Dermatologic manifestations of polycystic ovary syndrome

Clinical management of androgen excess and defect in women

INTRODUCTION

Hyperandrogenism and hypoandrogenism are complex disorders involving multiple-organ systems. While androgen excess is a well-characterized condition, androgen deficiency still needs diagnostic criteria, as there are no specific cutoffs.

AREAS COVERED

We highlight the most recent findings on the role of androgens in female pathophysiology, investigating clinically relevant conditions of androgen insufficiency or excess throughout a woman's life, and their possible therapeutic management.

EXPERT OPINION

Combined oral contraceptives (COCs) should be considered as first-line therapy for the management of menstrual irregularity and/or clinical hyperandrogenism in adolescents with a clear diagnosis of polycystic ovary syndrome (PCOS). There are limited evidence-based data regarding specific types or doses of COCs for management of PCOS in women; however, the lowest effective estrogen dose should be considered for treatment. Despite evidence regarding safety, efficacy, and clinical use, testosterone therapy has not been approved for women by most regulatory agencies for treatment of hypoactive sexual desire disorder (HSDD). The long-term safety for treatments with testosterone is still to be evaluated, and this review highlights the need for more research in this area.

The effect of the ketogenic diet on Acne: Could it be a therapeutic tool?

Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from androgen-induced increased sebum production, altered keratinization, inflammation, and bacterial colonization of the hair follicles of the face, neck, chest and back by Propionibacterium acnes. Overall, inflammation and immune responses are strongly implicated in the pathogenesis of acne. Although early colonization with Propionibacterium acnes and family history may play an important role in the disease, it remains unclear exactly what triggers acne and how treatment affects disease progression. The influence of diet on acne disease is a growing research topic, yet few studies have examined the effects of diet on the development and clinical severity of acne disease, and the results have often been contradictory. Interestingly, very low-calorie ketogenic diet (VLCKD) has been associated with both significant reductions in body weight and inflammatory status through the production of ketone bodies and thus it has been expected to reduce the exacerbation of clinical manifestations or even block the trigger of acne disease. Given the paucity of studies regarding the implementation of VLCKD in the management of acne, this review aims to provide evidence from the available scientific literature to support the speculative use of VLCKD in the treatment of acne.

Evaluation of androgen-dependent skin findings of polycystic ovary syndrome (PCOS)

AIM

The purpose of the study was to investigate the biochemical and metabolic abnormalities related to the cutaneous characteristics of PCOS.

MATERIAL–METHODS

Patients diagnosed with PCOS were included in the study. Demographic data and accompanying androgen-dependent skin findings (acne, seborrhea, androgenic alopecia, acanthosis nigricans, skin tag, and hirsutism) were recorded. The free testosterone, total testosterone, dehydroepiandrosterone sulfate, androstenedione,17-Hidroksi progesterone, sex hormone binding globulin, prolactin, fasting glucose, fasting insulin, HbA1C, HDL, and triglycerides, follicle-stimulating hormone, luteinized hormone, free androgen index, and HOMA-IR levels of the patients were measured. The hormonal values of the patients with PCOS with and without skin findings were compared.

RESULTS

The HOMA-IR values of the acanthosis nigricans (+) PCOS group were significantly higher than the acanthosis nigricans (-) PCOS group (p < .001). The DHEA-SO4, FAI, and FI values of patients with hirsutism (HR) (+) PCOS were found to be statistically higher than patients with HR (-) PCOS (p = .006, p = .015, p = .004).

CONCLUSION

PCOS is among the most common endocrine disorders of women of reproductive age and was associated with some hormonal, metabolic, and skin findings. Certain androgenic and metabolic variables developing in PCOS might correlate with cutaneous symptoms.

Revisiting the physiological role of androgens in women

INTRODUCTION

Extensive research underlines the critical functions of androgens in females. Nevertheless, the precise mechanisms of their action are poorly understood. Here, we review the existing literature regarding the physiological role of androgens in women throughout life.

AREAS COVERED

Several studies show that androgen receptors (ARs) are broadly expressed in numerous female tissues. They are essential for many physiological processes, including reproductive, sexual, cardiovascular, bone, muscle, and brain health. They are also involved in adipose tissue and liver function. Androgen levels change with the menstrual cycle and decrease in the first decades of life, independently of menopause.

EXPERT OPINION

To date, studies are limited by including small numbers of women, the difficulty of dosing androgens, and their cyclical variations. In particular, whether androgens play any significant role in regulating the establishment of pregnancy is poorly understood. The neural functions of ARs have also been investigated less thoroughly, although it is expressed at high levels in brain structures. Moreover, the mechanism underlying the decline of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) with age is unclear. Other factors, including estrogen's effect on adrenal androgen production, reciprocal regulation of ARs, and non-classical effects of androgens, remain to be determined.

