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Abstract
PURPOSE OF REVIEW Polycystic ovary syndrome (PCOS) is often difficult to diagnose in adolescents. Recent recommendations and concepts regarding the diagnosis and treatment of PCOS in the adolescent girl are considered. RECENT FINDINGS The diagnosis of PCOS in adolescents should be primarily based on clinical and biochemical signs of hyperandrogenism and presentation with irregular menses. Because of the similarity of normal pubertal development and features of PCOS, the diagnosis should be deferred until at least 2 years following menarche. For girls who do not fulfill the diagnostic criteria, the focus should be on treatment of symptoms. SUMMARY PCOS is a complex, multifaceted disorder, and should be diagnosed and treated in adolescents after taking into consideration the patient's full diagnostic picture, metabolic risks, and individual concerns, to both avoid overdiagnosis but yet be able to provide early and meaningful interventions.
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Fulghesu AM, Melis F, Murru G, Canu E, Melis GB. Very low dose of flutamide in the treatment of hyperandrogenism. Gynecol Endocrinol 2018; 34:394-398. [PMID: 29108453 DOI: 10.1080/09513590.2017.1397114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Hyperandrogenism is a condition affecting 5-10% of adolescents. The aim of this study was to evaluate the efficacy of very low dose of flutamide in the treatment of hyperandrogenism in adolescence. One hundred and fifty-eight patients, presenting severe acne and/or hirsutism, received 62.5 mg/day of flutamide + ethinylestradiol + gestodene for 18 months. The patients were subjected to assessments of hepatic enzymes levels. Thirty subjects treated with drospirenone + ethinylestradiol represented the control group. After 18 months of treatment, it was obtained a decrease of hirsutism (-39.9%), an almost recovery of acne (98% of patients) with better results of those obtained in control group. Only one case of light hypertransaminasemia was recorded, regressed spontaneously. Very low dose of flutamide was successful and safe and in the treatment of hyperandrogenism in adolescence.
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Affiliation(s)
- Anna Maria Fulghesu
- a Department of Obstetric and Gynecology , Univ di Cagliari , Cagliari , Italy
| | - Federica Melis
- a Department of Obstetric and Gynecology , Univ di Cagliari , Cagliari , Italy
| | - Giulia Murru
- b Department of Obstetrics and Gynecology , Ospedale San Paolo, Università di Milano , Milano , Italy
| | - Elena Canu
- a Department of Obstetric and Gynecology , Univ di Cagliari , Cagliari , Italy
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Moretti C, Guccione L, Di Giacinto P, Simonelli I, Exacoustos C, Toscano V, Motta C, De Leo V, Petraglia F, Lenzi A. Combined Oral Contraception and Bicalutamide in Polycystic Ovary Syndrome and Severe Hirsutism: A Double-Blind Randomized Controlled Trial. J Clin Endocrinol Metab 2018; 103:824-838. [PMID: 29211888 DOI: 10.1210/jc.2017-01186] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT Hirsutism often occurs in women with polycystic ovary syndrome (PCOS). The efficacy of oral contraceptive pill (OCP) plus antiandrogens in the treatment of its severe expression is controversial due to the lack of randomized, double-blind, long-term studies. OBJECTIVE The primary outcome was the reduction of hirsutism in PCOS women objectively measured by videodermoscopy on the androgen-sensitive skin areas assessed by the modified Ferriman and Gallwey (mF&G) total score, after 12 months of therapy with OCP + bicalutamide (BC) vs OCP plus placebo (P). The secondary outcomes were to evaluate tolerability of BC and body composition as well as the occurrence of adverse events. DESIGN An experimental, phase 3, prospective, multicenter, randomized, double-blind, P-controlled trial. Patients were evaluated at the baseline visit, at 6 and 12 months during treatment, and 6 months' posttreatment. PARTICIPANTS Seventy women with classic PCOS (severe hirsutism, oligoanovulation, and ovarian polycystic ovarian morphology). INTERVENTION Patients received OCP + BC (50 mg/d) or OCP + P for 12 months. RESULTS The repeated measures analysis of variance showed that both treatments were effective in reducing hirsutism: The OCP + BC group had a higher reduction compared with the OCP + P group. No adverse effects were described during treatment except an increase in total cholesterol and low-density lipoprotein in the OCP + BC group. CONCLUSIONS The association of OCP + BC is well tolerated and significantly more effective than OCP alone in treating severe hirsutism. We suggest a combined use of the videodermoscopic index and mF&G to evaluate the effects of androgen deprivation therapy for hirsutism.
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Affiliation(s)
- Costanzo Moretti
- Department of Systems' Medicine, Unit of Endocrinology, Section of Reproductive Endocrinology, "San Giovanni Calibita" Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Laura Guccione
- Department of Systems' Medicine, Unit of Endocrinology, Section of Reproductive Endocrinology, "San Giovanni Calibita" Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Paola Di Giacinto
- Department of Systems' Medicine, Unit of Endocrinology, Section of Reproductive Endocrinology, "San Giovanni Calibita" Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Ilaria Simonelli
- Service of Medical Statistics & Information Technology, Fatebenefratelli Foundation for Health Research and Education, Rome, Italy
| | - Caterina Exacoustos
- Department of Surgery, Unit of Obstetrics and Gynecology, University of Rome Tor Vergata, Rome, Italy
| | - Vincenzo Toscano
- Unit of Endocrinology, Sant'Andrea Hospital, II Faculty of Medicine, University of Rome "Sapienza," Rome, Italy
| | - Cecilia Motta
- Unit of Endocrinology, Sant'Andrea Hospital, II Faculty of Medicine, University of Rome "Sapienza," Rome, Italy
| | - Vincenzo De Leo
- Unit of Obstetrics and Gynecology, "Santa Maria alle Scotte" Hospital, University of Siena, Siena, Italy
| | - Felice Petraglia
- Unit of Obstetrics and Gynecology, "Santa Maria alle Scotte" Hospital, University of Siena, Siena, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Unit of Endocrinology, "Policlinico Umberto I" Hospital, University of Rome "Sapienza," Rome, Italy
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Baldani DP, Skrgatic L, Ougouag R, Kasum M. The cardiometabolic effect of current management of polycystic ovary syndrome: strategies of prevention and treatment. Gynecol Endocrinol 2018; 34:87-91. [PMID: 28944709 DOI: 10.1080/09513590.2017.1381681] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder amongst women of reproductive age, which is characterized by reproductive and cardiometabolic disturbances with long-term health repercussions. Insulin resistance (IR), impaired glucose tolerance, type 2 diabetes mellitus (DM2), obesity and dyslipidemia occur more in women with PCOS than in age-comparable women without PCOS. Long term data regarding risks or benefits of medical intervention for metabolic dysfunction of PCOS are lacking. Therapies, such as oral contraceptives (OCPs) and anti-androgenic medications used to manage the reproductive manifestations of PCOS, may themselves be the cause of cardiometabolic perturbations. Hence, strategies regarding the management of reproductive issues in PCOS encompass a patient-specific tailored approach. Factors that influence the cardiometabolic side effects arising during treatment of the reproductive manifestations of PCOS (hirsutism/anovulation) are also discussed in this paper in order to build future strategies to minimize the overall cardiometabolic risk.
