Comprehensive clinical management of hirsutism

Utility of 4-chloro-7-nitrobenzofurazan for spectrofluorimetric and spectrophotometric determinations of the anti-hirsutism agent (α-difluoromethylornithine) in pharmaceutical cream samples

α-Difluoromethylornithine is an effective medication for the treatment of African Trypanosomiasis and widely distributed for the treatment of hirsutism. This work provides an adequate analytical protocol for the spectrophotometric and the spectrofluorimetric determination of α-difluoromethylornithine through its interaction with 4-chloro-7-nitrobenzofurazan (NBD-chloride) reagent. After optimization of the reaction conditions (NBD-chloride volume, buffer volume, the best diluting solvent, heating time and temperature and pH of the medium) the reaction product was measured spectrophotometrically at λ_max = 478 nm and spectrofluorimetrically at λ_emission = 540 nm after λ_excitation = 475 nm. The proposed methods were linear over the ranges 5-30 μg ml^-1 and 0.4-2 μg ml^-1 for the spectrophotometric method and the spectrofluorimetric method, respectively. Moreover, the proposed work offers an adequate sensitive and selective determination for α-difluoromethylornithine where the detection limits were 0.90 μg ml^-1 and 0.071 μg ml^-1 for the spectrophotometric method and the spectrofluorimetric method, respectively. Furthermore, both methods were successfully applied for the quantification of α-difluoromethylornithine in the pharmaceutical cream samples with acceptable recovery results.

Screening and Management of the Hyperandrogenic Adolescent: ACOG Committee Opinion, Number 789

Although androgen excess can manifest in many ways, the most common and recognizable symptoms are hirsutism and acne. Reports of hirsutism and acne should be taken seriously because of their possible association with medical disorders, their substantial effect on self-esteem and quality of life, and the potential for psychosocial morbidity. In patients with symptoms of androgen excess, the differential diagnosis should include physiologic hyperandrogenism of puberty, idiopathic hyperandrogenism, and polycystic ovary syndrome (PCOS). There is a great deal of overlap between the symptoms of PCOS and those of normal puberty, which makes the diagnosis of PCOS in the adolescent difficult. Treatment of acne and hirsutism should not be withheld during the ongoing longitudinal evaluation for possible PCOS. On physical examination, body mass index, blood pressure, and signs of hyperandrogenism, such as acne and hirsutism, should be evaluated. Although guidelines differ on recommended laboratory studies, most include measurement of total testosterone, free testosterone, or both, and screening for nonclassic congenital adrenal hyperplasia with a 17-hydroxyprogesterone test. Elevation of the free or total testosterone level higher than the adult female normative values is a key diagnostic feature of biochemical hyperandrogenism. Because treatment is indicated only when symptoms are distressing to the patient, the degree to which acne or hirsutism bothers the patient should be assessed. Before initiation of any medical therapy, expectations of treatment should be discussed with the patient. Anticipatory guidance is critical to help patients understand the timeline for expected responses to therapy.

Evaluation of serum level of omentin-1 in females with hirsutism

BACKGROUND

Hirsutism is a common clinical condition encountered in day-to-day practice. The androgenic causes account for more than 80% of these patients and include polycystic ovary syndrome (PCOS), which affects about 70%-80% of hirsute women. The second most common cause is idiopathic hirsutism. Omentin-1 is an adipokine mainly produced by visceral adipose tissue.

AIM

The current study aimed at evaluating omentin-1 levels in hirsute females with PCOS and in idiopathic hirsutism.

PATIENTS AND METHODS

Eighty-five females were included in this study. They were classified into three groups: thirty hirsute patients with PCOS, thirty females with idiopathic hirsutism, and twenty-five healthy control females. The participants were subjected to history taking, physical and dermatological examination. A gynecological history and radiological examination of the ovary also were done. Serum testosterone and omentin-1 were measured by ELISA.

RESULTS

Serum testosterone was statistically elevated in PCOS than other groups. Serum omentin-1 in females with idiopathic hirsutism was statistically significantly higher than control and PCOS. There was a significant inverse correlation between serum testosterone level and serum omentin-1 level.

CONCLUSION

Omentin-1 may be involved in the pathogenic process of hirsutism.

Long-term satisfaction and tolerability with low-dose flutamide: a 20-year surveillance study on 120 hyperandrogenic women

OBJECTIVE

To evaluate the long-term safety, satisfaction and tolerability of flutamide therapy for female hyperandrogenism.

DESIGN

A 20-year surveillance study.

METHODS

Setting: Gynecology Department in a teaching hospital.

PATIENTS

Hyperandrogenic women complaining for hirsutism treatment were followed between February 1995 and April 2015.

INTERVENTIONS

Women received flutamide 125 or 250 mg/day alone (n = 55) or combined with oral contraceptives (n = 65).

MAIN OUTCOME MEASURES

Adverse events, safety, tolerability satisfaction and efficacy were assessed every 6 months during all the follow-up. Lab tests including liver and lipid profiles were also recorded in each control.