Prevalence of Low Serum Vitamin D Levels in Patients Presenting With Androgenetic Alopecia: A Review

The role of vitamin D receptor (VDR) has been well established and extensively studied in the hair cycle. Its deficiency is also closely linked to several types of alopecia, including alopecia areata, telogen effluvium, and androgenetic alopecia (AGA). Since there is limited research on the correlation between androgenetic alopecia and low serum vitamin D levels, our review aims to find relevant articles and comprehensively present them. A review of the literature was performed to gain insight into AGA. Specifically, PubMed and Google Scholar databases were searched to identify any relevant articles with a focus on androgenetic alopecia, male pattern baldness, and serum vitamin D levels. References within the included articles were also reviewed and taken into the study if found appropriate. All articles that met the inclusion criteria were analyzed for demographics, clinical, laboratory, radiographic, treatment, and outcomes data. We found 13 relevant studies that elucidated the relationship between low serum vitamin D levels and androgenetic alopecia and included them in the review. We concluded that serum vitamin D might be a possible parameter for diagnosing the onset and severity of AGA. Vitamin D supplementation has proven to be useful in the regrowth of hair in non-human subjects. Vitamin D could be a valid therapeutic approach, such as topical vitamin D (calcipotriol) seems to be a good treatment option to regrow hair follicles and prevent miniaturization of follicles due to androgenetic alopecia.

Cutaneous manifestation of polycystic ovary syndrome

The aim of this cross-sectional study, that included 146 polycystic ovary syndrome (PCOS) patients, was to evaluate the prevalence, severity and pattern of cutaneous manifestation in Jordanian women with PCOS, as well as their correlation with hormonal abnormalities. A thorough complete cutaneous examination, hormonal assays (Luteinizing hormone [LH], follicle stimulating hormone [FSH], prolactin, total testosterone, free testosterone, dehydroepiandrosterone sulfate) and pelvic ultrasonography were done. The most common cutaneous features of PCOS were acne vulgaris (75.3%) followed by hirsutism (59.6%) then seborrhea (43.2%) and androgenetic alopecia (42.5%). Patients who had acne vulgaris presented at a younger age than patients who did not. Patients who had androgenetic alopecia and stria were older than patients with no such features. Moreover, all cutaneous manifestations of PCOS, except for acne, were associated with higher body mass index (BMI). Elevated LH:FSH ratio of more than 2:1 was the most common hormonal abnormality, followed by increased LH and total testosterone. Acne, hirsutism, androgenetic alopecia, seborrhea, acanthosis nigricans and skin tags are common cutaneous manifestations among Jordanian patients with PCOS. The existence of one or more of these features, especially in overweight and obese patients, should alert the physician towards the possibility of having PCOS.

Is There Any Association Between Clinical and Biochemical Hyperandrogenism in Women With Female Pattern Hair Loss?

Background

The exact association between clinical and biochemical hyperandrogenism (HA) is heterogeneous and cannot be ascertained, especially in normoandrogenic women.

Objectives

Evaluate any association between clinical phenotypes and biochemical parameters of HA in premenopausal women with female pattern hair loss (FPHL).

Materials and methods

A cross-sectional observational study on 362 women, who were assessed for general characteristics, the different FPHL severities by Sinclair's score, hirsutism by modified Ferriman-Gallwey (mFG) score. Evaluation for biochemical HA included total, calculated free and bioavailable testosterone (TT), free testosterone (FT), and bioavailable testosterone (BT), respectively, and dehydroepiandrosterone sulfate. The variables of clinical HA were FPHL, hirsutism, and acne.

Results

The enrolled young premenopausal women's age range was (14-47 years). Around 78% were overweight or obese women. Eighty-percent of women had a mild FPHL, with a median of three years, where 2/3 of women had a duration <3 years with no significant relationship to FPHL severity. About 73% of women had either a mild to moderate hirsutism, and around 16% had acne. The biochemical HA was confirmed in around 52% of women (n=188), who show high levels of calculated FT. The calculated BT is high in 78.5% of women (n=284). The means of HA's biochemical indicators were in their reference ranges or slightly above, with no specific change pattern with the corresponding FPHL severity. None of these parameters had a significant relationship with the severity of FPHL. The FPHL duration was not affected by any presumed variable of clinical or biochemical HA.

Conclusions

FPHL severity was associated with other clinical HA signs like hirsutism and acne, but not to HA's biochemical parameter. Other parameters, like sex hormone-binding globulin (SHBG), and BMI, had no significant relation to the FPHL severity.

Clinical Implications of Polycystic Ovary Syndrome in Adolescents

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy, affecting as many as 5% to 20% of women of reproductive age, depending on the diagnostic criteria applied. Features of PCOS include physiologic anovulation, hyperandrogenism, elevated luteinizing hormone, and increased gonadotropin-releasing hormone pulse frequency, which often manifest physically as acne and hirsutism. The clinical presentation of PCOS often mimics normal pubertal physiologic development, which may delay diagnosis and treatment of the condition in adolescent girls. A diagnosis of PCOS has life-long implications and is associated with increased risk for infertility, obesity, Type 2 diabetes, endometrial hyperplasia, uterine carcinoma, metabolic disorder, and cardiovascular disease. In this article, we provide an overview of clinical presentation, diagnostic criteria, health consequences, and current evidence-based clinical guidelines for the appropriate diagnosis and management of PCOS in adolescents.

