Managing hirsutism in gynaecological practice

Hypertension Drug Therapy

Hypertension is still the number one global killer. No matter what causes are, lowering blood pressure can significantly reduce cardiovascular complications, cardiovascular death, and total death. Unfortunately, some hypertensive individuals simply do not know having hypertension. Some knew it but either not being treated or treated but blood pressure does not achieve goal. The reasons for inadequate control of blood pressure are many. One important reason is that we are not very familiar with antihypertensive agents and less attention has been paid to comorbidities, complications as well as the hypertension-modified target organ damage in patients with hypertension. The right antihypertensive drug was not given to the right hypertensive patients at right time. This reviewer studied comprehensively the literature, hopefully that the review will help improve antihypertensive drug selection and antihypertensive therapy.

A guide to understanding polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the commonest endocrine disorder affecting women of reproductive age. Some 20% of women will have polycystic ovaries on an ultrasound scan and around 7% of women have the additional clinical or biochemical features of PCOS. As a complex multisystem disorder its background can be confusing to understand. They key feature, however, is an increased production of androgen by the ovaries. This review uses ovarian biology to describe a strategy to aid understanding and explanation of PCOS. This framework can be also be used to teach about PCOS and to inform different approaches to its management.

Therapeutic options in the polycystic ovary syndrome

The polycystic ovary syndrome is the most common endocrine disorder affecting women. It is a heterogeneous familial condition of uncertain aetiology. The diagnosis is made by the detection of polycystic ovaries on ultrasound examination and the occurrence of single or multiple clinical features such as menstrual cycle disturbances, obesity, acne, hirsutism, alopecia and biochemical abnormalities such as hypersecretion of luteinising hormone and testosterone. In a significant number of women with this condition there is impaired insulin metabolism. Women with the polycystic ovary syndrome are at an increased risk of developing diabetes and possibly cardiovascular disease in later life. The management should be symptom-orientated. Menstrual cycle regulation may be attained with the combined oral contraceptive pill or cyclical progestogen therapy. In obese women, with the loss of weight, the symptoms and endocrine profile are generally improved. Short-term treatment with metformin may be useful in women with insulin resistance. Hyperandrogenism may be treated with the contraceptive pill containing cyproterone acetate or with short-term low-dose anti-androgen therapy, together with effective contraception. Ovulation may be induced with clomiphene citrate with careful monitoring, failing which low-dose gonadotrophin therapy or laparoscopic ovarian diathermy are effective options.

Polycystic ovary syndrome and its impact on women's quality of life: More than just an endocrine disorder

In the past, polycystic ovary syndrome has been looked at primarily as an endocrine disorder. Studies now show that polycystic ovary syndrome is a metabolic, hormonal, and psychosocial disorder that impacts a patient’s quality of life. It is extremely important to holistically treat these patients early on to help them deal with the emotional stress that is often overlooked with polycystic ovary syndrome. Early diagnosis and long term management can help control polycystic ovary syndrome so that women can still live a healthy active life and avoid long-term complications such as metabolic syndrome and cardiovascular diseases.

Women living with facial hair: the psychological and behavioral burden

OBJECTIVE

While unwanted facial hair is clearly distressing for women, relatively little is known about its psychological impact. This study reports on the psychological and behavioral burden of facial hair in women with suspected polycystic ovary syndrome.

METHODS

Eighty-eight women (90% participation rate) completed a self-administered questionnaire concerning hair removal practices; the impact of facial hair on social and emotional domains; relationships and daily life; anxiety and depression (Hospital Anxiety and Depression Scale); self-esteem (Rosenberg Self-esteem Scale); and quality of life (WHOQOL-BREF).

RESULTS

Women spent considerable time on the management of their facial hair (mean, 104 min/week). Two thirds (67%) reported continually checking in mirrors and 76% by touch. Forty percent felt uncomfortable in social situations. High levels of emotional distress and psychological morbidity were detected; 30% had levels of depression above the clinical cut off point, while 75% reported clinical levels of anxiety; 29% reported both. Although overall quality of life was good, scores were low in social and relationship domains--reflecting the impact of unwanted facial hair.

CONCLUSION

Unwanted facial hair carries a high psychological burden for women and represents a significant intrusion into their daily lives. Psychological support is a neglected element of care for these women.

