Treatment of hirsutism with spironolactone

Spironolactone use and oocyte maturation in patients undergoing controlled ovarian hyperstimulation

PURPOSE

To evaluate the association between spironolactone use and controlled ovarian hyperstimulation (COH) outcomes.

METHODS

Retrospective study, including patients who underwent COH. Oocyte yield and maturation rates were compared by categories of spironolactone use at the start of their cycle.

RESULTS

402 patients were included. 83 patients continued spironolactone, 44 patients discontinued spironolactone, and 275 matched control patients were spironolactone-naïve. No difference was observed in the number of oocytes retrieved (17 ± 14 vs. 15 ± 13, p = 0.4) or mature oocytes vitrified (15 ± 9.5 vs. 12 ± 11, p = 0.4) in patients who continued spironolactone use and spironolactone naïve patients, respectively. When comparing patients who continued spironolactone use and patients who discontinued spironolactone use, no difference was seen in the number of oocytes retrieved (17 ± 14 vs. 17.5 ± 7.8, p = 0.9) or mature oocytes vitrified (15 ± 9.5 vs. 13.5 ± 6.5, p = 0.5), respectively. There was no observed relationship between total daily spironolactone dose (< 100mg/day, 100mg/day, 150mg/day and > 200 mg/day) and the total number of mature oocytes vitrified (respectively, 14.0 ± 13.0, 16.0 ± 7.8, 14.0 ± 4.5, 11.0 ± 7.0 oocytes, p = 0.4).

CONCLUSIONS

This is the first study to evaluate the association between spironolactone and oocyte yield and maturation rates during COH cycles. These findings can assist in counseling patients on the implications of continuing spironolactone during COH cycle.

Guideline No. 444: Hirsutism: Evaluation and Treatment

OBJECTIVE

This guideline reviews the etiology, diagnosis, evaluation, and treatment of hirsutism.

TARGET POPULATION

Women with hirsutism.

OPTIONS

Three approaches to management include: 1) mechanical hair removal; 2) suppression of androgen production; and 3) androgen receptor blockade.

OUTCOMES

The main limitations of the management options include the adverse effects, costs, and duration of treatment.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in this guideline may improve the management of hirsutism in women with this condition. Adverse effects and a potential long duration of treatment are the main drawbacks to initiating treatment, as is the possibility of significant financial costs for certain treatments.

EVIDENCE

A comprehensive literature review was updated to April 2022, following the same methods as for the prior Society of Obstetricians and Gynaecologists of Canada (SOGC) Hirsutism guidelines. Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Primary care providers, family medicine physicians, obstetricians and gynaecologists, reproductive endocrinologists and others who manage the care of patients with hirsutism.

TWEETABLE ABSTRACT

Management of hirsutism involves a 3-pronged approach of mechanical hair removal, suppression of androgen production, and androgen receptor blockade.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Challenges in treatment of patients with non-classic congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) due to 21α-hydroxylase deficiency (21OHD) or 11β-hydroxylase deficiency (11OHD) are congenital conditions with affected adrenal steroidogenesis. Patients with classic 21OHD and 11OHD have a (nearly) complete enzyme deficiency resulting in impaired cortisol synthesis. Elevated precursor steroids are shunted into the unaffected adrenal androgen synthesis pathway leading to elevated adrenal androgen concentrations in these patients. Classic patients are treated with glucocorticoid substitution to compensate for the low cortisol levels and to decrease elevated adrenal androgens levels via negative feedback on the pituitary gland. On the contrary, non-classic CAH (NCCAH) patients have more residual enzymatic activity and do generally not suffer from clinically relevant glucocorticoid deficiency. However, these patients may develop symptoms due to elevated adrenal androgen levels, which are most often less elevated compared to classic patients. Although glucocorticoid treatment can lower adrenal androgen production, the supraphysiological dosages also may have a negative impact on the cardiovascular system and bone health. Therefore, the benefit of glucocorticoid treatment is questionable. An individualized treatment plan is desirable as patients can present with various symptoms or may be asymptomatic. In this review, we discuss the advantages and disadvantages of different treatment options used in patients with NCCAH due to 21OHD and 11OHD.

Long-Term Response of Hirsutism and Other Hyperandrogenic Symptoms to Combination Therapy in Polycystic Ovary Syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 5%-15% of women and is the most common cause of hirsutism. Data on the time-course of improvement to suppressive therapy and predictors of that response in PCOS are lacking. The objectives of our study are to determine the long-term response and identify predictors of response in PCOS women treated with suppressive therapy, including spironolactone (SPL) + oral contraceptives (OCs).

MATERIALS AND METHODS

Retrospective cross-sectional analysis of 200 women with PCOS (1990 NIH criteria) treated with suppressive therapy in general, and a subgroup of 138 subjects treated with OCP+SPL who had been prospectively included in a biorepository. Main outcome measure included improvement rate per 100 person-month of follow-up for hirsutism, menstrual irregularity and acne measured qualitatively as "feeling better", and changes in the severity of hirsutism quantified by modified Ferriman-Gallwey [mF-G] score.

RESULTS

During a mean follow-up of 34.2 months, 85.1%, 82.7%, and 79.3% of patients reported improvement in hirsutism, menstrual dysfunction, and acne, respectively. The modified Ferriman-Gallwey (mF-G) hirsutism score improved by 59.9%. The net reduction in mF-G score and the percent of patients reporting improvement in hirsutism were greater for OC+SPL than for either drug alone, with no difference in the percent of patients free of adverse effects. Among those treated with OC+SPL (n = 138), the initial mF-G and sex hormone-binding globulin (SHBG) independently predicted successful therapy for hirsutism.

