS over clomiphene citrate. Second-line treatments for anovulatory infertility include in vitro fertilization, gonadotropins, or ovarian drilling.

Consensus on women's health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in females, with a high prevalence. The etiology of this heterogeneous condition remains obscure, and its phenotype expression varies. Two widely cited previous ESHRE/ASRM sponsored PCOS consensus workshops focused on diagnosis (published in 2004) and infertility management (published in 2008), respectively. The present third PCOS consensus report summarizes current knowledge and identifies knowledge gaps regarding various women's health aspects of PCOS. Relevant topics addressed-all dealt with in a systematic fashion-include adolescence, hirsutism and acne, contraception, menstrual cycle abnormalities, quality of life, ethnicity, pregnancy complications, long-term metabolic and cardiovascular health, and finally cancer risk. Additional, comprehensive background information is provided separately in an extended online publication.

Polycystic ovary syndrome in the adolescent

Polycystic ovary syndrome (PCOS) is now recognized as a heterogeneous disorder that results in overproduction of androgens, primarily from the ovary, leading to anovulation and hirsutism and is associated with insulin resistance. Long-term sequellae of PCOS include higher risk for diabetes, obesity, metabolic syndrome, endometrial hyperplasia, and anovulatory infertility. Symptoms in the adolescent include oligomenorrhea, hirsutism, acne, and weight gain. Insulin resistance, impaired glucose tolerance, and diabetes have also been demonstrated in adolescents who have PCOS. Treatment should be instituted early to decrease symptoms and long term sequellae of PCOS. Weight loss, oral contraceptives, and antiandrogens are effective in treating the symptoms of this disorder. Insulin-sensitizing medications have been shown to be effective but should be used with caution until larger randomized trials have shown short- and long term benefits and efficacy over traditional therapies in the adolescent population.

Treatment of PCOS in adolescence

Polycystic ovary syndrome (PCOS) is increasingly being recognized in adolescent girls seeking treatment for signs and symptoms of hyperandrogenism. It is difficult to diagnose PCOS in adolescents, therefore a high index of suspicion is necessary. Timely screening and treatment are crucial because another important component of the syndrome is insulin resistance/hyperinsulinemia increasing the risk for type 2 diabetes, dyslipidemia, and cardiovascular sequelae. Diagnosis of PCOS in adolescents should include a thorough family history, exclusion of other causes of hyperandrogenism, and appropriate laboratory evaluation. The scarcity of controlled clinical trials makes treatment controversial. Therapeutic options include lifestyle intervention, oral contraceptive pills, and insulin sensitizers. Long-term follow-up is needed to determine the effectiveness of these approaches in changing the natural history of the reproductive and metabolic outcomes without causing undue harm.

Serum Müllerian-inhibiting substance levels in adolescent girls with normal menstrual cycles or with polycystic ovary syndrome

OBJECTIVE

To compare serum müllerian-inhibiting substance (MIS) concentrations in adolescent girls with polycystic ovary syndrome (PCOS) or normal menstrual cycles.

DESIGN

Prospective study.

SETTING

University department of obstetrics and gynecology.

PATIENT(S)

Thirty-one girls (12-18 years old) with PCOS and 17 girls (12-19 years old) with normal menstrual cycles.

INTERVENTION(S)

Serum was collected from girls with PCOS or normal cycles during the early follicular phase of the menstrual cycle, stored frozen until assayed.

MAIN OUTCOME MEASURE(S)

Serum levels of MIS, E2, free-T, androstenedione, LH, and FSH.

RESULT(S)

Serum MIS levels in girls with PCOS were significantly higher compared with normal girls (4.1 +/- 2.2 [SD] and 2.4 +/- 1.0 ng/mL, respectively). The subjects were stratified for body mass index (BMI) (< and >25 kg/m2). Serum MIS levels in PCOS girls (4.2 +/- 3.0 ng/mL [BMI <25 kg/m2] and 4.0 +/- 1.6 [BMI >25 kg/m2]) were significantly higher compared with normal girls (2.2 +/- 0.8 and 2.6 +/- 0.7 ng/mL, respectively).

CONCLUSION(S)

Adolescent girls with PCOS have significantly higher serum MIS levels compared with normally cycling girls. Serum MIS levels in PCOS were not influenced by BMI. Increased MIS production may represent an early manifestation of the disease.