A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome

BACKGROUND

Facial hirsutism is one of the characteristic features of polycystic ovary syndrome (PCOS), and this can lead to high levels of depression and anxiety.

OBJECTIVES

To evaluate the impact of laser treatment on the severity of facial hirsutism and on psychological morbidity in women with PCOS.

METHODS

A randomized controlled trial of five high-fluence treatments (intervention) vs. five low-fluence treatments (control) was performed over 6 months in a National Health Service teaching hospital. Subjects were 88 women with facial hirsutism due to PCOS recruited from hospital outpatient clinics and a patient support group in 2001-2002. The main outcomes were self-reported severity of facial hair (measured on a scale of 1-10), depression, anxiety (measured on the Hospital Anxiety and Depression Scale) and quality of life (measured on the WHOQOL-BREF).

RESULTS

Self-reported severity of facial hair in the intervention group (n = 51) fell from 7.3 to 3.6 over the 6-month study period; for the control group (n = 37) the corresponding scores were 7.1 and 6.1. The change was significantly greater in the intervention group [ancova F((1,83)) = 24.5, P < 0.05]. Self-reported time spent on hair removal declined from 112 to 21 min per week in the intervention group and from 92 to 56 min in the control group [F((1,80)) = 10.2, P </= 0.05]. Mean depression scores fell from 6.7 to 3.6 in the intervention group, compared with 6.1 to 5.4 in the control group [F((1,83)) = 14.7, P < 0.05]. A similar change was seen for mean anxiety scores: intervention 11.1 to 8.2, control 9.6 to 9.3 [F((1,84)) = 17.8, P < 0.05]. Psychological quality of life also improved more in the intervention group, from 49.6 to 61.2 vs. 50.1 to 51.5 in the control group [F((1,84)) = 10.9, P < 0.05].

CONCLUSIONS

Laser treatment appeared to reduce the severity of facial hair and time spent on hair removal as well as alleviating depression and anxiety in women with PCOS. These findings suggest that ways of making this method of hair removal more widely available to women with facial hirsutism should be considered.

Effect of metformin on the clinical and metabolic assessment of women with polycystic ovary syndrome

A longitudinal prospective study was conducted in 21 women with polycistic ovary syndrome (PCOS), aged 27.20 +/- 5.02 years and treated with metformin (1500 mg/day)for 8 weeks. The patients were assessed for spontaneous menstruation, weight, body mass index (BMI), waist circumference, waist/hip ratio (WHR), glucose and insulin concentrations under fasting conditions and after a 75-g glucose tolerance test, lipid profile, testosterone, androstenedione, dehydroepiandrosterone sulfate, sex-hormone binding globulin (SHBG), and insulin-like growth factor (IGF)-I. Spontaneous menstruation was observed in 81% of the women treated with metformin, with no changes in weight or BMI. Waist measurement and the WHR were reduced. The quantitative insulin sensitivity check index (QUICKI) improved from 0.33 +/- 0.03 to 0.35 +/- 0.04 (p < 0.005), and serum total cholesterol and low-density lipoprotein-cholesterol were reduced, while high-density lipoprotein-cholesterol was increased. Serum testosterone concentrations were also reduced. There were no differences in serum triglycerides, SHBG or IGF-I. The occurrence of spontaneous menstruation and changes in the pattern of body fat distribution, the reduction in serum testosterone concentrations, the improvement in lipid profile and the reduction of insulinemia with the use of metformin permit us to conclude that treatment with this drug is of benefit to women with PCOS.

Relative Safety and Efficacy of Finasteride for Treatment of Hirsutism

OBJECTIVE:

To evaluate the relative safety and efficacy of finasteride for treatment of hirsutism related to hyperandrogenism in women.

DATA SOURCES:

Literature retrieval was accessed through MEDLINE (1966-March 2003) using the terms finasteride and hirsutism. Additional information was obtained from the drug manufacturer.

DATA SYNTHESIS:

Finasteride has been evaluated for treatment of hirsutism in multiple observational and randomized trials. Finasteride lowered hirsutism scores by 30–60% in most trials, as well as decreasing average hair diameter. In comparative trials, finasteride demonstrated efficacy similar to that of other antiandrogens, with fewer adverse effects.