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Affiliation(s)
- Dinka Pavicic Baldani
- a Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility , University of Zagreb, School of Medicine, Clinical Hospital Centre Zagreb , Zagreb , Croatia
| | - Lana Skrgatic
- a Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility , University of Zagreb, School of Medicine, Clinical Hospital Centre Zagreb , Zagreb , Croatia
| | - Roya Ougouag
- b Medical Student , School of Medicine, University of Zagreb , Zagreb , Croatia
| | - Miro Kasum
- a Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility , University of Zagreb, School of Medicine, Clinical Hospital Centre Zagreb , Zagreb , Croatia
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Goodman NF, Cobin RH, Futterweit W, Glueck JS, Legro RS, Carmina E. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE EVALUATION AND TREATMENT OF POLYCYSTIC OVARY SYNDROME--PART 1. Endocr Pract 2016; 21:1291-300. [PMID: 26509855 DOI: 10.4158/ep15748.dsc] [Citation(s) in RCA: 284] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Polycystic Ovary Syndrome (PCOS) is recognized as the most common endocrine disorder of reproductive-aged women around the world. This document, produced by the collaboration of the American Association of Clinical Endocrinologists (AACE) and the Androgen Excess and PCOS Society (AES) aims to highlight the most important clinical issues confronting physicians and their patients with PCOS. It is a summary of current best practices in 2015. PCOS has been defined using various criteria, including menstrual irregularity, hyperandrogenism, and polycystic ovary morphology (PCOM). General agreement exists among specialty society guidelines that the diagnosis of PCOS must be based on the presence of at least two of the following three criteria: chronic anovulation, hyperandrogenism (clinical or biological) and polycystic ovaries. There is need for careful clinical assessment of women's history, physical examination, and laboratory evaluation, emphasizing the accuracy and validity of the methodology used for both biochemical measurements and ovarian imaging. Free testosterone (T) levels are more sensitive than the measurement of total T for establishing the existence of androgen excess and should be ideally determined through equilibrium dialysis techniques. Value of measuring levels of androgens other than T in patients with PCOS is relatively low. New ultrasound machines allow diagnosis of PCOM in patients having at least 25 small follicles (2 to 9 mm) in the whole ovary. Ovarian size at 10 mL remains the threshold between normal and increased ovary size. Serum 17-hydroxyprogesterone and anti-Müllerian hormone are useful for determining a diagnosis of PCOS. Correct diagnosis of PCOS impacts on the likelihood of associated metabolic and cardiovascular risks and leads to appropriate intervention, depending upon the woman's age, reproductive status, and her own concerns. The management of women with PCOS should include reproductive function, as well as the care of hirsutism, alopecia, and acne. Cycle length >35 days suggests chronic anovulation, but cycle length slightly longer than normal (32 to 35 days) or slightly irregular (32 to 35-36 days) needs assessment for ovulatory dysfunction. Ovulatory dysfunction is associated with increased prevalence of endometrial hyperplasia and endometrial cancer, in addition to infertility. In PCOS, hirsutism develops gradually and intensifies with weight gain. In the neoplastic virilizing states, hirsutism is of rapid onset, usually associated with clitoromegaly and oligomenorrhea. Girls with severe acne or acne resistant to oral and topical agents, including isotretinoin (Accutane), may have a 40% likelihood of developing PCOS. Hair loss patterns are variable in women with hyperandrogenemia, typically the vertex, crown or diffuse pattern, whereas women with more severe hyperandrogenemia may see bitemporal hair loss and loss of the frontal hairline. Oral contraceptives (OCPs) can effectively lower androgens and block the effect of androgens via suppression of ovarian androgen production and by increasing sex hormone-binding globulin. Physiologic doses of dexamethasone or prednisone can directly lower adrenal androgen output. Anti-androgens can be used to block the effects of androgen in the pilosebaceous unit or in the hair follicle. Anti-androgen therapy works through competitive antagonism of the androgen receptor (spironolactone, cyproterone acetate, flutamide) or inhibition of 5α-reductase (finasteride) to prevent the conversion of T to its more potent form, 5α-dihydrotestosterone. The choice of antiandrogen therapy is guided by symptoms. The diagnosis of PCOS in adolescents is particularly challenging given significant age and developmental issues in this group. Management of infertility in women with PCOS requires an understanding of the pathophysiology of anovulation as well as currently available treatments. Many features of PCOS, including acne, menstrual irregularities, and hyperinsulinemia, are common in normal puberty. Menstrual irregularities with anovulatory cycles and varied cycle length are common due to the immaturity of the hypothalamic-pituitary-ovarian axis in the 2- to 3-year time period post-menarche. Persistent oligomenorrhea 2 to 3 years beyond menarche predicts ongoing menstrual irregularities and greater likelihood of underlying ovarian or adrenal dysfunction. In adolescent girls, large, multicystic ovaries are a common finding, so ultrasound is not a first-line investigation in women <17 years of age. Ovarian dysfunction in adolescents should be based on oligomenorrhea and/or biochemical evidence of oligo/anovulation, but there are major limitations to the sensitivity of T assays in ranges applicable to young girls. Metformin is commonly used in young girls and adolescents with PCOS as first-line monotherapy or in combination with OCPs and anti-androgen medications. In lean adolescent girls, a dose as low as 850 mg daily may be effective at reducing PCOS symptoms; in overweight and obese adolescents, dose escalation to 1.5 to 2.5 g daily is likely required. Anti-androgen therapy in adolescents could affect bone mass, although available short-term data suggest no effect on bone loss.
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Chen MJ, Ho HN. Hepatic manifestations of women with polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol 2016; 37:119-128. [PMID: 27107966 DOI: 10.1016/j.bpobgyn.2016.03.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 03/05/2016] [Indexed: 12/11/2022]
Abstract
Women with polycystic ovary syndrome (PCOS) have a higher prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) than the general population. The link between NAFLD/NASH and PCOS is not just a coincidence. Indeed, both of these disorders comprise common risk factors, including central obesity, insulin resistance, chronic low-grade inflammation, and hyperandrogenemia. The characteristics of hyperandrogenemia in women with PCOS include elevated total and free testosterone levels and low sex hormone-binding globulin levels and are reported to be associated with NAFLD and elevated liver enzymes; however, not all elevated androgen levels in women with PCOS have the same adverse effects on the liver. With the exception of weight loss and encouraging exercise in obese women, few evidence-based effective treatments target NAFLD/NASH in women with PCOS. Selective antiandrogens and insulin sensitizers might be beneficial in treating NAFLD/NASH in women with PCOS, but further elucidation is needed.
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Affiliation(s)
- Mei-Jou Chen
- Departments of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hong-Nerng Ho
- Departments of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan.
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Chen Y, Liu WY, Zeng GS. Stimulus-responsive hydrogels reinforced by cellulose nanowhisker for controlled drug release. RSC Adv 2016. [DOI: 10.1039/c6ra14421g] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hybrid hydrogels (W–C gels), composed of PDMAEMA, cellulose nanowhisker (CNW) and carboxymethyl chitosan (CMCS), were prepared for developing a stimuli-responsive drug-release system.