CONCLUSION

There is a high rate of patient satisfaction with suppressive therapy in PCOS. The efficacy of suppressive therapy for hirsutism was greater with OC+SPL than with either drug alone. Successful treatment of hirsutism with combination OC+SPL requires at least 6 months of therapy, with the proportion of satisfied patients continuing to increase with treatment duration. The probability of patient satisfaction with OC+SPL treatment for hirsutism can be predicted by her initial mF-G score or SHBG level.

No. 350-Hirsutism: Evaluation and Treatment

OBJECTIVES

To review the etiology, evaluation, and treatment of hirsutism.

EVALUATION

A thorough history and physical examination plus selected laboratory evaluations will confirm the diagnosis and direct treatment.

TREATMENT

Pharmacologic interventions can suppress ovarian or adrenal androgen production and block androgen receptors in the hair follicle. Hair removal methods and lifestyle modifications may improve or hasten the therapeutic response.

OUTCOMES

At least 6 to 9 months of therapy are required to produce improvement in hirsutism.

EVIDENCE

The quality of evidence reported in this guideline has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.

RECOMMENDATIONS

Hirsutism can be slowly but dramatically improved with a 3-pronged approach to treatment: mechanical hair removal, suppression of androgen production, and androgen receptor blockade. Lifestyle changes, including weight loss and exercise, will lower serum androgen levels and improve self-esteem in patients with polycystic ovary syndrome. The patient should be educated regarding the associated health problems or long-term medical consequences of hyperandrogenism, particularly in the context of polycystic ovary syndrome, including obesity, irregular menses, anovulation, infertility, pregnancy-induced hypertension, diabetes, hyperlipidemia, hypertension, and heart disease.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Visually scoring hirsutism

BACKGROUND

Hirsutism is the presence of excess body or facial terminal (coarse) hair growth in females in a male-like pattern, affects 5-15% of women, and is an important sign of underlying androgen excess. Different methods are available for the assessment of hair growth in women.

METHODS

We conducted a literature search and analyzed the published studies that reported methods for the assessment of hair growth. We review the basic physiology of hair growth, the development of methods for visually quantifying hair growth, the comparison of these methods with objective measurements of hair growth, how hirsutism may be defined using a visual scoring method, the influence of race and ethnicity on hirsutism, and the impact of hirsutism in diagnosing androgen excess and polycystic ovary syndrome.

RESULTS

Objective methods for the assessment of hair growth including photographic evaluations and microscopic measurements are available but these techniques have limitations for clinical use, including a significant degree of complexity and a high cost. Alternatively, methods for visually scoring or quantifying the amount of terminal body and facial hair growth have been in use since the early 1920s; these methods are semi-quantitative at best and subject to significant inter-observer variability. The most common visual method of scoring the extent of body and facial terminal hair growth in use today is based on a modification of the method originally described by Ferriman and Gallwey in 1961 (i.e. the mFG method).

CONCLUSION

Overall, the mFG scoring method is a useful visual instrument for assessing excess terminal hair growth, and the presence of hirsutism, in women.

Evaluation of effects of an oral contraceptive containing ethinylestradiol combined with drospirenone on adrenal steroidogenesis in hyperandrogenic women with polycystic ovary syndrome

OBJECTIVE

To investigate whether the administration of an oral contraceptive containing the new antiandrogenic drospirenone is associated with reduced adrenal androgen synthesis in hyperandrogenic women with diagnosis of polycystic ovary syndrome. Drospirenone, an analogue of spironolactone and aldosterone antagonist, is a novel progestin under clinical development that is similar to the natural hormone progesterone, combining potent progestogenic with antimineralocorticoid and antiandrogenic activities.

DESIGN

Prospective study.

SETTING

Healthy volunteers in University Department of Obstetrics and Gynecology.

PATIENT(S)

Fifteen women ages 18 to 28 years with the diagnosis of polycystic ovary syndrome.

INTERVENTION(S)

Three months of contraceptive use (30 mcg ethinylestradiol, 3 mg drospirenone).

MAIN OUTCOME MEASURE(S)

An adrenocorticotropic hormone test was performed before and after the study.

RESULT(S)

Adrenal production of cortisol was unchanged after therapy with oral contraceptives. An interesting observation was reduced basal concentrations of androgens such as androstenedione, dehydroepiandrosterone sulfate, testosterone, and free testosterone during therapy. The ratios of the areas of substrates to products before and after oral contraceptive administration were compared for differences in 17alpha-hydroxylase (17-hydroxyprogesterone/progesterone) and 17,20-lyase (androstenedione/17-hydroxyprogesterone); activities were significantly reduced, indicating a reduction in the activities of these enzymes.

CONCLUSION(S)

The present results show for the first time that oral contraceptives containing drospirenone affect adrenal steroidogenesis by reducing synthesis and release of androgens in response to adrenocorticotropic hormone, leaving adrenal production of cortisol unchanged.