Hyperandrogenism in polycystic ovarian syndrome and role of CYP gene variants: a review

Background

Polycystic ovary syndrome (PCOS) is a multifactorial endocrine disorder characterized by anovulation, hyperandrogenism, and polycystic ovarian morphology. The pathophysiology of PCOS is not clear; however, disturbance in hypothalamic-pituitary-ovarian axis and abnormal steroidogenesis along with genetic and environmental factors act as main contributors to this disorder.

Main text

Hyperandrogenism, the hallmark feature of PCOS, is clinically manifested as hirsutism, acne, and alopecia. Excessive androgen production by ovaries as well as from adrenals contributes to hyperandrogenism. Abnormalities in the neuroendocrine system like increased pulse frequency of gonadotropin-releasing hormone, stimulating the pituitary for excessive production of luteinizing hormone than that of follicle-stimulating hormone is seen in PCOS women. Excess LH stimulates ovarian androgen production, whereas a relative deficit in FSH impairs follicular development. The imbalance in LH: FSH causes proliferation of ovarian theca cells leading to increased steroidogenesis, and ultimately leading to hyperandrogenism in PCOS women. Various genetic factors have been shown to be associated with abnormal steroidogenesis. CYP genes involved in steroidogenesis play an important role in androgen production and are considered as key players in hyperandrogenism in PCOS.

Conclusion

Polymorphisms in CYP genes can aggravate the hyperandrogenic phenotype in women with PCOS by either upregulating or downregulating their expression, thus increasing androgens further. However, this hypothesis needs to be validated by further studies.

Threats to Feminine Identity as the Main Concern of Iranian Adolescents with Polycystic Ovary Syndrome: A Qualitative Study

PURPOSE

Polycystic Ovary Syndrome (PCOS) is a prevalent hormonal disorder in adolescents; this study seeks to elaborate the main concerns of adolescents with PCOS.

DESIGN AND METHODS

This qualitative content analysis was conducted on 15 adolescents with PCOS using purposive sampling in 2018. Semi-structured in-depth interviews were held for data collection, and data saturation occurred when no new data were being obtained. Data were analyzed concurrently with data collection.

RESULTS

Fifteen adolescents with PCOS aged 13-19 years were enrolled into the study. Thirteen were single and two were married. The data analysis led to the extraction of "threats to feminine identity" as the main theme of this research, which was then divided into two categories: 1) concerns about attractiveness, with subcategories including fashion-related stress and the loss of physical beauty 2) concerns about femininity, with subcategories including the underlying issues of worrying about future marriage prospects, anxiety about infertility in the future and stress about menstrual abnormalities.

CONCLUSION

According to the results of this study, attractiveness and threat to femininity is the main concern of adolescents with PCOS that should be further considered in the management of their treatment.

IMPLICATIONS FOR PRACTICE

Understanding the main concerns of adolescents with PCOS can help healthcare professionals better manage this disease in this population subgroup.

Skin disease related to metabolic syndrome in women

Sex hormones are involved in pathways of metabolic syndrome (MetS), an observation supported by animal studies. The relationships of sex hormones with components of MetS, such as insulin resistance and dyslipidemia, have been studied in pre- and postmenopausal women. High testosterone, low sex hormone-binding globulin, and low estrogen levels increase the risks of MetS and type 2 diabetes in women. Cutaneous diseases that are sex hormone mediated, such as polycystic ovary syndrome, acanthosis nigricans, acne vulgaris, and pattern alopecia, have been associated with insulin resistance and increased risk for MetS. Furthermore, inflammatory skin conditions, such as hidradenitis suppurativa and psoriasis, increase the risk for MetS. Patients with such skin conditions should be followed for metabolic complications, and early lifestyle interventions toward these populations may be warranted.

Update on Management of Polycystic Ovarian Syndrome for Dermatologists

Polycystic ovarian syndrome (PCOS) is the commonest endocrine disorder in women having wide range of clinical manifestation. These women may present with reproductive, dermatological, metabolic, psychological, or neoplastic implications from adolescence to menopause. The common dermatological manifestations include hirsutism, acne, alopecia, or acanthosis nigricans. Women presenting with these dermatological manifestations must be evaluated for PCOS. A multidisciplinary team approach involving a reproductive endocrinologist, dermatologist, psychologist/psychiatrist, dietician, and sometimes a bariatric surgeon should be undertaken for long-term management of these patients. Unless metabolic and underlying endocrinal disturbances arecorrected and simultaneous life-style modification is adopted, cosmetic treatment would give only temporary relief.

Efficacy and Safety of a Topical Botanical in Female Androgenetic Alopecia: A Randomized, Single-Blinded, Vehicle-Controlled Study

INTRODUCTION

Androgenetic alopecia (AGA) in females is a difficult to treat skin disorder. A novel topical botanical lotion has been approved for its treatment. It acts by increasing Bcl-2, perifollicular Langerhans and mast cells, and perifollicular collagen. The aim of this study was to evaluate the efficacy and safety of this lotion in females.