CONCLUSIONS:

Finasteride does reduce the overall hair diameter and number in androgen-sensitive areas. Reported adverse effects have been minimal. Concern over potential teratogenicity and lack of long-term safety information leave finasteride a secondary treatment option for hirsutism.

Sibutramine has a positive effect on clinical and metabolic parameters in obese patients with polycystic ovary syndrome

OBJECTIVE

To evaluate the effectiveness of sibutramine therapy alone and in combination with ethinyl estradiol-cyproterone acetate (EE-CPA) on the clinical and metabolic parameters of obese women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective randomized, controlled study.

SETTING

Endocrinology and gynecology clinics.

PATIENT(S)

Forty obese women with PCOS.

INTERVENTION(S)

Group 1 was treated with oral EE-CPA (35 microg-2 mg/day), group 2 with oral sibutramine (10 mg/day), and group 3 with a combination of EE-CPA plus sibutramine for 6 months. All groups were advised to consume a diet of 1200 kcal/day.

MAIN OUTCOME MEASUREMENT(S)

Measurements were performed before and 6 months after treatment of body mass index, waist-to-hip ratio, systolic and diastolic blood pressure, Ferriman-Gallwey hirsutism score, total testosterone, free testosterone, sex hormone-binding globulin, dihydroepiandrosterone sulfate (DHEAS), total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, glucose and insulin during oral glucose tolerance test, and insulin sensitivity index; area under the curve for glucose and insulin were obtained from OGTT.

RESULT(S)

Body mass index, Ferriman-Gallwey hirsutism score, serum total testosterone, free testosterone, and DHEAS levels were significantly decreased and SHBG was significantly increased in all groups at the end of the study. WHR, diastolic blood pressure, and serum triglyceride level were significantly reduced only in the sibutramine group.

CONCLUSION(S)

Sibutramine might have a positive effect on hyperandrogenemia, and clinical and metabolic risk factors for cardiovascular disease in obese women with PCOS.

Metformin therapy in the management of polycystic ovary syndrome: endocrine, metabolic and reproductive effects

Polycystic ovary syndrome (PCOS) is a convergence of multisystem endocrine derangements. Impairment in insulin metabolism is a prominent feature of the syndrome and appears to play a key pathogenetic role precipitating the cascade of other disorders associated with PCOS. Recent studies report that insulin-sensitizing agents, such as metformin, reduce hyperinsulinemia, reverse the endocrinopathy of PCOS and normalize endocrine, metabolic and reproductive functions, leading to the resumption of menstrual cyclicity and ovulation. In this review, we report the most recent evidence regarding metformin usage in women with PCOS.

Metformin therapy decreases hyperandrogenism and hyperinsulinemia in women with polycystic ovary syndrome

OBJECTIVE

To evaluate the effects of 12 weeks of metformin therapy on hormonal and clinical indices in polycystic ovary syndrome (PCOS).

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Thirty-nine women with PCOS and fasting hyperinsulinemia.

INTERVENTION(S)

Twelve weeks of therapy with oral metformin (500 mg three times per day).

MAIN OUTCOME MEASURE(S)

Levels of insulin, T, DHEAS, insulin-like growth factor-I (IGF-I), gonadotropins, and sex hormone-binding globulin (SHBG); and clinical symptoms including acne, hirsutism, and length of the menstrual cycle were assessed before and after treatment with metformin.

RESULT(S)

Metformin therapy resulted in a significant decrease in fasting insulin and total T and an increase in SHBG, leading to a decrease in the free T index. In addition, there was a significant decline in mean body mass index, waist-hip ratio, hirsutism, and acne, as well as an improvement in the menstrual cycle. No changes in LH and LH-FSH ratio were observed. Multiple regression analysis demonstrated that the greatest decline of T and free T index in response to metformin was observed among patients with the most pronounced hyperandrogenemia. Subjects with elevated DHEAS differed from those with normal DHEAS in their responses to metformin treatment. Women with high DHEAS exhibited less improvement of menstrual cycle regularity, no change in hirsutism, and an increase in levels of IGF-I after treatment.

CONCLUSION(S)

Metformin treatment of women with PCOS results in a decline of insulin as well as total and bioavailable T, leading to significant improvement of clinical manifestations of hyperandrogenism. Responses to metformin are related to the severity of hyperandrogenemia and to adrenal function.