Mineralocorticoid Synthesis During the Periovulatory Interval in Macaques1

Ovulation and luteal formation in primates are associated with the sustained synthesis of progesterone. The observed high intrafollicular concentrations of progesterone during the periovulatory interval raise the possibility that this steroid serves as a precursor for mineralocorticoids. The aim of this study was to determine if mineralocorticoids are synthesized by the luteinizing macaque follicle during controlled ovarian stimulation cycles in which follicular fluid and granulosa cell aspirates were obtained before or after an ovulatory hCG bolus. Follicular fluid concentrations of progesterone and 17alpha-hydroxyprogesterone increased within 3 h of an ovulatory hCG bolus. Their respective metabolites, 11-deoxycorticosterone (DOC) and 11-deoxycortisol, were not detectable before an ovulatory stimulus and increased starting at 6 h after hCG, while corticosterone and aldosterone were undetectable. Cortisol was present before and after hCG administration and had increased 2-fold at 24 h after an ovulatory stimulus. The expression of 21-hydroxylase (CYP21A2) mRNA increased within 3 h of hCG administration, while 11beta-hydroxylase-1 (CYP11B1) and 11beta-hydroxylase-2 (CYP11B2) mRNAs were not detectable. 11beta-Hydroxysteroid dehydrogenase-1 (HSD11B1) mRNA had increased at 12 h after hCG administration, and 11beta-hydroxysteroid dehydrogenase-2 (HSD11B2) had decreased by 3 h after hCG administration. Mineralocorticoid receptor mRNA levels did not change following hCG administration, while glucocorticoid receptor mRNA levels increased in response to an ovulatory stimulus. Treatment of granulosa cells with the mineralocorticoid receptor antagonist spironolactone blocked hCG-induced progesterone synthesis in vitro. These data indicate that macaque granulosa cells can synthesize mineralocorticoids in response to an ovulatory stimulus and that the mineralocorticoid receptor plays a key role in steroid synthesis associated with luteinization of macaque granulosa cells.

Low-dose (2.5 mg/day) finasteride treatment in hirsutism

This study was performed to confirm the therapeutic effects of low-dose, (2.5 mg/day) finasteride in hirsute women. Our study was a non-randomized prospective clinical trial. Twenty-nine patients with hirustism were included in the study. The patients received 2.5 mg finasteride once a day over a period of 12 months. Follicle stimulating hormone, luteinizing hormone, sex hormone binding globulin, 17 alpha-hydroxyprogesterone, estradiol, androstenedione, total and free testosterone, dehydroepiandrosterone sulfate levels and hirsutism scores were determined in all patients before treatment and at every 6 months during the therapy. The hirsutism score decreased from a mean of 18.4 +/- 4.6 to 8.4 +/- 4.2 during the study. The per cent reduction in hirsutism score (mean +/- SD) at 6 and 12 months was 29.2 +/- 14.5 and 55.7 +/- 14.9%, respectively. There were no significant differences in any of the hormone levels and no serious side-effects were observed during the treatment. In conclusion, low-dose finasteride (2.5 mg/day) is a cost-effective, well-tolerated therapeutic agent without significant abnormal biochemical findings and can be used in place of high-dose (5 mg/day) finasteride in the treatment of hirsutism.

New treatments of hyperandrogenism and hirsutism

Approximately 5% to 8% of the female population demonstrates some form of hirsutism, the presence of prominent facial and body hair caused by excessive androgen effect. Treatment methods are classified into three categories: (1) hormonal suppression consisting of medical therapy to decrease androgen production, (2) the administration of antiandrogens to block the androgen effect at the hair follicle, and (3) physical methods of hair removal. Most patients require a combination of medical and physical therapy.

Comparison of Diane 35 and Diane 35 plus finasteride in the treatment of hirsutism

OBJECTIVE

To compare the clinical efficacy of an original combined therapy with cyproterone acetate, 2 mg, and ethinylestradiol, 35 microgram (Diane 35), plus finasteride (5 mg) for 2 weeks per month with that of Diane 35 alone in hirsute women.

DESIGN

Prospective randomized, single-blinded study.

SETTING

Outpatients in an academic research environment.

PATIENT(S)

Fifty women with idiopathic hirsutism (IH) or the polycystic ovary syndrome (PCOS).

INTERVENTION(S)

Group 1 (n = 25) received Diane 35 alone and group 2 (n = 25) received Diane 35 plus finasteride. The latter drug was administered using a new therapeutic scheme: 14 consecutive days for each therapeutic cycle.

MAIN OUTCOME MEASURE(S)

Hormonal evaluation was done before beginning treatment and after 3 and 6 months of therapy. Hirsutism was graded at 3-month intervals.

RESULT(S)

The combination of Diane 35 plus finasteride for 14 days significantly decreased the hirsutism score after 3 months of therapy, while Diane 35 alone induced this effect after 6 months.

CONCLUSION(S)

Finasteride in combination with Diane 35 for 14 days is effective, well accepted, and safe in hirsute patients, as the amount of antiandrogenic drugs administered is much lower than that in conventional treatment.

Treatment of hirsutism with lowest-dose flutamide (62.5 mg/day)

Flutamide has been used successfully in the treatment of hirsutism. However, flutamide may cause important side-effects. The aim of this study was to evaluate the clinical and hormonal effects of lowest-dose flutamide therapy. Sixty-one women with hirsutism aged 18-37 years (mean +/- SD 23.4 +/- 5.9 years) were included in the study. Patients received 62.5 mg flutamide once per day for a period of 12 months. A hirsutism score was determined according to a modified Ferriman-Gallwey scoring system. Before therapy, multiscreen blood chemistry, hormonal analysis and complete blood counts were performed. These parameters and hirsutism scores were repeated at 3, 6, 9 and 12 months during therapy. The modified Ferriman-Gallwey scores significantly decreased from 19.1 +/- 4.9 to 5.8 +/- 3.3 during the study (p < 0.0001). The percentage reductions in hirsutism scores (mean +/- SD) were 60.3 +/- 14.4% at 6 months, and 70.3 +/- 13.2% at 12 months. No significant side-effects or modifications in the menstrual cycles were observed. There were no significant differences in any of the hormone levels during therapy. In conclusion, the lowest dose of flutamide, 62.5 mg/day, is a well-tolerated therapeutic agent and can be used in the treatment of hirsutism.

Recurrence rate of hirsutism after 3 different antiandrogen therapies

BACKGROUND

Although antiandrogens are frequently and successfully used to treat hirsutism, little attention has been paid to optimal duration of treatment and recurrence rate after cessation of therapy.