Different routes of progesterone administration and polycystic ovary syndrome: a review of the literature

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in woman of reproductive age. Although extensive studies have been performed in past decades to investigate the pathobiological mechanisms underlying the unset of this disease, its etiology remains unknown. Progesterone is a hormone of paramount importance in ovulation, implantation and luteal phase support. Low levels of progesterone have been found in the early luteal phase in PCOS patients. Granulosa cells from polycystic ovaries show an altered progesterone production. Moreover, the lack of cyclical exposure to progesterone may have a role in the development of the gonadotropin and androgen abnormalities found in PCOS patients. Ovulation failure and progesterone deficiency may facilitate the hypothalamic-pituitary abnormalities causing the associated disordered luteinizing hormone secretion in PCOS. Progesterone may be administered to PCOS patients in the following cases: to induce withdrawal bleeding, to suppress secretion of luteinizing hormone, in ovulation induction in clomiphene citrate-resistant patients and in luteal phase support in assisted reproduction. We discuss the pharmacologic characteristics of the different routes of progesterone administration with reference to these diverse indications, the therapeutic objectives and patient compliance.

Polycystic ovary syndrome in adolescent girls

Polycystic ovary syndrome (PCOS) has traditionally been thought of as a triad of oligomenorrhea, hirsutism, and obesity. PCOS is now recognized as a heterogeneous disorder that results in overproduction of androgens primarily from the ovary leading to anovulation and hirsutism and is associated with insulin resistance. Symptoms in the adolescent include oligomenorrhea, hirsutism, acne, and weight gain. These symptoms are often attributed to normal pubertal events, which can lead to a delay in diagnosis. Insulin resistance, impaired glucose tolerance and diabetes have been shown to occur in adolescents with PCOS. Treatment should be instituted early to decrease symptoms and long-term sequellae of PCOS. Weight loss, oral contraceptives and antiandrogens are very effective in treating the symptoms of this disorder. Insulin-sensitizing medications show promise, but should be used with caution until larger randomized trials have shown short- and long-term benefit and efficacy over traditional therapies in the adolescent population.

Prevalence of endocrine diseases and abnormal glucose tolerance tests in 340 caucasian premenopausal women with hirsutism as the referral diagnosis

OBJECTIVE

To perform an audit on the examination of hirsute patients and to establish a rational routine examination program in an outpatient endocrine clinic.

DESIGN

Systematic, retrospective audit.

SETTING

Academic tertiary-care medical center.

PATIENT(S)

Three hundred forty women with hirsutism as the referral diagnosis.

INTERVENTION(S)

Hormone analyses and ACTH tests during cycle days 2-8, 2 hours of oral glucose tolerance test (OGTT), and vaginal ultrasound.

MAIN OUTCOME MEASURE(S)

End diagnosis, fasting, 30-, 60-, and 120-minute oral glucose-stimulated levels of insulin and capillary blood glucose.

RESULT(S)

Two hundred one patients were diagnosed as having idiopathic hirsutism (IH) and 134 as having polycystic ovary syndrome (PCOS). End diagnosis: prolactinoma: n = 1, Cushing's syndrome: n = 1, androgen-producing ovarian tumor: n = 1, late-onset 21-hydroxylase defects: n = 2. During OGTT, 4.9% (13 of 263) had previously undiagnosed diabetes; no significant difference in diabetes prevalence was found between idiopathic hirsutism and PCOS. For 50.8%, fasting insulin values were in the upper quartile for a reference population.

CONCLUSION(S)

Initial evaluation of hirsute patients with irregular menses should include serum (s)-17alpha-hydroxyprogesterone, s-prolactin, s-Testosterone (T), and s-sex hormone-binding globulin. Further evaluation is needed in patients with markedly elevated s-T or with clinical Cushing's syndrome. Hirsute patients have a high risk of diabetes, although this could be due to the high number of overweight patients among this population.

Hirsutism and acne in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality affecting reproductive age women. Population-based studies estimate a prevalence of 5-10% [Obstet Gynecol 101 (2003) 995; Aust N Z J Obstet Gynaecol 41 (2001) 202]. The clinical characteristics of PCOS include hyperandrogenism, chronic anovulation, insulin resistance and infertility. Hyperandrogenism is generally manifested as hirsutism and acne. Both these clinical symptoms are treated with similar drug therapies, including oral contraceptive pills (OCPs), topical medications or antiandrogens such as spironolactone, flutamide and finasteride, as well as topical medications. Recent studies have shown that lower doses of these medications are as efficacious as high doses and have the advantage of decreased cost and an improved side-effect profile. Although hirsutism and acne can be considered cosmetic in nature, they cause significant social embarrassment and emotional distress. Physicians should be sensitive to these issues and approach patients in a caring and sympathetic manner.