METHODS

Forty women with AGA were randomized to apply the active lotion or placebo, twice daily for 24 weeks. Subjects were evaluated at 0, 12, and 24 weeks by clinical examination, photographic documentation, quality of life evaluation (DLQI), and trichogram (anagen to telogen ratio).

RESULTS

The clinical evaluation demonstrated an increased hair density in the intervention group (great improvement in 7.7$, moderate in 88.5$, and stable in 3.8$). The self-assessment score increased from 4.5 to 6.0 (24 weeks), and the DLQI improved from 4 to 3 in the intervention group (p < 0.001). The mean anagen to telogen ratio in the intervention group was 2.1, 3.9, and 6.0 at 0, 12, and 24 weeks, respectively, whereas in the control group it was 2.2, 3.8, and 3.3, respectively.

CONCLUSION

The new topical botanical lotion showed remarkable efficacy, with a high degree of patient satisfaction and improvement of their quality of life.

Gynecologic and andrologic dermatology and the metabolic syndrome

The relationship of sex hormones to obesity and inflammation has been extensively studied. Research on endogenous and exogenous sex steroids, including studies on animal models of metabolic syndrome (MetS), has indicated that sex hormones are involved in metabolic pathways relevant to MetS. Lower testosterone levels in men and higher levels in women increase risks of MetS and type 2 diabetes mellitus (T2DM). Lower levels of sex hormone-binding globulin increase risks of MetS and T2DM in both sexes. Skin diseases that are sex hormone mediated, such as polycystic ovary syndrome, acanthosis nigricans, acne vulgaris, and pattern alopecia, have been associated with insulin resistance. Insulin resistance increases the risk for metabolic and potentially cardiovascular complications, and patients with such skin diseases should be followed for a prolonged time to determine whether they develop these complications. Early intervention may help delay or prevent the onset of T2DM and decrease cardiovascular risks.

Cutaneous Manifestations of Polycystic Ovary Syndrome: A Cross-Sectional Clinical Study

Background:

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women, affecting 5–10% of reproductive-aged women. The dermatologic manifestations of hyperandrogenism, chiefly hirsutism, acne vulgaris, androgenic alopecia, and acanthosis nigricans, are among the cardinal manifestations of PCOS.

Aim:

To study the incidence and prevalence of various cutaneous manifestations in patients with PCOS and to correlate these skin manifestations with hormonal changes.

Settings and Design:

This study was conducted at a dermatology centre over a period of 1 year from November 2012 to 2013.

Materials and Methods:

The present study included 100 women diagnosed to have PCOS. Hormonal analysis as well as radiological assessment was done in all the cases. Cutaneous manifestations were ascertained and inferences were drawn.

Statistical Analysis:

Statistical analysis was carried out by the Chi-square test and independent samples t-test. Statistical significance was determined at a level of P < 0.05.

Results:

In our study, the prevalence of hirsutism, acne, female pattern hair loss, acanthosis nigricans, seborrhea, striae and acrochordons was 78%, 48%, 31%, 30%, 29%, 13%, and 9%, respectively.

Conclusion:

Dermatologic manifestations of PCOS play a significant role in making the diagnosis and constitute a substantial portion of the symptoms experienced by women with this syndrome.

Female Pattern Hair Loss: a clinical and pathophysiological review

Female Pattern Hair Loss or female androgenetic alopecia is the main cause of hair loss in adult women and has a major impact on patients' quality of life. It evolves from the progressive miniaturization of follicles that lead to a subsequent decrease of the hair density, leading to a non-scarring diffuse alopecia, with characteristic clinical, dermoscopic and histological patterns. In spite of the high frequency of the disease and the relevance of its psychological impact, its pathogenesis is not yet fully understood, being influenced by genetic, hormonal and environmental factors. In addition, response to treatment is variable. In this article, authors discuss the main clinical, epidemiological and pathophysiological aspects of female pattern hair loss.

Psychosocial Factors Associated with Polycystic Ovary Syndrome: a Case Control Study

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a disorder in women of reproductive age. Psychosocial factors can play a role in PCOS.

METHODS

To determine the psychosocial factors associated with PCOS in a case control study, 742 PCOS cases were compared to 798 women without PCOS for psychiatric disorders and social conditions. The data were collected using a validated questionnaire of the Minnesota Multiphasic Personality Inventory (MMPI). The Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire (DSM-IV) was used to diagnose major psychopathological disorders and other depressive and anxiety syndromes. The suspected psychopathology was evaluated by a clinical psychiatrist.

RESULTS

There was a significant difference between cases and controls in education level (71.8% vs. 80.4%; (P<0.001), and employment status (60% vs. 53%; P=0.01) (respectively). Chronic anxiety (35.7% vs. 26.8%; P<0.001), depression (18.9% vs. 7.9 %; P<0.001), anxiety disorders (7.7% vs. 3.3%; P<0.001), and personality disorders (2.9% vs. 1.7%; P=0.01), were higher in the PCOS patients compared controls, respectively.

CONCLUSION

The results showed that chronic anxiety and depression were the most pscycologic pattern in PCO patients. Lower educational level and unemployment were higher in the cases than controls.