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Affiliation(s)
- Y. Chen
- Institute of Packaging and Materials Engineering
- Department of Polymer Materials and Engineering
- Hunan University of Technology
- Zhuzhou 412008
- China
| | - W. Y. Liu
- Institute of Packaging and Materials Engineering
- Department of Polymer Materials and Engineering
- Hunan University of Technology
- Zhuzhou 412008
- China
| | - G. S. Zeng
- Institute of Packaging and Materials Engineering
- Department of Polymer Materials and Engineering
- Hunan University of Technology
- Zhuzhou 412008
- China
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Spritzer PM, Motta AB. Adolescence and polycystic ovary syndrome: current concepts on diagnosis and treatment. Int J Clin Pract 2015; 69:1236-46. [PMID: 26289303 DOI: 10.1111/ijcp.12719] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 07/25/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Adolescence is a time characterised by changes in reproductive hormones and menstrual patterns, which makes it difficult to diagnose polycystic ovary syndrome (PCOS) in this population. The diagnosis of PCOS has a great physical and psychosocial impact on the young person. Despite the importance of a diagnosis of PCOS at adolescence, data available are limited. AIMS This review focuses on analysing markers of PCOS diagnosis and possible treatments in adolescence. RESULTS Although, during adolescence, diagnosis criteria of PCOS overlap with physiological changes including clinical manifestations of hyperandrogenism (acne and hirsutism), oligo/amenorrhoea, anovulation and ovarian microcysts, there is agreement that irregular menses and hyperandrogenaemia should be used to diagnose PCOS in this population. Moreover, considering that PCOS phenotype could change through the reproductive age and that adolescents display heterogeneous ovarian morphology, it has been proposed that diagnosis of PCOS should be confirmed after the age of 18. The first-line treatment for menstrual irregularity and hirsutism are oral contraceptive pills (OCPs) and for obesity and metabolic abnormalities are lifestyle changes. Insulin-sensitizer drugs, such as metformin, may be added to the treatment in the presence of metabolic alterations. Antiandrogen drugs may also be associated for treating moderate to severe hirsutism. During adolescence, physiological changes overlap with signs and symptoms of PCOS; thus the diagnosis criteria should be carefully considered. Regarding the treatment of adolescents with PCOS, non-pharmacological interventions include lifestyle changes. Pharmacological treatments comprise OCPs, antiandrogens and metformin, used isolated or combined. CONCLUSIONS During adolescence, physiological changes overlap with signs and symptoms of PCOS; thus the diagnosis criteria should be carefully considered. Regarding the treatment of adolescents with PCOS, non-pharmacological interventions include lifestyle changes. Pharmacological treatments comprise OCPs, antiandrogens and metformin, used isolated or combined.
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Affiliation(s)
- P M Spritzer
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre and Laboratory of Molecular Endocrinology, Department of Physiology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - A B Motta
- Laboratorio de Fisio-patología Ovárica, Facultad de Medicina, Universidad de Buenos Aires (UBA), Centro de Estudios Farmacológicos y Botánicos (CEFYBO)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
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Polycystic ovary syndrome: A review for dermatologists. J Am Acad Dermatol 2014; 71:859.e1-859.e15; quiz 873-4. [DOI: 10.1016/j.jaad.2014.05.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/05/2014] [Accepted: 05/05/2014] [Indexed: 01/19/2023]
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Conway G, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Franks S, Gambineri A, Kelestimur F, Macut D, Micic D, Pasquali R, Pfeifer M, Pignatelli D, Pugeat M, Yildiz BO. The polycystic ovary syndrome: a position statement from the European Society of Endocrinology. Eur J Endocrinol 2014; 171:P1-29. [PMID: 24849517 DOI: 10.1530/eje-14-0253] [Citation(s) in RCA: 364] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Polycystic ovary syndrome (PCOS) is the most common ovarian disorder associated with androgen excess in women, which justifies the growing interest of endocrinologists. Great efforts have been made in the last 2 decades to define the syndrome. The presence of three different definitions for the diagnosis of PCOS reflects the phenotypic heterogeneity of the syndrome. Major criteria are required for the diagnosis, which in turn identifies different phenotypes according to the combination of different criteria. In addition, the relevant impact of metabolic issues, specifically insulin resistance and obesity, on the pathogenesis of PCOS, and the susceptibility to develop earlier than expected glucose intolerance states, including type 2 diabetes, has supported the notion that these aspects should be considered when defining the PCOS phenotype and planning potential therapeutic strategies in an affected subject. This paper offers a critical endocrine and European perspective on the debate on the definition of PCOS and summarises all major aspects related to aetiological factors, including early life events, potentially involved in the development of the disorder. Diagnostic tools of PCOS are also discussed, with emphasis on the laboratory evaluation of androgens and other potential biomarkers of ovarian and metabolic dysfunctions. We have also paid specific attention to the role of obesity, sleep disorders and neuropsychological aspects of PCOS and on the relevant pathogenetic aspects of cardiovascular risk factors. In addition, we have discussed how to target treatment choices based according to the phenotype and individual patient's needs. Finally, we have suggested potential areas of translational and clinical research for the future with specific emphasis on hormonal and metabolic aspects of PCOS.
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Affiliation(s)
- Gerard Conway
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Didier Dewailly
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Evanthia Diamanti-Kandarakis
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Héctor F Escobar-Morreale
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Stephen Franks
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Alessandra Gambineri
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Fahrettin Kelestimur
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Djuro Macut
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Dragan Micic
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Renato Pasquali
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Marija Pfeifer
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Duarte Pignatelli
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Michel Pugeat
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Bulent O Yildiz
- Department of EndocrinologyUniversity College London Hospitals, 250 Euston Road, London NW1 2BU, UKDepartment of Endocrine Gynaecology and Reproductive MedicineCentre Hospitalier de Lille, Hopital Jeanne de Fiandre, Lille, FranceEndocrine Unit3rd Department of Medicine, University of Athens Medical School, Athens, GreeceDepartment of Endocrinology and NutritionUniversidad de Alcalá and Hospital Universitario Ramón y Cajal and Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, SpainImperial College LondonInstitute of Reproductive and Developmental Biology, London, UKDivision of EndocrinologyDepartment of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Via Massarenti 9, 40138 Bologna, ItalyDepartment of EndocrinologySchool of Medicine, Erciyes University, Kayseri, TurkeyClinic for EndocrinologyDiabetes and Metabolic Diseases, School of Medicine, University of Belgrade, Belgrade, SerbiaDepartment of EndocrinologyDiabetes and Metabolic Diseases, Medical Faculty, University Medical Centre, University of Ljubljana, Ljubljana, SloveniaDepartment of EndocrinologyFaculty of Medicine of Porto, Hospital S. Joao, Porto, PortugalInsermFédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université Lyon-1, Lyon, France andDivision of Endocrinology and MetabolismDepartment of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
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Domecq JP, Prutsky G, Mullan RJ, Sundaresh V, Wang AT, Erwin PJ, Welt C, Ehrmann D, Montori VM, Murad MH. Adverse effects of the common treatments for polycystic ovary syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab 2013; 98:4646-54. [PMID: 24092830 PMCID: PMC5399491 DOI: 10.1210/jc.2013-2374] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 09/16/2013] [Indexed: 12/12/2022]
Abstract
CONTEXT Polycystic ovary syndrome (PCOS) is common among women of childbearing age and the available pharmacological therapies have different side-effect profiles. OBJECTIVE We summarized the evidence about the side effects of oral contraceptive pills, metformin, and anti-androgens in women with PCOS. DATA SOURCE Sources included Ovid Medline, OVID EMBASE, OVID Cochrane Library, Web of Science, Scopus, PsycInfo, and CINAHL from inception through April 2011. STUDY SELECTION We included comparative observational studies enrolling women with PCOS who received the agents of choice for at least 6 months and reported adverse effects. DATA EXTRACTION Using a standardized, piloted, and Web-based data extraction form and working in duplicate, we abstracted data from each study and performed meta-analysis when possible. DATA SYNTHESIS We found 22 eligible studies of which 20 were randomized. No study reported severe side effects (eg, lactic acidosis, thromboembolic episodes, liver toxicity, cancer incidence, or pregnancy loss). Meta-analysis demonstrated no significant change in weight in oral contraceptive pills or flutamide users. Indirect evidence from populations without PCOS demonstrated no increased risk of lactic acidosis with metformin, only case reports of liver toxicity with flutamide (no comparative evidence), and increased relative risk difference of venous thromboembolism with oral contraceptive pills but very low absolute risk. Evidence on mortality, cardiovascular mortality, and cancer was inconclusive. CONCLUSIONS Drugs commonly used to treat PCOS appear to be associated with very low risk of severe adverse effects although data are extrapolated from other populations.