OBJECTIVE

Our purpose was to determine the recurrence rate of hirsutism after 3 different antiandrogen therapies.

METHODS

Eighty-one hirsute women referred to a tertiary hirsutism clinic were assigned to one of three regimens: spironolactone 100 mg/day with an oral contraceptive, cyproterone acetate 50 mg/day on days 1 to 10 with an oral contraceptive, or flutamide 250 mg twice a day. Hirsutism scores according to the Ferriman-Gallwey scoring system and endocrine parameters were evaluated before, during, and 1 year after withdrawal of treatment regimens.

RESULTS

Hirsutism scores decreased significantly and similarly in spironolactone, flutamide, and cyproterone acetate treatment groups. However, 1 year after withdrawal of treatment in all antiandrogen therapy groups, hirsutism returned.

CONCLUSION

Antiandrogens are effective in the treatment of hirsutism. However, cessation of antiandrogen therapy is followed by recurrence.

Clinical efficacy of lower dose flutamide 125 mg/day in the treatment of hirsutism

Thirty-four patients with moderate-severe hirsutism were enrolled in this study. The patients received 125 mg/day flutamide for a period of 6 months. Hirsutism score and hormone parameters including FSH, LH, T, free T, androstenedione (A), DHEAS, PRL and sex hormone-binding globulin (SHBG) levels were evaluated in all patients before treatment and repeated at every three-monthly intervals. Hirsutism greatly improved during flutamide therapy, and the hirsutism score significantly decreased at month 3 and 6 from a mean (+/-SD) of 17.19+/-4.55 to 10.75+/-3.84 (p<0.001) and 17.19+/-4.55 to 5.91+/-2.53 (p<0.001), respectively. A significant reduction in hirsutism score (mean%+/-SD) as compared to baseline was observed at 3 months (37.78+/-13.30, p<0.001) and at 6 months (65.47+/-13.49, p<0.001). No significant changes in the levels of hormone and no serious side effects were observed in the patients. The lower dose flutamide, 125 mg/day, is a safe and cost-effective drug in the treatment of hirsutism. Lower dose flutamide may be used in place of high dose flutamide, 250 to 750 mg/day.

Effects of flutamide on pituitary and adrenal responsiveness to corticotrophin releasing factor (CRF)

OBJECTIVE

Flutamide is a non-steroid antiandrogen that specifically blocks the androgen receptor. We have investigated the effect of flutamide treatment on the adrenal androgen response to corticotrophin releasing factor (CRF) in eight patients with polycystic ovary syndrome (PCOS).

PATIENTS

Eight women with moderate to severe hirsutism, ranging in age from 19 to 23 years were enrolled in the study. Basal hormonal pattern showed anovulatory cycles, increased concentrations of LH, androstenedione and testosterone and increased LH/ FSH ratio. A baseline ultrasound scan revealed polycystic ovaries in all patients. Each received 250 mg of Flutamide twice a day for 6 months.

MEASUREMENTS

Before treatment and at the end of the sixth month, women were evaluated for hirsutism score and a CRF test was performed to evaluate ACTH, cortisol and adrenal androgen responses.

RESULTS

Androstenedione (delta 4), DHEA-S, 17-hydroxy-progesterone, testosterone and free-testosterone showed significantly reduced responses after six months of flutamide therapy whereas ACTH and cortisol response were similar to those before treatment. Clinical improvement in the degree of hirsutism was observed in all patients. The Ferriman-Gallwey scores decreased from a mean of 22 +/- 2 to 8 +/- 1.5.

CONCLUSION

Flutamide induces a significant reduction in adrenal androgen response to the CRF test but not in the response of ACTH and cortisol. The finding that flutamide does not alter the pituitary-adrenal axis shows that flutamide acts by reducing adrenal androgens. These results demonstrate that flutamide is not only effective in the treatment of hirsutism but also reduces adrenal androgen secretion.

Comparison of cyproterone acetate plus ethinyl estradiol and finasteride in the treatment of hirsutism

The aim of this study was to compare the clinical efficacy and safety of low dose cyproterone acetate-estrogen combination (Diane) and the 5 alpha-reductase inhibitor finasteride in the treatment of hirsutism. Fourty-two women with hirsutism were included in the study. Twenty-one patients treated with cyproterone acetate (CPA) 2 mg and ethinyl estradiol (E) 35 micrograms daily on days 5-25 of the menstrual cycle, 21 with finasteride 5 mg daily. Hirsutism score, hormone levels, multiscreen blood chemistry and side effects were evaluated at three-monthly intervals for 9 months. A significant decrease in hirsutism score as compared to baseline was observed after 9 months with either CPA + E (Diane) (mean +/- SE, 15.81 +/- 1.19 vs 8.38 +/- 1.21) or finasteride treatment (17.81 +/- 1.05 vs 10.86 +/- 0.91) (p < 0.0005). The reductions in hirsutism scores (mean% +/- SE) were 14.23 +/- 2.29 vs 19.77 +/- 2.22 (p < 0.05) at 3, 40.23 +/- 4.58 vs 29.49 +/- 2.69 (p < 0.02) at 6 and 50.99 +/- 4.13 vs 39.87 +/- 3.30 (p < 0.02) at 9 months in CPA + E and finasteride groups, respectively. No significant changes were observed in hormone levels during finasteride treatment. Serum free testosterone significantly decreased at the third month of treatment, and remained suppressed for the duration of treatment in CPA + E group. DHEAS levels also decreased significantly after 6 and 9 months of therapy with CPA + E. SHBG significantly increased during CPA + E treatment. We conclude that both drugs are effective and well tolerated, but CPA + E appears to be more effective than 5 alpha-reductase inhibitor finasteride in long-term treatment of hirsute women. Diane is also a cost-effective drug.