Comparison of desogestrel/ethinyl estradiol plus spironolactone versus cyproterone acetate/ethinyl estradiol in the treatment of polycystic ovary syndrome: a randomized controlled trial

AIM

To compare the effects of ethinyl estradiol (EE) 30 mcg/desogestrel 150 mcg plus spironolactone 25 mg/day (group A) versus EE 35 mcg/cyproterone acetate 2 mg (group B) on hyperandrogenism and metabolism in PCOS.

METHODS

This was a randomized clinical study. Eighteen women in groups A and B received medications for three cycles. Acne score, androgens and metabolic parameters were assessed before and after treatment.

RESULTS

One and two women in groups A and B, respectively, were excluded from the study. Both groups had significantly decreased acne score and free androgen index, and increased sex hormone-binding globulin levels. Cholesterol and high-density lipoprotein were significantly increased in group B, and androstenedione was significantly decreased in group A. The regular withdrawal bleeding was obtained in both groups.

CONCLUSION

Both regimens had quite similar efficacy on hyperandrogenism after three cycles of therapy and without any changes in metabolic parameters.

Skin disorders associated with obesity in children and adolescents: a population-based study

Obesity in children is a major public health concern in the United States. The objectives of the current study were to determine the prevalence of various groups of cutaneous disorders in obese children and adolescents and to compare the use of dermatology services in obese subjects with that those with a normal body mass index (BMI). This was a retrospective, population-based study at the Kaiser Permanente Northern California Managed Healthcare System. The main outcome measures were the relative risk of cutaneous disorders associated with insulin resistance, androgen excess, bacterial infection, fungal infection, viral infection, inflammation, mechanical changes, and other skin conditions (hidradenitis, hyperhidrosis) in three weight groups (normal, overweight, obese) and the number of dermatology visits. A total of 248,775 subjects were included. Bivariate analyses showed a higher proportion of insulin resistance disorders, bacterial infection, fungal infection, inflammatory disorders, mechanical changes, and other skin conditions in obese subjects than in subjects with a normal BMI (p < 0.001). Disorders of androgen excess and viral infection were significantly less common in obese subjects (p < 0.001). Obese subjects had significantly lower odds of having at least one dermatology encounter than subjects with a normal BMI (odds ratio = 0.92, 95% confidence interval 0.88, 0.96, p = 0.003). Early onset obesity is associated with cutaneous disorders characterized by hyperproliferation, inflammation, bacterial and fungal infection, and mechanical changes but lower rates of disorders of androgen excess and viral infection. The use of dermatology services was not greater in obese patients. Heightened recognition and further analysis of adipose tissue as an endocrine organ that is capable of affecting the skin is warranted.

Prevalence of androgenic alopecia in patients with polycystic ovary syndrome and characterization of associated clinical and biochemical features

OBJECTIVE

To describe the prevalence of androgenic alopecia (AGA) in patients with polycystic ovary syndrome (PCOS) and to characterize associated clinical and biochemical features.

DESIGN

Cross-sectional study.

SETTING

Multidisciplinary PCOS clinic at a tertiary academic center.

PATIENT(S)

A total of 254 women with PCOS according to the Rotterdam criteria were systematically examined from 2007 to 2012 by a reproductive endocrinologist, a dermatologist, and a psychologist.

INTERVENTION(S)

Comprehensive dermatologic exams, ultrasonic imaging, serum testing, and Beck Depression Inventory Fast Screen (BDI-FS).

MAIN OUTCOME MEASURES

Presence of AGA, acne, hirsutism, biochemical hyperandrogenemia, metabolic dysfunction, and clinical depression.

RESULT(S)

Fifty-six of 254 patients with PCOS (22.0%) had AGA. Subjects with PCOS and AGA were more likely to have acne or hirsutism than those without AGA (96.3% vs. 70.6%). Subjects with AGA were more likely to report concern with hair loss (70.4% vs. 37.7%); however, their BDI-FS scores were no different from subjects without AGA. There were no differences between subjects with and without AGA in biochemical hyperandrogenism or metabolic parameters.

CONCLUSION(S)

AGA is prevalent in 22% of subjects meeting diagnostic criteria for PCOS. AGA is associated with other manifestations of clinical hyperandrogenism, but not with greater risk of biochemical hyperandrogenemia or metabolic dysfunction than with PCOS alone.

Evaluation of only the chin or lower abdomen for predicting hirsutism

BACKGROUND

Hirsutism is defined as the growth of terminal hair in a male pattern in women; it affects 5-15% of women.

OBJECTIVE

The aim of this study is evaluation of only the chin or lower abdomen for predicting hirsutism.

MATERIALS AND METHODS

In this cross-sectional diagnostic study, we randomly selected 695 women aged 15-45 years. The examiners scored the subjects on a scale of 0 - 4 for terminal hair growth on nine different body areas according to the Ferriman-Gallwey (FG) scoring system in a form given to the examiners before the examination. An FG score of 8 or more was considered diagnostic of hirsutism. If the sum of the FG scores for the chin or lower abdomen was 2 or more, the test result was assumed to be positive. Statistical analysis was performed using the MacNemar test, and a P value of less than 0.05 was considered to be statistically significant.