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Affiliation(s)
- Juan Pablo Domecq
- MD, MPH, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
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Williams RM, Ong KK, Dunger DB. Polycystic ovarian syndrome during puberty and adolescence. Mol Cell Endocrinol 2013; 373:61-7. [PMID: 23384539 DOI: 10.1016/j.mce.2013.01.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 01/10/2013] [Accepted: 01/10/2013] [Indexed: 12/30/2022]
Abstract
PCOS has reasonably well defined clinical, biochemical and radiological features in adult women, but in the adolescent population, some of these features may overlap with normal puberty leading to difficulties in making a diagnosis. In addition, the rising prevalence of obesity in the paediatric population may compound insulin resistance in girls predisposed to ovarian hyperandrogenism leading to younger age of presentation and more severe phenotype. It is important to distinguish between normal puberty and true ovarian hyperandrogenism, as well as excluding other causes of androgen excess such as adrenal tumours or non classical congenital adrenal hyperplasia. The long term co-morbidities associated with ovarian hyperandrogenism presenting during adolescence are not well defined but there is likely to be increased cardiovascular risk. There are little data on intervention in the adolescent population and studies in adult women often focus on ovulation and fertility which are less of a concern to adolescents. Current options include insulin sensitisation with metformin, anti androgens, or the oral contraceptive pill, with each girl being treated on an individual basis. There is a requirement for establishment of normative data in adolescence, in conjunction with physiological phenotyping in order to elucidate potential mechanisms thus informing potential intervention.
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13
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Reply of the Authors. Fertil Steril 2012. [DOI: 10.1016/j.fertnstert.2012.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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14
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Unluhizarci K, Sahin Y, Kelestimur F. The evaluation and treatment of hirsute women. ACTA ACUST UNITED AC 2012; 1:429-35. [PMID: 19803884 DOI: 10.2217/17455057.1.3.429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Hirsutism in women is defined as an excess of body hair in the androgen-sensitive skin regions. The different genetic backgrounds of various populations may affect the causes of hirsutism. In fact, the most important reason for investigation is to identify those women with androgen-secreting tumors, since they require different therapy. Hirsutism may have various causes, such as polycystic ovary syndrome, enzyme defects in adrenal steroid biosynthesis, Cushing's syndrome, acromegaly, ovarian or adrenal tumors, or it may be idiopathic. In most patients, hirsutism is associated with hyperandrogenemia and the most common cause of androgen excess is polycystic ovary syndrome. Androgen-secreting tumors should be suspected when the onset and progression of hirsutism is rapid and/or when it is associated with virilization. Patients should be informed about the type and duration of therapy. The selection of drug/drugs depends on the severity of the hirsutism, associated conditions such as menstrual irregularities, systemic disorders such as diabetes mellitus, hypertension and any contraindication to possible therapeutic agents. Diane(R) 35 is the most common drug used for the suppression of ovarian androgen production. Peripheral blockade of androgen actions, by using spironolactone, finasteride or flutamide on the skin, is also effective in the treatment of hirsutism.
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Affiliation(s)
- Kursad Unluhizarci
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey. kursad@ erciyes.edu.tr
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Hepatotoxicity with low- and ultralow-dose flutamide: a surveillance study on 203 hyperandrogenic young females. Fertil Steril 2012; 98:1047-52. [DOI: 10.1016/j.fertnstert.2012.06.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 06/01/2012] [Accepted: 06/08/2012] [Indexed: 01/25/2023]
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Escobar-Morreale HF, Carmina E, Dewailly D, Gambineri A, Kelestimur F, Moghetti P, Pugeat M, Qiao J, Wijeyaratne CN, Witchel SF, Norman RJ. Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update 2011; 18:146-70. [PMID: 22064667 DOI: 10.1093/humupd/dmr042] [Citation(s) in RCA: 230] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Hirsutism, defined by the presence of excessive terminal hair in androgen-sensitive areas of the female body, is one of the most common disorders in women during reproductive age. METHODS We conducted a systematic review and critical assessment of the available evidence pertaining to the epidemiology, pathophysiology, diagnosis and management of hirsutism. RESULTS The prevalence of hirsutism is ~10% in most populations, with the important exception of Far-East Asian women who present hirsutism less frequently. Although usually caused by relatively benign functional conditions, with the polycystic ovary syndrome leading the list of the most frequent etiologies, hirsutism may be the presenting symptom of a life-threatening tumor requiring immediate intervention. CONCLUSIONS Following evidence-based diagnostic and treatment strategies that address not only the amelioration of hirsutism but also the treatment of the underlying etiology is essential for the proper management of affected women, especially considering that hirsutism is, in most cases, a chronic disorder needing long-term follow-up. Accordingly, we provide evidence-based guidelines for the etiological diagnosis and for the management of this frequent medical complaint.
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Affiliation(s)
- H F Escobar-Morreale
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramon y Cajal & Universidad de Alcalá & Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS & CIBER Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM, 28034 Madrid, Spain.
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Paradisi R, Fabbri R, Porcu E, Battaglia C, Seracchioli R, Venturoli S. 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. Gynecol Endocrinol 2011; 27:823-9. [PMID: 21117864 DOI: 10.3109/09513590.2010.526664] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Roberto Paradisi
- Department of Obstetrics and Gynecology and Reproductive Biology, S. Orsola Hospital, University Alma Mater Studiorum of Bologna, Bologna, Italy.