RESULTS

Patients under flutamide therapy showed significant improvements in hirsutism scores after 6 months of treatment with a maximum effect at 12 months that was maintained during all the therapy time. Satisfaction reported by patients with the efficacy of the drug in a visual scale was also high. A total of 54.2 % women presented one or more adverse effects during the follow-up; 33.3% showed at least one adverse effect possibly related with the study drug; and 24.1% withdrew from the study because of adverse effects. During the follow-up, as many as 89.9 % of patients abandoned flutamide. Reasons include: questions linked to medical problems (50%), attempt pregnancy (4%) and significant improvement in the symptomatology (35.8%).

CONCLUSIONS

Flutamide is very effective for hirsutism treatment; however, adverse effects are very frequent and affect compliance.

Interventions for hirsutism excluding laser and photoepilation therapy alone: abridged Cochrane systematic review including GRADE assessments

Hirsutism is a common disorder with a major impact on quality of life. The most frequent cause is polycystic ovary syndrome. Effects of interventions (except laser and light-based therapies) were evaluated, including Grading of Recommendations Assessment, Development and Evaluation assessments. Searches included Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, Medline, Embase and five trials registers to June 2014. We included 157 randomized controlled trials (RCTs) with 10 550 participants. The majority were assessed as having a 'high risk' of bias (123 of 157). The quality of evidence was rated moderate to very low for most outcomes. Pooled data for an oral contraceptive (OCP) (ethinyl oestradiol and cyproterone acetate) compared with another OCP (ethinyl oestradiol and desogestrel) demonstrated that both treatments were effective in reducing Ferriman-Gallwey scores, but the mean difference (MD) was not statistically significant [-1·84, 95% confidence interval (CI): -3·86-0·18]. Flutamide was more effective than placebo in two studies (MD -7·60, 95% CI: -10·53 to -4·67 and MD -7·20, 95% CI: -10·15 to -4·25), as was spironolactone (MD -7·69, 95% CI: -10·12 to -5·26). Spironolactone appeared to be as effective as flutamide (two studies) and finasteride (two studies). However, finasteride and the gonadotropin-releasing analogues showed discrepant results in several RCTs. Metformin was ineffective. Cyproterone acetate combined with OCPs demonstrated greater reductions in Ferriman-Gallwey scores. Lifestyle interventions reduced body mass index but did not show improvement in hirsutism, and although cosmetic measures are frequently used, no RCTs investigating cosmetic treatments were identified. RCTs investigating OCPs in combination with antiandrogens or finasteride vs. OCP alone, or the different antiandrogens and 5α-reductase inhibitors are warranted.

Interventions for hirsutism (excluding laser and photoepilation therapy alone)

BACKGROUND

Hirsutism occurs in 5% to 10% of women of reproductive age when there is excessive terminal hair growth in androgen-sensitive areas (male pattern). It is a distressing disorder with a major impact on quality of life. The most common cause is polycystic ovary syndrome. There are many treatment options, but it is not clear which are most effective.

OBJECTIVES

To assess the effects of interventions (except laser and light-based therapies alone) for hirsutism.

SEARCH METHODS

We searched the Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974), and five trials registers, and checked reference lists of included studies for additional trials. The last search was in June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in hirsute women with polycystic ovary syndrome, idiopathic hirsutism, or idiopathic hyperandrogenism.

DATA COLLECTION AND ANALYSIS

Two independent authors carried out study selection, data extraction, 'Risk of bias' assessment, and analyses.