RESULTS

The age group with the highest prevalence rate was 21-25 years. From the 695 subjects examined, 81 subjects (11.7%) had an FG score of 8 or more with a resultant prevalence rate of 11.7% for hirsutism. In our study population, 39% of the patients had an FG score of 2 or more for the chin or lower abdomen, and 61% of the patients had an FG score of less than 2 for the chin or lower abdomen.

CONCLUSION

Evaluating terminal hair growth on the chin or lower abdomen for predicting hirsutism seems to be an acceptable screening method.

Acne in the adult female patient: a practical approach

Acne vulgaris is a common reason why adult women present to dermatologists and can be a clinical challenge to treat. It may also be an important sign of an underlying endocrine disease such as Polycystic Ovary Syndrome (PCOS). Although standard acne therapies can be successfully used to treat acne in adult female patients, hormonal treatment is a safe and effective therapeutic option that may provide an opportunity to better target acne in this population, even when other systemic therapies have failed. In this article, a practical approach to the adult female patient with acne will be reviewed to enhance the dermatologist's ability to use hormonal acne therapies and to better identify and evaluate patients with acne in the setting of a possible endocrine disorder.

Effects of Polycystic Ovary Syndrome and Menopause on Rat Soft Palate and Base of Tongue

Objective

To investigate the histopathologic changes in rat soft palate and base of tongue by performing experimental polycystic ovary syndrome (PCOS) and menopause models.

Study Design

Experimental study.

Setting

The study was conducted at the animal care facility of Haydarpasa Numune Education and Research Hospital.

Subject and Methods

Thirty healthy female Albino Wistar rats were divided into 4 groups (PCOS study group [n = 10], per oral letrozole given; PCOS control group [n = 6], per oral saline given; menopause study group [n = 8], ovariectomized; menopause control group [n = 6], sham operated). At the end of the follow-up periods, all animals were euthanized, and soft palates and base of tongues of all groups were removed to observe the histopathologic changes.

Results

When we compared the PCOS study group with the PCOS control group, submucous gland hypertrophy, mast cell infiltration, vascular engorgement, and acanthosis were significantly different in the soft palate ( P < .05), and in addition to these findings, lymphocyte infiltration, subepithelial edema, and dilated glandular excretory duct were significantly different in base of tongue ( P < .05). When we compared the menopause study group with the menopause control group, only vascular engorgement was significantly different in the soft palate ( P < .05), and in addition to this finding, submucous gland hypertrophy, lymphocyte infiltration, polymorphonuclear leukocyte infiltration, and subepithelial edema were significantly different in base of tongue ( P < .05).

Conclusion

Our findings suggest that PCOS and menopause induce significant histopathologic changes in the soft palate and base of tongue that are similar to the histopathologic changes seen in the soft palate and base of tongue of patients with obstructive sleep apnea syndrome.

Polycystic ovary syndrome: a dermatologic approach

Polycystic ovary syndrome (POS) is one of the most common endocrine abnormalities affecting women of reproductive age. It is a cause of significant social embarrassment and emotional distress. The pathogenesis of the disease is not yet fully understood, but it is thought to be a complex multigenic disorder, including abnormalities in the hypothalamic-pituitary axis, steroidogenesis, and insulin resistance. The main diagnostic findings of the syndrome are: hyperandrogenism, chronic anovulation and polycystic ovarian morphology seen on ultrasound. Hyperandrogenism is generally manifested as hirsutism, acne, seborrhea, androgenic alopecia and, in severe cases, signs of virilization. Treatment may improve the clinical manifestations of excess androgen production, normalize menses and ameliorate metabolic syndrome and cardiovascular complications. This article reviews the diagnosis, clinical manifestations, metabolic complications, and treatment of the syndrome. Early diagnosis and the consequent early treatment may prevent metabolic complications and emotional distress that negatively impact the patients' quality of life.

The 5 alpha-reductase isozyme family: a review of basic biology and their role in human diseases

Despite the discovery of 5 alpha-reduction as an enzymatic step in steroid metabolism in 1951, and the discovery that dihydrotestosterone is more potent than testosterone in 1968, the significance of 5 alpha-reduced steroids in human diseases was not appreciated until the discovery of 5 alpha-reductase type 2 deficiency in 1974. Affected males are born with ambiguous external genitalia, despite normal internal genitalia. The prostate is hypoplastic, nonpalpable on rectal examination and approximately 1/10th the size of age-matched normal glands. Benign prostate hyperplasia or prostate cancer does not develop in these patients. At puberty, the external genitalia virilize partially, however, secondary sexual hair remains sparse and male pattern baldness and acne develop rarely. Several compounds have been developed to inhibit the 5 alpha-reductase isozymes and they play an important role in the prevention and treatment of many common diseases. This review describes the basic biochemical properties, functions, tissue distribution, chromosomal location, and clinical significance of the 5 alpha-reductase isozyme family.