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Affiliation(s)
- Claudia Brufani
- Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Geller DH, Pacaud D, Gordon CM, Misra M. State of the Art Review: Emerging Therapies: The Use of Insulin Sensitizers in the Treatment of Adolescents with Polycystic Ovary Syndrome (PCOS). INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2011; 2011:9. [PMID: 21899727 PMCID: PMC3180691 DOI: 10.1186/1687-9856-2011-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 08/26/2011] [Indexed: 12/14/2022]
Abstract
PCOS, a heterogeneous disorder characterized by cystic ovarian morphology, androgen excess, and/or irregular periods, emerges during or shortly after puberty. Peri- and post-pubertal obesity, insulin resistance and consequent hyperinsulinemia are highly prevalent co-morbidities of PCOS and promote an ongoing state of excess androgen. Given the relationship of insulin to androgen excess, reduction of insulin secretion and/or improvement of its action at target tissues offer the possibility of improving the physical stigmata of androgen excess by correction of the reproductive dysfunction and preventing metabolic derangements from becoming entrenched. While lifestyle changes that concentrate on behavioral, dietary and exercise regimens should be considered as first line therapy for weight reduction and normalization of insulin levels in adolescents with PCOS, several therapeutic options are available and in wide use, including oral contraceptives, metformin, thiazolidenediones and spironolactone. Overwhelmingly, the data on the safety and efficacy of these medications derive from the adult PCOS literature. Despite the paucity of randomized control trials to adequately evaluate these modalities in adolescents, their use, particularly that of metformin, has gained popularity in the pediatric endocrine community. In this article, we present an overview of the use of insulin sensitizing medications in PCOS and review both the adult and (where available) adolescent literature, focusing specifically on the use of metformin in both mono- and combination therapy.
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Affiliation(s)
- David H Geller
- Division of Pediatric Endocrinology, Cedars-Sinai Medical Center, David Geffen-UCLA School of Medicine 8700 Beverly Blvd,, Rm 4220, Los Angeles, CA 90048, USA.
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Paradisi R, Porcu E, Fabbri R, Seracchioli R, Battaglia C, Venturoli S. Prospective Cohort Study on the Effects and Tolerability of Flutamide in Patients with Female Pattern Hair Loss. Ann Pharmacother 2011; 45:469-75. [DOI: 10.1345/aph.1p600] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Flutamide has been rarely used (or the treatment of female pattern hair loss (FPHL). Flutamide treatment for FPHL has not been evaluated in long-term studies with sufficiently large numbers of women. Objective: To evaluate long-term effects, safety, and tolerability of flutamide in women with FPHL. Methods: A prospective cohort study was conducted in our tertiary care university hospital. The cohort included 101 women diagnosed with FPHL from January 1991 to January 2006. These women received yearly reducing doses (250, 125, and 62.5 mg/day) of flutamide for 4 years. The cohort included 33 patients treated with flutamide alone and 68 treated with flutamide combined with an oral contraceptive. Clinical and endocrine evaluations were assessed semiannually and annually, respectively, in the first 3 years of the study, and once in the following year. Liver function was evaluated quarterly. Results: Both groups showed a marked decrease in alopecia scores after 12 months of flutamide therapy, compared with baseline values. The maximum drug effect occurred after 2 years and was maintained during the following 2 years of treatment. Androgens were strongly suppressed. During the first year of treatment, 4% of patients abandoned the study due to hepatic disorders related to the drug. During the following years, with the lower treatment regimen, no patient abandoned the study because of hepatic alterations. Conclusions: Flutamide is a satisfactory therapeutic regimen for treatment of FPHL in the long run. Moreover, the use of very low doses (62.5 mg/day) of flutamide is associated with complete hepatic tolerability and high adherence.
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Affiliation(s)
- Roberto Paradisi
- Department of Obstetrics, Gynecology and Reproductive Biology, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Eleonora Porcu
- Department of Obstetrics, Gynecology and Reproductive Biology, S. Orsola Hospital
| | - Raffaella Fabbri
- Department of Obstetrics, Gynecology and Reproductive Biology, S. Orsola Hospital
| | - Renato Seracchioli
- Department of Obstetrics, Gynecology and Reproductive Biology, S. Orsola Hospital
| | - Cesare Battaglia
- Department of Obstetrics, Gynecology and Reproductive Biology, S. Orsola Hospital
| | - Stefano Venturoli
- Department of Obstetrics, Gynecology and Reproductive Biology, S. Orsola Hospital
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Ibáñez L, López-Bermejo A, Díaz M, Enríquez G, Del Río L, De Zegher F. Low-dose pioglitazone, flutamide, metformin plus an estro-progestagen for non-obese young women with polycystic ovary syndrome: increasing efficacy and persistent safety over 30 months. Gynecol Endocrinol 2010; 26:869-73. [PMID: 20500100 DOI: 10.3109/09513590.2010.487589] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Therapy of androgen excess should not only confer cosmetic benefit, but also improve long-term markers of endocrine-metabolic and cardiovascular health. Here we report on our pilot experience with a low-dose polytherapy for 30 months. DESIGN, PATIENTS, INTERVENTION: Unblinded extension (24-30 months) of a double-placebo study exploring low-dose polytherapy over 24 months. Between 24 and 30 months, women with hyperinsulinemic androgen excess (N = 36; mean age: 19.4 year; BMI: 23.7 kg/m(2)) received metformin (850 mg/day), flutamide (62.5 mg/day), pioglitazone (7.5 mg/day), ethinylestradiol (20 μg/day) plus drospirenone (3 mg/day) for 24/28 days. MAIN OUTCOMES Carotid IMT, body composition (by absorptiometry), abdominal fat (by magnetic resonance), hirsutism score, fasting glycaemia, insulin, androgens, HDL cholesterol, C-reactive protein and hepatic safety indices. RESULTS Low-dose polytherapy for 30 months was not accompanied by a change in body weight or bone mineral density, but it was associated with a marked rise of insulin sensitivity (p < 0.00001), with a loss of visceral fat (mean: -27%; p < 0.00001) and with a lowering of IMT (-0.16 mm; p < 0.00001). Aspartate aminotransferase, gamma-glutamyl transferase and lactate dehydrogenase levels decreased slightly over 30 months. CONCLUSION Low-dose polytherapy (24/28 day) with pioglitazone, flutamide, metformin and estro-progestagen was found to improve, without changing weight, a spectrum of long-term health markers in young women with hyperinsulinemic androgen excess.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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22
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Paradisi R, Venturoli S. Retrospective observational study on the effects and tolerability of flutamide in a large population of patients with various kinds of hirsutism over a 15-year period. Eur J Endocrinol 2010; 163:139-47. [PMID: 20371655 DOI: 10.1530/eje-10-0100] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The aim of the study was to evaluate the long-term effects and tolerability of flutamide (Flu) in hirsute women. To the best of our knowledge, this study represents the largest report, concerning the population studied and the duration of treatment, to evaluate Flu use in hirsutism treatment. DESIGN, PATIENTS AND METHODS Over a 15-year period spanning from January 1991 to January 2006, a total of 414 premenopausal women with hirsutism of different aetiopathogeneses received yearly reducing doses (250, 125 and 62.5 mg/day) of Flu alone or in combination with oral contraceptives for a period varying from at least 3 to 8 years and more. Clinical and endocrine evaluations were assessed half-yearly and yearly respectively in the first 3 years of the study, and yearly in the following years. Liver function evaluations were assessed quarterly. RESULTS Both the groups of patients under Flu therapy showed a marked decrease in hirsutism scores after 12 months compared with basal values. The maximum drug effect was observed after 2 years, and it was maintained during the following years of treatment. Androgens were strongly suppressed during treatment. During the first year of treatment, 6.0% of patients abandoned the study due to hepatic disorders related to the drug. During the following years with the lowest treatment regimen, none of the patients abandoned the study due to hepatic discomfort. CONCLUSIONS Flu is a satisfactory therapeutic regimen for any form of hirsutism in the long run. Moreover, the use of very low doses of Flu is associated with minimal side-effects and high compliance.