Hair regrowth. Therapeutic agents

Today there are new classes of hair growth promotors with proven efficacy. This article reviews the current state of the art agents for treatment of two of the most common forms of hair loss encountered in clinical practice, androgenetic alopecia and alopecia areata. Current therapeutic strategies are based on recent advances in the understanding of disordered hair growth. Practical treatment protocols are presented.

Comparison of finasteride versus spironolactone in the treatment of idiopathic hirsutism

OBJECTIVE

To compare the efficacy of finasteride and spironolactone in the treatment of idiopathic hirsutism.

DESIGN

Prospective, randomized, single-blind study.

SETTING

A tertiary hirsutism clinic.

PATIENT(S)

Forty women with idiopathic hirsutism were selected.

INTERVENTION(S)

Patients were assigned randomly to receive either 5 mg of finasteride or 100 mg of spironolactone for 9 months.

MAIN OUTCOME MEASURE(S)

Hirsutism scores were measured according to the Ferriman-Gallwey scoring system, and side effects were monitored for 9 months of treatment. Blood samples were taken at each visit for assessment of endocrine, biochemical, and hematologic parameters.

RESULT(S)

Hirsutism scores were decreased significantly in both groups at the end of 9 months. The mean percent change (+/- SD) in hirsutism scores in the finasteride and spironolactone groups was as follows: 5.91% +/- 7.18% and 20.60% +/- 12.59% at 3 months, 10.61% +/- 12.18% and 32.57% +/- 15.68% at 6 months, and 15.15% +/- 15.38% and 42.36% +/- 12.31% at 9 months, respectively. There was a significantly better response with spironolactone treatment at the end of 9 months. Eleven (55%) of 20 patients in the spironolactone group experienced side effects. However, none of them stopped treatment because of side effects.

CONCLUSION(S)

The present data suggest that both finasteride and spironolactone are effective in the treatment of idiopathic hirsutism. However, it appears that the spironolactone group responded significantly better.

Steroid 5alpha-reductase inhibitors in androgen-dependent disorders

Inhibition of the steroid 5alpha-reductases shows promise in the treatment of a number of androgen-dependent disorders, such as benign prostatic hyperplasia, male pattern baldness, and acne. The design of potent and isozyme-selective inhibitors has provided biologists and clinicians with important tools for elucidating complex androgen physiology, and has already resulted in the development of one marketed drug.

Gonadotropin-releasing hormone analog plus an oral contraceptive containing desogestrel in women with severe hirsutism: effects on hair, bone, and hormone profile after 1-year use

To evaluate the usefulness of D-Trp-6-luteinizing hormone-releasing hormone (LHRH) (triptorelin), a gonadotropin-releasing hormone (GnRH) analog (GnRHa), plus an oral contraceptive (OC) in the treatment of severe hirsutism, a total of 48 women between 19 and 35 years of age suffering from polycystic ovary syndrome (PCOS) with severe hirsutism were studied. Hyperandrogenism of adrenal origin was excluded in all subjects. Twenty-three patients received 3.75 mg D-Trp-6-LHRH intramuscularly monthly for 1 year plus an OC containing 30 micrograms ethinyl-estradiol and 150 micrograms desogestrel. A second group of 25 subjects received an OC containing 35 micrograms ethinyl-estradiol and 2 mg cyproterone acetate (CPA). Immediately before and after months 6 and 12 of therapy, bone mineral density (BMD) and Ferriman-Gallwey scores were evaluated and follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), prolactin (PRL), testosterone (T), androstenedione (A), dehydroepiandrosterone sulfate (DHEAS), 17-OH-progesterone (17-OHP), and sex hormone-binding globulin (SHBG) were determined. After 1 year of follow-up study, the combination of a GnRHa plus OC resulted in a decrease of hirsutism similar to that observed in the CPA group (41.9% v 40.5%) and in a suppression of gonadotropins and ovarian steroids in all treated women, without significant changes in bone density. The GnRHa-OC combination can potentially be used in the treatment of hirsutism and hyperandrogenism.

Comparison of spironolactone-oral contraceptive versus cyproterone acetate-estrogen regimens in the treatment of hirsutism

OBJECTIVE

To compare the efficacy of two antiandrogens, cyproterone acetate (CPA) and spironolactone, in the treatment of hirsutism.

DESIGN

Prospective randomized single-blinded study.

SETTING

A tertiary hirsutism clinic.

PATIENTS

Forty-two premenopausal patients with hirsutism were selected.

INTERVENTIONS

Subjects were randomized to receive either 100 mg spironolactone and an oral contraceptive (OC) containing 150 microg desogestrel and 30 microg ethinyl E2 or 50 mg CPA daily on days 1 to 10 of the menstrual cycle, which was administered with 35 microg ethinyl E2 daily on days 1 to 21.

MAIN OUTCOME MEASURES

Hirsutism scores were measured according to Ferriman-Gallwey scoring system and side effects were monitored for 9 months of treatment. Blood samples were taken at each visit for assessment of endocrine, biochemical, and hematologic parameters.

RESULTS

Hirsutism scores were decreaded significantly in both groups at the end of 9 months. The percent of change in hirsutism scores in CPA and spironolactone group were as follows: 19.23% +/- 14.77% and 24.48% +/- 14.27% at 3 months; 39.01% +/- 19.77% and 37.46% +/- 16.90% at 6 months; and 51.89% +/- 20.87% and 46.39% +/- 16.10% at 9 months, respectively. There was a trend toward a better response with CPA treatment, which did not achieve significance. None of the patients stopped treatment because of side effects.

CONCLUSION

The present data suggest that both spironolactone and CPA were similarly effective in treatment of hirsutism.