MAIN RESULTS

We included 157 studies (sample size 30 to 80) comprising 10,550 women (mean age 25 years). The majority of studies (123/157) were 'high', 30 'unclear', and four 'low' risk of bias. Lack of blinding was the most frequent source of bias. Treatment duration was six to 12 months. Forty-eight studies provided no usable or retrievable data, i.e. lack of separate data for hirsute women, conference proceedings, and losses to follow-up above 40%.Primary outcomes, 'participant-reported improvement of hirsutism' and 'change in health-related quality of life', were addressed in few studies, and adverse events in only half. In most comparisons there was insufficient evidence to determine if the number of reported adverse events differed. These included known adverse events: gastrointestinal discomfort, breast tenderness, reduced libido, dry skin (flutamide and finasteride); irregular bleeding (spironolactone); nausea, diarrhoea, bloating (metformin); hot flushes, decreased libido, vaginal dryness, headaches (gonadotropin-releasing hormone (GnRH) analogues)).Clinician's evaluation of hirsutism and change in androgen levels were addressed in most comparisons, change in body mass index (BMI) and improvement of other clinical signs of hyperandrogenism in one-third of studies.The quality of evidence was moderate to very low for most outcomes.There was low quality evidence for the effect of two oral contraceptive pills (OCPs) (ethinyl estradiol + cyproterone acetate versus ethinyl estradiol + desogestrel) on change from baseline of Ferriman-Gallwey scores. The mean difference (MD) was -1.84 (95% confidence interval (CI) -3.86 to 0.18).There was very low quality evidence that flutamide 250 mg, twice daily, reduced Ferriman-Gallwey scores more effectively than placebo (MD -7.60, 95% CI -10.53 to -4.67 and MD -7.20, 95% CI -10.15 to -4.25). Participants' evaluations in one study with 20 participants confirmed these results (risk ratio (RR) 17.00, 95% CI 1.11 to 259.87).Spironolactone 100 mg daily was more effective than placebo in reducing Ferriman-Gallwey scores (MD -7.69, 95% CI -10.12 to -5.26) (low quality evidence). It showed similar effectiveness to flutamide in two studies (MD -1.90, 95% CI -5.01 to 1.21 and MD 0.49, 95% CI -1.99 to 2.97) (very low quality evidence), as well as to finasteride in two studies (MD 1.49, 95% CI -0.58 to 3.56 and MD 0.40, 95% CI -1.18 to 1.98) (low quality evidence).Although there was very low quality evidence of a difference in reduction of Ferriman-Gallwey scores for finasteride 5 mg to 7.5 mg daily versus placebo (MD -5.73, 95% CI -6.87 to -4.58), it was unlikely it was clinically meaningful. These results were reinforced by participants' assessments (RR 2.06, 95% CI 0.99 to 4.29 and RR 11.00, 95% CI 0.69 to 175.86). However, finasteride showed inconsistent results in comparisons with other treatments, and no firm conclusions could be reached.Metformin demonstrated no benefit over placebo in reduction of Ferriman-Gallwey scores (MD 0.05, 95% CI -1.02 to 1.12), but the quality of evidence was low. Results regarding the effectiveness of GnRH analogues were inconsistent, varying from minimal to important improvements.We were unable to pool data for OCPs with cyproterone acetate 20 mg to 100 mg due to clinical and methodological heterogeneity between studies. However, addition of cyproterone acetate to OCPs provided greater reductions in Ferriman-Gallwey scores.Two studies, comparing finasteride 5 mg and spironolactone 100 mg, did not show differences in participant assessments and reduction of Ferriman-Gallwey scores (low quality evidence). Ferriman-Gallwey scores from three studies comparing flutamide versus metformin could not be pooled (I² = 62%). One study comparing flutamide 250 mg twice daily with metformin 850 mg twice daily for 12 months, which reached a higher cumulative dosage than two other studies evaluating this comparison, showed flutamide to be more effective (MD -6.30, 95% CI -9.83 to -2.77) (very low quality evidence). Data showing reductions in Ferriman-Gallwey scores could not be pooled for four studies comparing finasteride with flutamide as the results were inconsistent (I² = 67%).Studies examining effects of hypocaloric diets reported reductions in BMI, but which did not result in reductions in Ferriman-Gallwey scores. Although certain cosmetic measures are commonly used, we did not identify any relevant RCTs.

AUTHORS' CONCLUSIONS

Treatments may need to incorporate pharmacological therapies, cosmetic procedures, and psychological support. For mild hirsutism there is evidence of limited quality that OCPs are effective. Flutamide 250 mg twice daily and spironolactone 100 mg daily appeared to be effective and safe, albeit the evidence was low to very low quality. Finasteride 5 mg daily showed inconsistent results in different comparisons, therefore no firm conclusions can be made. As the side effects of antiandrogens and finasteride are well known, these should be accounted for in any clinical decision-making. There was low quality evidence that metformin was ineffective for hirsutism and although GnRH analogues showed inconsistent results in reducing hirsutism they do have significant side effects.Further research should consist of well-designed, rigorously reported, head-to-head trials examining OCPs combined with antiandrogens or 5α-reductase inhibitor against OCP monotherapy, as well as the different antiandrogens and 5α-reductase inhibitors against each other. Outcomes should be based on standardised scales of participants' assessment of treatment efficacy, with a greater emphasis on change in quality of life as a result of treatment.

A method to improve the efficacy of topical eflornithine hydrochloride cream

CONTEXT

Facial hirsutism is a cosmetic concern for women and can lead to significant anxiety and lack of self-esteem. Eflornithine cream is indicated for the treatment of facial hirsutism. However, limited success rate and overall patient's satisfaction, even with a long-term and high-frequency application, leave room for improvement.

OBJECTIVE

The objective of this study is to test the effect of microneedle treatment on the in vitro skin permeation and the in vivo efficacy of eflornithine cream in a mouse model.

MATERIALS AND METHOD

In vitro permeation study of eflornithine was performed using Franz diffusion cell. In vivo efficacy study was performed in a mouse model by monitoring the re-growth of hair in the lower dorsal skin of mice after the eflornithine cream was applied onto an area pretreated with microneedles. The skin and the hair follicles in the treated area were also examined histologically.

RESULTS AND DISCUSSION

The hair growth inhibitory activity of eflornithine was significantly enhanced when the eflornithine cream was applied onto a mouse skin area pretreated with microneedles, most likely because the micropores created by microneedles allowed the permeation of eflornithine into the skin, as confirmed in an in vitro permeation study. Immunohistochemistry data revealed that cell proliferation in the skin and hair follicles was also significantly inhibited when the eflornithine cream was applied onto a skin area pretreated with microneedles.

CONCLUSION

The integration of microneedle treatment into topical eflornithine therapy represents a potentially viable approach to increase eflornithine's ability to inhibit hair growth.