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Affiliation(s)
- Roberto Paradisi
- Department of Obstetrics and Gynecology and Reproductive Biology, S Orsola Hospital, University Alma Mater Studiorum of Bologna, Massarenti 13, I-40138 Bologna, Italy.
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23
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Bachelot A, Chabbert-Buffet N, Salenave S, Kerlan V, Galand-Portier MB. Anti-androgen Treatments. ANNALES D'ENDOCRINOLOGIE 2010; 71:19-24. [DOI: 10.1016/j.ando.2009.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/25/2009] [Indexed: 10/19/2022]
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Abstract
BACKGROUND The nonsteroidal antiandrogenic drug flutamide is a safe and generally well-tolerated drug used for the treatment of prostate cancer and female hyperandrogenism. CASE We describe the case of a 26-year-old girl with amenorrhea and severe hirsutism who was treated with flutamide 250 mg/day and developed liver toxicity during therapy. RESULTS Other causes of liver toxicity were appropriately ruled out. The use of the standard Council for International Organization of Medical Sciences (CIOMS) scale and the Maria & Vitorino (M&V) scale indicated a highly probable relationship between the development of liver toxicity and flutamide therapy. Severe liver dysfunction has been rarely documented in women with hirsutism treated with flutamide, even though cases of fulminant liver failure have been described. The mechanisms responsible for the occurrence of hepatotoxicity during treatment with flutamide are unknown, but mitochondrial dysfunction seems to be implicated. CONCLUSION The potential of flutamide to act as a potent hepatotoxin should be kept in mind when treatment with this drug is being planned. This case reminds us that patients who are receiving flutamide should be regularly monitored for liver function. If drug-induced liver injury is suspected, flutamide must be discontinued promptly to avoid progression of liver injury.
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Affiliation(s)
- Camil Castelo-Branco
- Clinic Institute of Gynecology, Obstetrics and Neonatologya, University of Barcelona, Hospital Clínic - Institut d'Investigacions Biomediques August Pi i Sunyer, Villarroel 170, Barcelona 08036, Spain.
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25
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Unluhizarci K, Ozel D, Tanriverdi F, Karaca Z, Kelestimur F. A comparison between finasteride, flutamide, and finasteride plus flutamide combination in the treatment of hirsutism. J Endocrinol Invest 2009; 32:37-40. [PMID: 19337013 DOI: 10.1007/bf03345676] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
To investigate the clinical efficacy and safety of the finasteride (5 mg/day) plus flutamide (125 mg/day) combination therapy in unselected women with hirsutism, 44 women were involved in the study. The effects of such combination treatment have not been reported previously. The patients were assigned to 3 treatment groups: 14 patients (group 1) were treated with finasteride (5 mg per day), 16 patients (group 2) were treated with flutamide (125 mg per day), and 14 patients (group 3) were treated with finasteride (5 mg per day) plus flutamide (125 mg per day) for 12 months. Serum FSH, LH, estradiol, total testosterone, free testosterone, androstenedione, DHEAS, and SHBG were obtained. Hirsutism score was measured before and after treatment. Blood chemistry and side effects were evaluated during the study. The reductions in hirsutism score (% of the baseline) at 6 months were as follows: 24% for group 1, 35% for group 2, and 33% for group 3. Combination therapy resulted in (49%) similar improvement to flutamide alone (45%), but significantly (p<0.05) more efficacious improvement in hirsutism when compared to finasteride (32%) after 12 months of treatment. In conclusion, flutamide is more effective than finasteride and the combination of these two drugs is not better than flutamide alone, but better than finasteride in hirsute women.
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Affiliation(s)
- K Unluhizarci
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey.
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de Zegher F, Ibáñez L. Low-dose flutamide for women with androgen excess: anti-androgenic efficacy and hepatic safety. J Endocrinol Invest 2009; 32:83-4. [PMID: 19337022 DOI: 10.1007/bf03345685] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- F de Zegher
- Department of Woman & Child, University of Leuven, Leuven, Belgium
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The risk of hepatotoxicity during long-term and low-dose flutamide treatment in hirsutism. Arch Gynecol Obstet 2008; 279:321-7. [DOI: 10.1007/s00404-008-0719-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 06/19/2008] [Indexed: 11/27/2022]
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Ong KK, de Zegher F, López-Bermejo A, Dunger DB, Ibáñez L. Flutamide metformin for post-menarcheal girls with preclinical ovarian androgen excess: evidence for differential response by androgen receptor genotype. Eur J Endocrinol 2007; 157:661-8. [PMID: 17984247 DOI: 10.1530/eje-07-0261] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Addition of androgen receptor (AR) blockade (flutamide) to insulin-sensitising therapy (metformin) may confer synergistic benefits in girls with hyperinsulinaemic androgen excess. We hypothesised that girls with shorter AR gene CAG repeat alleles, and thus greater receptor sensitivity, might benefit more from the addition of low-dose flutamide. DESIGN Open randomised crossover study. METHODS In this study, 32 post-menarcheal girls (mean age 12.1 years) with a history of low birth weight and precocious pubarche were subgrouped by CAG genotype ('short': CAG mean length 20, n=14; 'long': CAG >20, n=18). Within each subgroup, girls were 1:1 randomised to metformin alone (850 mg/day) or in combination with flutamide (62.5 mg/day) for 12 months. To allow comparisons with no treatment, long-CAG girls randomised to flutamide-metformin, and short-CAG girls randomised to metformin alone were observed for 12 months before treatment. Body composition by absorptiometry, fasting lipid profiles and levels of insulin, glucose and androgens were measured during the first 12 months on each treatment. RESULTS In all girls, 12 months flutamide-metformin lowered body fat and improved lipid profiles when compared with no treatment. Compared with metformin alone, flutamide-metformin achieved greater reductions in the percentage of body fat and abdominal fat mass in the short-CAG subgroup (P=0.001 to P<0.0001). In contrast, in the long-CAG subgroup, flutamide-metformin produced no further improvements when compared with metformin alone. CONCLUSIONS In young post-menarcheal girls with preclinical androgen excess, low-dose flutamide-metformin improved body composition and key endocrine-metabolic abnormalities. However, only those girls with genetic markers of greater AR sensitivity may benefit from the addition of flutamide above metformin alone.