The efficacy of 250 mg/day flutamide in the treatment of patients with hirsutism

OBJECTIVE

To investigate the effects of low dose flutamide (250 mg/d) on hirsutism score and hormone levels in women with hirsutism.

DESIGN

Nonrandomized, prospective clinical trial.

PATIENTS

Forty-one patients with moderate-severe hirsutism were included in the study.

INTERVENTION

Hirsute patients received 250 mg/d flutamide for a period of 6 months.

MAIN OUTCOME MEASURES

Hirsutism score, FSH, LH, E2, total T, free T, androstenedione, DHEAS, PRL, 17-hydroxyprogesterone, and sex hormone-binding globulin levels were detected in all the patients before treatment and every 3 months during treatment.

RESULTS

Treatment with the antiandrogen flutamide resulted in a particularly rapid and marked decrease in the hirsutism score, which decreased from 17.48 +/- 5.35 to 5.07 +/- 2.89 after 6 months. No significant changes in the levels of hormone and no serious side effects were observed in the study.

CONCLUSION

The low-dose flutamide, 250 mg/d, is a cost-effective drug in the treatment of hirsutism. Low-dose flutamide may be used in place of high-dose flutamide, 500 to 750 mg/d.

Effects of a long-acting gonadotropin-releasing hormone analog on the pituitary-ovarian-adrenal axis in women with severe hirsutism

We evaluated modifications in the pituitary-ovarian-adrenal axis in severely hirsute women after administration of the gonadotropin-releasing hormone analog (GnRHa), D-Trp-6-luteinizing hormone-releasing hormone (LHRH) (Triptorelin) in a prospective study at a tertiary hospital. A total of 20 hirsute women aged 19 to 38 years were included. Hyperandrogenism of adrenal origin was excluded in all subjects. Patients received 3.75 mg D-Trp-6-LHRH intramuscularly (Decapeptyl 3.75; Lasa-Ipsen, Barcelona, Spain). Serum levels of follicle-stimulating hormone (FSH), LH, estradiol (E2), prolactin (PRL), testosterone (T), androstenedione (delta 4 An), dehydroepiandrosterone sulfate (DHEAS), 17-OH-progesterone (17-OHP), and sex hormone-binding globulin (SHBG) were determined before GnRHa administration, 24 and 48 hours after, and on days 7, 15, 30, and 45. GnRHa suppresses FSH, LH, and E2 in all women. Unexpectedly, adrenal steroids showed a flare-up phenomenon in the first days and subsequent decrease to lower values than before GnRHa administration. SHBG showed slight changes. After GnRHa, patients showed a significant decrease in T and delta 4 An: these hormones were reduced to half the basal levels. We conclude that GnRHa can potentially be used in the treatment of hyperandrogenism to reduce androgen levels in hirsute women.

Electrolysis: observations from 13 years and 140,000 hours of experience

Electrolysis has been performed since 1875. Electrolysis satisfactorily removes hair from women with static hair growth, but women with hirsutism often require concomitant management of their hormonal problems. We have found the blend method to be the most effective modality for permanent hair removal. Attention must be given to proper electrolysis technique, including accurate needle insertion and appropriate intensities and duration. Scarring does not occur with properly performed electrolysis. Hair is not an electrical conductor and electronic tweezers do not result in permanent hair removal. Shaving 1 to 5 days before electrolysis greatly increases efficacy because it ensures that only growing anagen hairs are epilated. The recent availability of EMLA (eutectic mixture of local anesthetics) has been beneficial in reducing the sensations of electrolysis. The availability of prepackaged, presterilized, individual electrolysis needles has greatly reduced the need for more complicated sterilization procedures.

Prolonged treatment of hirsutism with flutamide alone in patients affected by polycystic ovary syndrome

Hirsutism is a common symptom of women affected by polycystic ovary syndrome (PCOS). The effectiveness of the antiandrogen flutamide alone was studied in 25 patients affected by PCOS with severe hirsutism for a period of 24 months. Seventeen of these patients had not been treated before and eight had had previous but unsatisfactory therapy. Nineteen patients showed a normal body weight (BMI < 25 kg/m2) whereas six were obese (BMI > 35 kg/m2). A chemical and endocrinological evaluation and an assessment of the degree of hirsutism, assigned by Ferriman-Gallwey score (mean 22 +/- 3.038), was performed under baseline conditions. Patients started treatment with flutamide (Eulexin, Schering-Plough, Kenilworth, USA) at the dose of 500 mg daily. A chronobiological assessment of gonadotropin episodic secretion and of gonadotropin response to GnRH challenge (10 micrograms in bolus) was done before and on day 7 of flutamide administration. During treatment, our patients showed a marked and significant reduction of hirsutism starting from a score of 6 and reaching the maximum (9.6 + 2.1) at 24 months of therapy. No relevant hormonal changes or side-effects were observed during therapy. Our data demonstrate that hirsutism in PCOS can rapidly and markedly respond to treatment with flutamide alone without important side-effects even if administered for a long period.