Factors affecting the degree of hirsutism in patients with polycystic ovary syndrome

PURPOSE

To investigate the clinical features of patients with polycystic ovary syndrome (PCOS) and compare the patients with hirsutism to those without.

METHODS

In total, 304 consecutive females with PCOS were evaluated. The cases were divided into two groups of hirsute or non-hirsute. The risk factors recorded were age, age at menarche, body mass index (BMI), luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, prolactin, and total testosterone (tT) levels and hirsutism scores. Statistical analyses were performed using the Student's t test and logistic regression.

RESULTS

Of all the cases, 224 were hirsute (hirsutism score ≥ 8). No significant difference was observed between the groups for age or age at menarche. BMI and hormone levels, including LH, FSH, estradiol and tT, were higher in hirsute patients than those in non-hirsute patients (p < 0.05). The logistic regression model showed that BMI, tT, LH, and estradiol were significant risk factors with odds ratios and 95% confidence intervals of 5.81 (2.22-15.18), 4.57 (2.34-8.90), 2.61 (1.73-3.94), and 2.29 (1.30-4.05), respectively.

CONCLUSIONS

Hirsute patients with PCOS have different clinical characteristics from those that are non-hirsute in terms of BMI, LH, FSH, estradiol, and tT levels. We also determined the odds ratios of these different parameters. BMI was the most important risk factor for the degree of hirsutism.

Insulin sensitiser agents alone and in co-treatment with r-FSH for ovulation induction in PCOS women

OBJECTIVE

The aim of this study was to compare the effectiveness of myo-inositol (MYO) and metformin, in monotherapy or in association with recombinant follicle stimulating hormone (r-FSH), in the treatment of menstrual irregularities, chronic anovulation, and female infertility in patients with polycystic ovary syndrome (PCOS).

MATERIALS AND METHODS

One hundred twenty patients were randomly treated with metformin 1500 mg/day orally (n = 60), or 4 g MYO plus 400 microg folic acid daily (n = 60), continuously. If no pregnancy occurred, r-FSH (37.5 units/day) was added to the treatment for a maximum of three attempts.

RESULTS

Fifty percent of the patients who assumed metformin restored spontaneous ovulation, 18.3% of these obtained pregnancy. The remaining 42 patients were treated with metformin plus r-FSH. Pregnancy occurred in a total of 11 women (26.1%). The total pregnancy rate was 36.6%. Sixty-five percent of the patients treated with MYO plus folic acid restored spontaneous ovulation activity, 30% of these obtained pregnancy. The remaining 38 patients were treated with MYO, folic acid plus r-FSH. Pregnancy occurred in a total of 11 women (28.9%). The total pregnancy rate was 48.4%.

CONCLUSIONS

Both metformin and MYO, can be considered as first line treatment for restoring normal menstrual cycles in most patients with PCOS, even if MYO treatment seems to be more effective than metformin.

Specific dermatologic features of the polycystic ovary syndrome and its association with biochemical markers of the metabolic syndrome and hyperandrogenism

OBJECTIVE

To investigate biochemical and metabolic abnormalities in relation with cutaneous features of polycystic ovary syndrome (PCOS).

DESIGN

Prospective descriptive analysis.

SETTING

University-based tertiary care.

SAMPLE

One-hundred and fifteen untreated consecutive women diagnosed as having PCOS.

METHODS

Each woman underwent an evaluation of body habitus, acne, hirsutism, seborrhea, androgenic alopecia and acanthosis nigricans. Associations between cutaneous features and hormonal and metabolic parameters were analyzed by means of multivariate logistic regression models.

MAIN OUTCOME MEASURES

Prevalence of cutaneous features in PCOS and associations among the features and biochemical and metabolic parameters.

RESULTS

The prevalence of acne, hirsutism, seborrhea, androgenetic alopecia and acanthosis nigricans was 53%, 73.9%, 34.8%, 34.8% and 5.2%, respectively. Acne was not associated with the hormonal, metabolic and anthropometric variables. Hirsutism had positive associations with total testosterone, fasting glucose and total cholesterol, and a negative association with age. Seborrhea was found to be related with free testosterone, fasting glucose and insulin. A negative association was determined among androgenic alopecia and free testosterone, low-density lipoprotein and insulin.

CONCLUSIONS

Acne and androgenic alopecia are not good markers for the hyperandrogenism in PCOS. Hirsutism appears to be strongly related with hyperandrogenism and metabolic abnormalities in PCOS women.