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Affiliation(s)
- Ken K Ong
- Medical Research Council Epidemiology Unit, Cambridge CB0 2QQ, UK
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Abstract
Although hepatotoxicity is a frequent concern with all medications, chemotherapeutic agents are more often implicated in causing liver damage than most other drug classes. In many instances, these reactions are considered dose related because cytotoxic therapy directed at rapidly growing cancer cells may readily impact hepatocytes even though they are dividing more slowly. Because the stakes (remission of cancer) are high, so are the risks that the oncologist and the patient are willing to assume. The dose of many chemotherapeutic agents is limited by the toxic effects on the lungs, bone marrow, kidneys, and gastrointestinal system, including the liver. An awareness of the toxic potential of each chemotherapeutic agent is necessary before initiation of new oncologic treatments.
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Affiliation(s)
- Edmundo A Rodriguez-Frias
- Department of Internal Medicine, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Ibáñez L, López-Bermejo A, del Rio L, Enríquez G, Valls C, de Zegher F. Combined low-dose pioglitazone, flutamide, and metformin for women with androgen excess. J Clin Endocrinol Metab 2007; 92:1710-4. [PMID: 17299064 DOI: 10.1210/jc.2006-2684] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT AND OBJECTIVE One of the treatments for hyperinsulinemic hyperandrogenism in nonobese women is combined androgen receptor blockade (with flutamide; Flu), insulin sensitization (with metformin; Met) plus an estroprogestagen contraceptive. We tested whether adding low-dose pioglitazone (Pio; 7.5 mg/d) confers more benefit. SETTING The study was conducted at a university hospital. STUDY POPULATION AND DESIGN This double-blind study enrolled 38 young women with hyperinsulinemic hyperandrogenism [mean body mass index (BMI) 24 kg/m(2)], all of whom started on Flu (62.5 mg/d) and Met (850 mg/d) plus a transdermal estroprogestagen, each for 21 of 28 d over 6 months. Patients were randomly assigned to receive, in addition, placebo (n=19) or Pio (n=19; 7.5 mg/d) for the same 21 of 28 d over 6 months. MAIN OUTCOMES BMI, waist to hip ratio, hirsutism score, fasting endocrine-metabolic markers, body composition, abdominal fat (visceral vs. sc), and carotid intima-media thickness were measured at study start and after 6 months. RESULTS PioFluMet reduced intima-media thickness more than FluMet and lowered glucose, IGF-I, and C-reactive protein more as well as the ratio of low-density lipoprotein to high-density lipoprotein cholesterol and the ratio of neutrophils to lymphocytes. PioFluMet treatment was followed by a leaner body composition and a loss of visceral fat (both P < 0.001). In the total group, the changes included not only decreases in waist to hip ratio, hirsutism score, and testosterone (all P < 0.001) but also minor drops in alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, and lactate dehydrogenase (all P < 0.005), indicating absence of hepatotoxicity; BMI remained unchanged. Clinical side effects were not detected. CONCLUSION In this proof-of-concept study, addition of Pio to FluMet plus an estroprogestagen led to improvements in the endocrine-metabolic condition, in low-grade inflammation, in total and visceral adiposity, and in markers of cardiovascular health.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu 2, 08950 Esplugues, Barcelona, Spain.
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Mehta RV, Malcom PJ, Chang RJ. The effect of androgen blockade on granulosa cell estradiol production after follicle-stimulating hormone stimulation in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2006; 91:3503-6. [PMID: 16804036 DOI: 10.1210/jc.2006-0752] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Previously, we have shown that women with polycystic ovary syndrome (PCOS) exhibit an exaggerated serum estradiol (E(2)) response to recombinant human FSH (rhFSH) (150 IU) compared with similarly treated normal women. This enhanced granulosa cell responsiveness is consistent with excessive follicular development after gonadotropin therapy and the corresponding risk of ovarian hyperstimulation syndrome. In vitro studies have shown that granulosa cells treated with androgens display greater FSH-induced E(2) production than untreated cells, suggesting a role for androgens in granulosa cell responsiveness. MAIN OBJECTIVE This study was conducted to determine whether blockade of androgen action in PCOS women by administration of the antiandrogen flutamide would alter E(2) responses to rhFSH. DESIGN We conducted a prospective cohort study. SUBJECTS AND SETTING We studied 11 women with PCOS at an institutional general clinical research center. INTERVENTION On study d 1, each subject received 150 IU rhFSH iv. Frequent blood samples were obtained over 24 h. After completion of rhFSH stimulation, each subject was treated with flutamide, 125 mg, twice daily, for 6 wk. Thereafter, the rhFSH stimulation test was repeated. MAIN OUTCOME MEASURES Baseline and stimulated E(2) levels before and after treatment were assayed. RESULTS Mean baseline and maximally stimulated E(2), integrated E(2) response, and fold change in E(2) were not different before and after treatment. Levels of testosterone, androstenedione, progesterone, 17-hydroxyprogesterone, estrone, and SHBG before and after treatment were unchanged. Baseline dehydroepiandrosterone sulfate levels declined significantly after flutamide therapy. CONCLUSION These findings indicate that in women with PCOS, the E(2) hyperresponsiveness to FSH may not be attributable to increased circulating androgens.
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Affiliation(s)
- Rinku V Mehta
- Department of Reproductive Medicine, University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, California 92093-0633, USA
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Ibáñez L, de Zegher F. Low-dose flutamide-metformin therapy for hyperinsulinemic hyperandrogenism in nonobese adolescents and women. Fertil Steril 2006; 86 Suppl 1:S24-5. [PMID: 16798281 DOI: 10.1016/j.fertnstert.2006.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Revised: 03/10/2006] [Accepted: 03/10/2006] [Indexed: 11/30/2022]
Abstract
Hyperinsulinemic hyperandrogenism is the core of polycystic ovary syndrome (PCOS), and, accordingly, low-dose flutamide-metformin proved so far to be a most effective approach to normalize the broad spectrum of PCOS anomalies in nonobese adolescents and young women. For safety reasons, it is wise to combine flutamide-metformin with a contraceptive, for example, an oral or transdermal estroprogestagen.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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Tevell A, Lennernäs H, Jönsson M, Norlin M, Lennernäs B, Bondesson U, Hedeland M. Flutamide metabolism in four different species in vitro and identification of flutamide metabolites in human patient urine by high performance liquid chromatography/tandem mass spectrometry. Drug Metab Dispos 2006; 34:984-92. [PMID: 16540588 DOI: 10.1124/dmd.105.008516] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A new metabolic scheme of flutamide is proposed in this article. Some patients treated with flutamide, a nonsteroidal antiandrogen, have developed severe hepatic dysfunction. Toxic metabolites have been proposed to be responsible for these negative effects. In this study, the qualitative aspects of the in vitro metabolism of flutamide in liver microsomes from human, dog, pig, and rat were evaluated. A direct comparison of the flutamide metabolism in liver and prostate microsomes from pig was made, and the in vivo metabolism of flutamide was investigated in urine from orally treated prostate cancer patients. Liquid chromatography/tandem mass spectrometry was used for analysis. The mass spectrometer was equipped with an electrospray interface and operated in the negative ion mode. In liver microsomes from pig, dog, and rat, extensive hydroxylation of flutamide occurred. One, two, or three hydroxy groups were attached, and isomeric forms were detected for both monohydroxylated and trihydroxylated drug. In pig liver microsomes, isomers of a third metabolite, hydroxylated 4-nitro-3-(trifluoromethyl)-aniline, were also found after incubation with either flutamide or 2-hydroxyflutamide. In human liver microsomes, the pharmacologically active 2-hydroxyflutamide was the only metabolite detected. Several phase I metabolites as well as four intact phase II metabolites could be recovered from the urine samples. For the first time in humans, glucuronic acid conjugates of hydroxylated 4-nitro-3-(trifluoromethyl)-aniline, and mono- and dihydroxylated flutamide were identified, together with hydroxylated 4-nitro-3-(trifluoromethyl)-aniline conjugated with sulfate. In addition, one mercapturic acid conjugate of hydroxylated flutamide, probably formed from flutamide via a reactive intermediate, was detected.