Androgenic disorders of women: diagnostic and therapeutic decision making

Women with androgenic disorders usually seek medical attention to ameliorate the effects of androgens on appearance or on fertility, less commonly for oligomenorrhea or for prevention of metabolic complications. These conditions affect at least 5-10% of women and can be very disturbing to the affected woman. Careful attention to possible androgenic changes is necessary when performing physical examination because changes are often concealed. Treatment for skin and hair changes depends less on the nature of the changes than on the underlying endocrine causation. The two endocrine factors are androgen levels and receptor sensitivity. The latter is a factor in all androgenic changes, and therapy is rarely successful without use of medication to block androgen receptors. If androgen levels are even minimally elevated, suppression of the source gland--ovary or adrenal--is appropriate. Ovarian suppression is usually by means of an oral contraceptive; for adrenal suppression, a glucocorticoid is effective. Response to medical therapy of androgenic disorders is slow; physicians and patients must be willing to wait weeks, or months, for the beginning of improvement. Endocrine therapy does not seem to help associated diabetes or dyslipidemia. Overall, medical therapy of androgenic disorders is more effective than generally recognized. The principal pitfalls are failing to select medication based on the specific endocrine disturbance and failing to wait long enough for improvement to appear. Side effects do occur but are generally uncomfortable or inconvenient rather than dangerous. Treatment is highly rewarding, however, for there are few situations in medicine in which treatment is so appreciated by the patient.

Comparison of flutamide and spironolactone in the treatment of hirsutism: a randomized controlled trial

OBJECTIVE

To compare the clinical efficacy and safety of the pure antiandrogen flutamide and the steroidal derivative spironolactone in the treatment of hirsutism in women.

DESIGN

Fifty-three premenopausal women suffering from moderate to severe hirsutism were randomized into two groups and received either flutamide or spironolactone in association with a triphasic oral contraceptive (OC) pill. Hirsutism, acne, seborrhea, alopecia, and side effects were monitored monthly for a treatment period of 9 months and a follow-up after treatment period of 6 months. Blood samples were taken at each visit for assessment of endocrine, biochemical, and hematologic parameters.

RESULTS

After only 6 months of therapy, flutamide caused a maximal reduction in the hirsutism score to a value within almost normal range; during the same period, spironolactone caused only a 30% reduction of the hirsutism score. Whereas flutamide caused a dramatic (80%) decrease in total acne, seborrhea, and hair loss score after only 3 months of therapy, spironolactone caused only a 50% reduction in acne and seborrhea, with no significant effect on the hair loss score. Four patients in the spironolactone group but only one in the flutamide group stopped the medication because of adverse side effects.

CONCLUSION

The present data obtained in a randomized prospective study clearly demonstrate that the pure antiandrogen flutamide is superior to spironolactone in the treatment of female hirsutism and its related androgen-dependent symptoms and signs in women.

Endocrine emergencies in pregnancy

A number of endocrine conditions and emergencies have unique characteristics when present in the pregnant woman. Often the abnormal endocrine state affects both mother and fetus and the various diagnostic and therapeutic approaches have to be altered to avoid harming the fetus. Furthermore, the pregnant state itself may alter the natural course of the underlying endocrine condition. Prolactinomas may enlarge due to the hormonal milieu of pregnancy, causing mass effects and even apoplexy. Anticipation of this possibility and prompt recognition may prevent disastrous consequences. This stimulatory state may extend to the normal pituitary, resulting in Sheehan's syndrome. An acute form of Sheehan's may go unrecognized, leading to unnecessary maternal deaths. Autoimmune endocrine disorders may sometimes be exacerbated and at other times be ameliorated during pregnancy. Witness the development of lymphocytic hypophysitis during pregnancy, a condition best left alone if it can be diagnosed without surgery. Graves's disease usually improves during pregnancy but it may occasionally flare, resulting in potentially lethal thyroid storm. The various therapeutic alternatives for hyperthyroidism are very much affected by effects on the fetus. Cushing's syndrome has very bad consequences for the fetus and must be diagnosed and treated urgently, if not emergently. Phaeochromocytomas are always endocrine emergencies requiring urgent and sometimes emergent treatment. Hyperparathyroidism is usually mild, but severe hypercalcaemia can be a true endocrine emergency. Recognition of the interactions of these endocrine conditions and their specific treatments with the complicated maternal-fetal unit makes their diagnosis and treatment simultaneously both difficult and extremely rewarding.

Predictors of clinical response in hirsute women treated with spironolactone

OBJECTIVE

To examine the clinical efficacy of low dose spironolactone in hirsute women.

DESIGN

Retrospective.

SETTING

Outpatient endocrinology clinic.

PATIENTS

One hundred nine consecutive women prescribed 75 to 100 mg/d spironolactone for at least 4 months in whom adequate follow-up data were available.

RESULTS

Hirsutism improved in 72% of the women. Women with regular menses, whether or not they used oral contraceptives (OCs), had the highest response rate to spironolactone (78%), whereas women with irregular menses who did not use an OC had the lowest response rate (55%). Favorable responses were associated with increased severity of hirsutism (P = 0.04) and lower serum dehydroepiandrosterone sulfate levels (P = 0.05). Responders and nonresponders did not differ significantly in age (P = 0.10), duration of hirsutism (P = 0.14), pretreatment serum testosterone (T) (P = 0.48), or body mass index (P = 0.11). However, when each parameter was divided into subsets, trends toward decreasing response were observed with increasing age, duration of hirsutism over 15 years, and increasing serum T level.

CONCLUSION

Low-dose spironolactone improves hirsutism in a majority of hirsute women, irrespective of age, severity or duration of hirsutism, menstrual status, or serum hormone levels.