Polycystic Ovary Syndrome in Adolescence

Polycystic ovary syndrome (PCOS) is a common disorder among reproductive-age women, yet the diagnosis may be overlooked during adolescence. Although the clinical and metabolic features are similar to those found in adult women, it can be difficult to distinguish the young woman with PCOS from a normal adolescent. Irregular menses, anovulatory cycles, and acne are not uncommon in adolescent women. Adolescents with a history of premature pubarche, a family history of PCOS, Caribbean-Hispanic and African-American ancestry, and/or obesity are at risk for PCOS and deserve close surveillance. The laboratory evaluation of the adolescent with suspected PCOS or hyperandrogenism should be individualized based on the history, symptoms, and examination findings. The cornerstone of management of PCOS in adolescence includes either a combination oral contraceptive or progestin. Consideration of insulin-sensitizing agents, antiandrogens, topical treatments for acne, and various treatments for hair removal are dependent on the patient's symptoms and concerns. Healthy eating, regular exercise, and for the overweight adolescent, weight reduction, are encouraged to reduce the risk of cardiovascular disease and type II diabetes mellitus. Numerous studies have shown that weight loss and exercise decrease androgen levels, improve insulin sensitivity, and lead to the resumption of ovulation. Although initial studies suggest that Metformin may be particularly useful for treating the PCOS adolescent with insulin resistance and obesity, additional studies are needed to determine the efficacy and long-term outcome. Management of the adolescent with PCOS is challenging and requires a supportive, multidisciplinary team approach for optimal results.

Treatment of the adolescent patient with polycystic ovary syndrome

Frequently, a multidisciplinary approach is needed in the management of the adolescent with PCOS. Treatment must be provided in a supportive environment. Because adolescent females are concerned about their appearance any image, short-term treatment goals are usually directed toward the amelioration of hirsutism, acne, and irregular menstruation. Although not immediately concerning to the adolescent, the prevention of long-term sequelae from anovulation and hyperinsulinemia is also important. Multiple concomitant therapies are often necessary to address the variety of symptoms and achieve better results. Recent studies have investigated the role of the insulin-sensitizing agent, metformin, in the treatment of PCOS. Although most studies show a benefit, the conclusions are limited owing to the small numbers of select patients, observational designs, and short durations of follow-up. In addition, there are few data comparing insulin-sensitizing drugs with traditional therapies for PCOS. More long-term, randomized controlled trials are needed to determine the utility of insulin-sensitizing agents, their long-term benefits, and the ideal patient population for their use.

Effect of oral micronized progesterone on androgen levels in women with polycystic ovary syndrome

OBJECTIVE

To determine whether the use of oral micronized progesterone (OMP) to induce withdrawal bleeding in women suspected of having polycystic ovary syndrome (PCOS) alters circulating androgen levels.

DESIGN

Prospective clinical trial.

SETTING

Academic medical center.

PATIENT(S)

Eight reproductive-aged women with PCOS.

INTERVENTION(S)

Blood was sampled before (week 0) and weekly after (weeks 1 to 4) the administration of OMP (Prometrium, Solvay Pharmaceuticals, Marietta, GA), 100 mg in the morning and 200 mg before bedtime for 7 days.

MAIN OUTCOME MEASURE(S)

The levels of total testosterone (TT), free testosterone (FT), sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), and androstenedione (A4) were determined in the blood samples.

RESULT(S)

In seven of the eight women studied, menstrual cycle intervals were >3 months, while one was eumenorrheic; six of the eight women had hirsutism (modified Ferriman-Gallwey score >7). Mean age was 28.9 +/- 10.4 years and mean body mass index was 33.9 +/- 4.7 kg/m2. The mean values of TT, FT, SHBG, DHEAS, A4, and 17-OHP did not change with OMP administration. However, a higher 17-OHP level was observable at the completion of OMP administration (week 2).

CONCLUSION(S)

We conclude that the administration of OMP (100 mg in the morning and 200 mg before bedtime for 7 days) to induce withdrawal bleeding in women with PCOS does not significantly alter circulating androgen or 17-OHP levels, and can be used to time blood sampling in these patients.