Genetik der androgenetischen Alopezie

Die androgenetische Alopezie (AGA, erblich- bzw. hormonbedingter Haarausfall [MIM 109200; MIM 300710; MIM 612421]) ist die häufigste Form des Haarverlusts beim Menschen, wobei die Prävalenz stark altersabhängig ist. Im Alter von über 70 Jahren sind über 80% der europäischen Männer betroffen, bei Frauen liegt die AGA-Häufigkeit mit 30–40% deutlich niedriger. Die AGA führt, v. a. bei betroffenen Frauen, zu einer erheblichen psychologischen Belastung und entfaltet dabei Krankheitswert. Der Haarverlust geht auf einen veränderten Haarzyklus und eine Miniaturisierung des Haarfollikels zurück. Die Pathogenese ist androgenabhängig, und die genetische Anlage ist wesentliche Voraussetzung für den Phänotyp. In mehreren Studien konnten der Androgenrezeptor-/Ektodysplasin-A2-Rezeptor(EDA2R)-Locus auf dem X-Chromosom als stärkster beitragender Faktor und durch genomweite Assoziationsuntersuchungen ein weiterer Locus auf Chromosom 20p11 identifiziert werden. Das zum Assoziationssignal nächstgelegene in der Kopfhaut exprimierte Gen ist „paired box 1“ (PAX1). Zwischen PAX1 und dem Androgensignalweg gibt es keine offensichtliche Verbindung, jedoch sind die dem Assoziationssignal auf Chromosom 20p11 zugrunde liegenden pathophysiologischen Prozesse noch nicht geklärt. Bis heute ermöglichen die zur Verfügung stehenden medikamentösen Therapien der AGA bestenfalls ein Aufhalten des Haarverlusts. Mit der Identifizierung der AGA-assoziierten Gene und der Aufklärung ihrer Funktionen wird man die biologischen Ursachen der AGA schrittweise erschließen. Damit ist die Hoffnung auf die Entwicklung neuer Therapien verbunden.

Evidence-based and potential benefits of metformin in the polycystic ovary syndrome: a comprehensive review

Metformin is an insulin sensitizer widely used for the treatment of patients affected by type 2 diabetes mellitus. Because many women with polycystic ovary syndrome (PCOS) are insulin resistant, metformin was introduced in clinical practice to treat these patients also. Moreover, metformin's effect has other targets beside its insulin-sensitizing action. The present review was aimed at describing all evidence-based and potential uses of metformin in PCOS patients. In particular, we will analyze the uses of metformin not only for the treatment of all PCOS-related disturbances such as menstrual disorders, anovulatory infertility, increased abortion, or complicated pregnancy risk, hyperandrogenism, endometrial, metabolic and cardiovascular abnormalities, but also for the prevention of the syndrome.

Effects of two estroprogestins containing ethynilestradiol 30 microg and drospirenone 3 mg and ethynilestradiol 30 microg and chlormadinone 2 mg on skin and hormonal hyperandrogenic manifestations

Hyperandrogenic manifestation in women, such as seborrhea, acne and increased hair growth are common reasons of psychological distress. Skin appearance is very important for young women. This study evaluated the hormonal and skin effects of two estroprogestins (EPs) containing ethinyl-estradiol (EE) 30 microg associated with drospirenone (DRSP) 3 mg or chlormadinone acetate (CMA) 2 mg, respectively. Fifty-five women with signs and symptoms of hyperandrogenism (seborrhea, acne and increased hair growth) were enrolled in the study; randomly, 30 women were treated with EE 30 microg + DRSP 3 mg and 25 with EE 30 microg + CMA 2 mg. Follicle-stimulating hormone (FSH), luteinising hormone (LH), 17-hydroxyprogesterone (17OHP), androstenedione (A), testosterone (T), dehydroepiandrosterone sulfate (DHEAS), sex hormone binding globulin (SHBG) and free androgen index (T x 100/SHBG, FAI) were assessed at baseline, and after 3 and 6 months of treatment with EPs. Effects on seborrhea, acne and increased hair growth (as Ferriman-Gallwey score) were also evaluated at the same time points. Finally, skin hydration, transepidermal water loss (TEWL) and skin homogeneity were studied with non-invasive technique during the study. Treatment for 6 months with both EPs decreased significantly the circulating androgen levels (A, T, DHEAS) and FAI, and increased SHBG levels; also skin pattern was improved. EP containing EE and DRSP was better than EP containing EE and CMA as for skin changes, as seborrhea, acne, increased hair, hydration, homogeneity and overall quality of the skin; moreover, hormonal changes (as FAI) under therapy were more pronounced with EE/DRSP than EE/CMA. These effects may be considered in EP choice and could be important in improving patient's compliance and quality of life in hyperandrogenic women.

Adolescent hair loss

PURPOSE OF REVIEW

Hair loss, or alopecia, may occur as a primary skin disorder or because of an underlying health problem. It may be upsetting to patients, particularly adolescents who are experiencing physical, emotional, and psychological transitions. Understanding the impact of alopecia is important for care providers who see adolescents.

RECENT FINDINGS

The most common forms of alopecia in adolescence are telogen effluvium, androgenetic alopecia, and alopecia areata. Telogen effluvium may present suddenly or insidiously secondary to a variety of triggers. Androgenetic alopecia may begin in adolescence, and topical minoxidil is effective at retarding further hair loss. It may be a sign of underlying androgen excess, particularly polycystic ovary syndrome in women. Alopecia areata is less common, but may be distressing, especially if hair loss is extensive. Because treatments for alopecia are not curative, helping affected patients cope by offering support and nonpharmacologic techniques to help appear more like their peers should be part of care.

SUMMARY

Physicians need to be skilled in evaluating the most common forms of alopecia presenting in adolescence and should be aware of potential treatments, including the value of psychosocial support.