Antiandrogens: clinical applications

Antiandrogens, preventing androgen action at target tissue level, are used in the treatment of various androgen-dependent diseases. Pharmacologically these substances have either a steroidal structure, like cyproterone acetate (CPA) and spironolactone (SPL), or a non-steroidal structure, like flutamide (FLU). In women with hyperandrogenism (PCO syndrome, idiopathic hirsutism, acne), clinical benefit may be obtained with CPA, which also displays a progestational activity and an antigonadotropic effect. CPA (25-50 mg/day) is used in combination with ethinyl-estradiol (EE) (20-30 micrograms/day) in reversed sequential regimen. SPL, less effective than CPA may be employed in moderate hirsutism and acne at dosages of 100-200 mg/day. During SPL treatment menstrual irregularities are frequent: in this case an association with oral contraceptives is indicated. SPL + bromocriptine (2.5-5 mg/day) has been experienced with success in PCO syndrome. The pure antiandrogen FLU, inducing progressive increase in LH and testosterone secretion, may be used only in combination with oral contraceptives. In men antiandrogens have been tested in BPH and prostatic carcinoma. In BPH the decrease in nuclear receptors and DHT nuclear content during CPA or FLU may represent the rational base of the medical treatment. An improvement in urinary obstructive manifestation has been observed with CPA alone or associated with tamoxifen (100 mg + 100 mg day). In advanced prostatic carcinoma antiandrogens represent a good alternative to estrogen therapy with less side effects and in combination with surgical or medical castration (LH-RH analogues) achieve a complete androgen blockade. An increase in the percentage of remissions and survival has been reported.

Treatment of hirsutism with the pure antiandrogen flutamide

The effectiveness of the antiandrogen flutamide in combination with an oral contraceptive was studied in 20 patients with moderate to severe hirsutism. Eight patients had no previous therapy, whereas 12 had failed to respond to oral contraceptives, spironolactone, or dexamethasone therapy. Treatment with the antiandrogen flutamide (250 mg twice daily) and an oral contraceptive (Ortho 1/35) resulted in a particularly rapid and marked decrease in the total hirsutism score, which reached the normal range at 7 months. Seborrhea, acne, and hair loss score were also rapidly corrected. Treatment was associated with a decrease in plasma luteinizing hormone, progesterone, and estradiol levels. Plasma sex hormone-binding globulin levels were initially low in 18 to 20 patients but increased significantly during therapy. No clinically significant side effects were observed.

Lack of effect of spironolactone on hair shaft diameter in hirsute females

Because of its anti-androgenic activity spironolactone 50-200 mg daily is advocated widely for the management of female hirsutism but this practice lacks adequately controlled experimental support. In a double-blind placebo controlled study of the efficacy of spironolactone 100 mg daily in idiopathic hirsutism we were unable to demonstrate objective benefit from spironolactone treatment. The mean effect of spironolactone given over a 9 month period was to increase hair shaft diameter by +15% with 95% CI (-0.4% to +29%). In addition there were no changes in circulating serum androgen concentrations.

Clinical applications of antiandrogens

Antiandrogens, substances that prevent androgens from expressing their activity at target cells, play an important role in the treatment of prostate cancer. The most frequently used substances have either a steroidal structure (cyproterone acetate) or a non-steroidal structure (Flutamide or Anandron). Antiandrogens have been tested both alone and in combination with treatments aimed at inhibiting testicular secretion (castration, LH-RH analogs), thereby producing complete blockade of androgen secretion and action. Patients treated by such combination protocols have often shown an improvement in the percentage of remissions and, less often, improvement in survival. Administration of antiandrogens improves the clinical symptoms of patients with benign prostatic hypertrophy, but the exact mechanism of their action requires further investigation. Cutaneous manifestations due to hyperandrogenicity (hirsutism, alopecia, acne) have also been improved by cyproterone acetate, which is often given together with estrogens (reversed sequential regime), by spironolactone or topically applied products. Finally, antiandrogens have been successfully used to treat breast cancer in men, early puberty, hypersexuality and sexual deviations.

Tolerance of spironolactone

A survey of 54 patients taking spironolactone for hirsutes or acne showed that side-effects occurred in 91%; in 80% of patients, these were related to the anti-androgenic mechanism of the drug (menstrual disturbances, and breast enlargement and tenderness). The concomitant use of a contraceptive pill gave a lower incidence of menstrual abnormalities. Only seven patients (13%) had to stop the drug. In a further eight patients, a reduction in dose to between 125 and 175 mg daily achieved a compromise of controlling the disease and the side-effects. Side-effects tended to occur early and so regular review during the initial 3 months of treatment is advised. Two patients in our study developed 'chloasma'--a previously unreported complication of spironolactone. This was the only side-effect which occurred late in treatment.

Plasma levels of C-19 steroids and 5 alpha-reduced steroid glucuronides in hyperandrogenic and idiopathic hirsute women

In the present study, the authors measured the plasma levels of unconjugated and glucuronide (G) derivatives of C-19 steroids in hirsute women divided into two groups, depending upon their dehydroepiandrosterone sulfate (DHEAS). This quite restrictive classification was the result of an arbitrary decision of the authors, who wanted to focus interpretation of their data on DHEAS, the well-known adrenal androgen. In the hyperandrogenic hirsute woman (HH), the DHEAS levels were higher than 3.0 micrograms/ml; in idiopathic hirsute women (IH), values of DHEAS were comparable to those observed in normal women (1.2 to 2.5 micrograms/ml). In the HH group, the levels of dehydroepiandrosterone, androstenedione, androst-5-ene-3 beta,17 beta-diol (delta 5-diol), testosterone, dihydrotestosterone (DHT), androstane-3 alpha, 17 beta-diol (3 alpha-diol), androstane-3 beta,17 beta-diol (3 beta-diol), androsterone (ADT), DHTG, 3 alpha-diol-G, 3 beta-diol-G, and ADTG were higher than the normal range whereas, in the IH group, only delta 5-diol, DHT, 3 beta-diol-G and ADTG were elevated. These data are compatible with the hypothesis that the plasma levels of steroid G represent the peripheral formation of androgen in target tissues. Because the pattern of androgen metabolism is most probably changed in many cases of hirsutism, these data suggest that for research purposes, it would be preferable to measure 3 beta-diol-G and ADTG in addition to 3 alpha-diol-G in order to gain additional information concerning androgen metabolites in this disorder.