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Affiliation(s)
- Annica Tevell
- Department of Medicinal Chemistry, Division of Analytical Pharmaceutical Chemistry, Uppsala University, Uppsala, Sweden
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de Ziegler D, Romoscanu I, Ventura P, Ibecheole V, Fondop JJ, de Candolle G. The Uterus and In Vitro Fertilization. Clin Obstet Gynecol 2006; 49:93-116. [PMID: 16456346 DOI: 10.1097/01.grf.0000197521.61306.51] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Dominique de Ziegler
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Geneva University Hospital, Geneva, Switzerland
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Ibáñez L, de Zegher F. Low-dose flutamide-metformin therapy for hyperinsulinemic hyperandrogenism in non-obese adolescents and women. Hum Reprod Update 2006; 12:243-52. [PMID: 16407452 DOI: 10.1093/humupd/dmi054] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is a variable disorder that is characterized in adolescents and young women by a broad spectrum of anomalies, including hyperandrogenemia, insulin resistance, dyslipidemia, body adiposity and low-grade inflammation. At present, there is no approved therapy for PCOS. Recent studies indicate that a low-dose combination of flutamide (Flu; a generic androgen-receptor blocker) and metformin (Met; a generic insulin-sensitizer) normalizes the adolescent PCOS spectrum more than an oral contraceptive (OC); in young women, the PCOS spectrum was found to be more normalized by OC plus Flu-Met than by OC alone. Within the pathophysiological cascade of PCOS, Flu-Met seems to counter upstream anomalies like hyperinsulinemia or hyperandrogenism, thereby preventing or reversing downstream effects. In contrast, an OC essentially masks downstream symptoms like hirsutism, acne or irregular menses, whereas the upstream aberrations remain unaltered or may even be worsened. The available experience with Flu-Met is limited but promising. We emphasize that Flu-Met may (as part of its efficacy) induce ovulation but is contra-indicated post-conception because of potential embryotoxicity; therefore, it seems wise to combine Flu-Met with an oral or a transdermal oestro-progestagen or with a non-endocrine method of contraception. May this update prompt further research into Flu-Met's therapeutic potential in patients with PCOS. Until the abovementioned effects have been broadly confirmed, Flu-Met should not be regarded as a standard therapy for widespread clinical practice.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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Ibáñez L, Valls C, de Zegher F. Discontinuous low-dose flutamide–metformin plus an oral or a transdermal contraceptive in patients with hyperinsulinaemic hyperandrogenism: normalizing effects on CRP, TNF-α and the neutrophil/lymphocyte ratio. Hum Reprod 2005; 21:451-6. [PMID: 16239318 DOI: 10.1093/humrep/dei329] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Low-dose flutamide-metformin (Flu-Met) with an oral contraceptive is a therapeutic option for women with hyperinsulinaemic hyperandrogenism. We questioned (i) whether Flu-Met maintains efficacy if given discontinuously; (ii) how the efficacy of discontinuous Flu-Met plus a transdermal contraceptive compares with Flu-Met plus oral contraceptive; and (iii) whether these treatments also lower circulating C-reactive protein (CRP) and tumour necrosis factor alpha (TNF-alpha) and the high neutrophil/lymphocyte ratio. METHODS Non-obese, young patients (n = 31) with hyperinsulinaemic hyperandrogenism were started on Flu-Met (21/28 days) and randomized to receive in addition either a drospirenone oral contraceptive or a transdermal contraceptive for 6 months. RESULTS The effects of Flu-Met were similar whether combined with oral or transdermal contraceptive. In both groups, CRP and TNF-alpha levels fell and the high neutrophil/lymphocyte ratio normalized (P < 0.001). Lean body mass increased (P < 0.001) in both groups but, in contrast to earlier experience with continuous Flu-Met, fat mass failed to decrease in either group. CONCLUSIONS Flu-Met seems less lipolytic, if given for only 21 days in every 28-day period. The efficacy of Flu-Met is comparable when combined with an oral contraceptive or a transdermal contraceptive. The range of Flu-Met effects may henceforth include lower levels of CRP and TNF-alpha, and a normalization of the neutrophil/lymphocyte ratio.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology Unit and Hormonal Laboratory, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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Ibáñez L, Jaramillo AM, Ferrer A, de Zegher F. High neutrophil count in girls and women with hyperinsulinaemic hyperandrogenism: normalization with metformin and flutamide overcomes the aggravation by oral contraception. Hum Reprod 2005; 20:2457-62. [PMID: 15905296 DOI: 10.1093/humrep/dei072] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The endocrine hallmark of polycystic ovary syndrome (PCOS) is hyperinsulinaemic hyperandrogenism; another facet of PCOS is low-grade inflammation. METHODS In adolescents and young women with hyperinsulinaemic hyperandrogenism (n = 118; mean age 16 years, body mass index 22 kg/m(2)), we analysed whether the PCOS-associated rise in leukocyte count is already detectable at young age and, if so, whether such elevation is lowered by metformin, flutamide-metformin, oral contraception (OC), or their combination. RESULTS Leukocyte count (x 1000/mm(3)) in patients was high versus controls (7.5 +/- 0.1 versus 6.4 +/- 0.1; P < 0.001) due to a rise in neutrophils (4.2 +/- 0.1 versus 3.0 +/- 0.1; P < 0.001). Randomized studies at mean ages of 12.5 years (n = 24) and 15.2 years (n = 33) demonstrated normalizing effects of metformin (850 mg/day; P < 0.001) and, respectively, metformin plus flutamide (62.5 mg/day) on neutrophil counts; in young women (18.3 years; n = 41), the neutrophil count rose further on OC monotherapy (P = 0.003), but normalized on the same OC plus flutamide-metformin (P < 0.001 versus OC alone). CONCLUSIONS (i) A high leukocyte count is already present in girls with hyperinsulinaemic hyperandrogenism, and this is due to a raised neutrophil count; (ii) this hyperneutrophilia is attenuated by metformin or flutamide-metformin, and is amplified by OC monotherapy; (iii) if these treatments are combined, the normalizing effect of flutamide-metformin overcomes the OC effect on neutrophil count.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology Unit, Hospital Sant Joan de Déu, University of Barcelona, Spain.
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