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Sardana K, Muddebihal A, Sehrawat M, Bansal P, Khurana A. An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists. Expert Rev Endocrinol Metab 2024; 19:111-128. [PMID: 38205927 DOI: 10.1080/17446651.2023.2299400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists. AREAS COVERED We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism. EXPERT OPINION Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.
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Affiliation(s)
- Kabir Sardana
- Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Aishwarya Muddebihal
- Department of Dermatology, North DMC Medical College & Hindu Rao Hospital, Gandhi Square, Malka Ganj, Delhi, India
| | - Manu Sehrawat
- Department of Dermatology, Buckhinghumshire NHS Trust, Buckhinghumshire, UK
| | - Prekshi Bansal
- Department of Dermatology, Gian Sagar Medical College and Hospital, Banur, Punjab, India
| | - Ananta Khurana
- Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
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Pikee S, Shivani S, Jayshree B. Endocrine and Metabolic Profile of Different Phenotypes of Polycystic Ovarian Syndrome. J Obstet Gynaecol India 2016; 66:560-6. [PMID: 27651661 PMCID: PMC5016474 DOI: 10.1007/s13224-016-0898-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Polycystic ovarian syndrome (PCOS) is a common endocrinopathy associated with wide heterogeneity and serious clinical implications. Prevalence and characteristics of different phenotypes are not well defined. Therefore, this study was planned to determine the prevalence of four phenotypes of PCOS and to evaluate their endocrine and metabolic parameters including insulin resistance and metabolic syndrome with respect to controls. METHODS This observational, case-control study was conducted in the gynecology outpatient department of a tertiary care center where 161 PCOS and 50 non-PCOS women were recruited and investigated. RESULTS All phenotypes of PCOS had higher BMI with respect to controls (P < 0.000). Overweight women were maximum in phenotype H + O followed by phenotype H + P. Significantly higher levels of luteinizing hormone (P < 0.01), testosterone (P < 0.0001), were observed in all phenotypes of PCOS as compared to controls. Serum cholesterol (P < 0.026) and triglycerides (P < 0.05) were significantly higher in all PCOS phenotypes compared to controls. Levels of fasting (P < 0.000) and post-prandial (P < 0.009) insulin were significantly higher in all phenotypes of PCOS with respect to controls. Mean insulin resistance (IR) was 24.09 % in PCOS and 2 % in controls, prevalence being highest in H + O phenotype followed by H + O + P. Prevalence of metabolic syndrome in women with PCOS was 36.02 %, being highest in H + O + P followed by H + O and that of control was 10 %. CONCLUSION All phenotypes of PCOS had deranged endocrine and metabolic profile compared to controls, but prevalence of IR and metabolic syndrome was maximum in hyperandrogenic phenotypes which require a strict surveillance for prospective metabolic disorders as compared to O + P phenotype.
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Affiliation(s)
- Saxena Pikee
- Department of Obstetrics and Gynaecology, Lady Hardinge Medical College & SSK Hospital, New Delhi, 110001 India
| | - Singh Shivani
- Delhi Institute of Pharmaceutical Sciences, New Delhi, India
| | - Bhattacharjee Jayshree
- Department of Biochemistry, Lady Hardinge Medical College & SSK Hospital, New Delhi, 110001 India
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Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol 2015; 73:672-90. [PMID: 26138647 DOI: 10.1016/j.jaad.2015.05.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 05/15/2015] [Accepted: 05/16/2015] [Indexed: 10/23/2022]
Abstract
Hirsutism, acne, and androgenetic alopecia are classically considered signs of cutaneous hyperandrogenism (CHA). These common skin findings have significant impacts on the quality of patients' lives and pose the diagnostic challenge of excluding underlying disorders. Many with CHA have normal serum androgen levels. Hirsutism is more strongly associated with hyperandrogenism than are acne or androgenetic alopecia. Variable association of CHA with hyperandrogenemia results from the complexity of the underlying pathophysiology, including factors local to the pilosebaceous unit. CHA often occurs in the setting of polycystic ovary syndrome, the most common disorder of hyperandrogenism, but can also present in uncommon conditions, including nonclassic adrenal hyperplasia and androgen-producing tumors. A thorough history and full skin examination are important to guide appropriate diagnostic evaluation. Oral contraceptive pills with or without antiandrogens can provide therapeutic benefit for hirsutism and acne. Medical options for androgenetic alopecia remain limited. Multidisciplinary approaches may be needed given endocrine, metabolic, reproductive, and psychiatric disorders associated with CHA. More high-quality studies into the mechanisms of CHA and the benefits of antiandrogenic therapies are needed. We provide an evidence-based review of key diagnostic and therapeutic considerations in the treatment of women with CHA.
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Affiliation(s)
- Timothy H Schmidt
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - Kanade Shinkai
- Department of Dermatology, University of California San Francisco, San Francisco, California.
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Polycystic ovary syndrome, insulin resistance, and obesity: navigating the pathophysiologic labyrinth. Int J Reprod Med 2014; 2014:719050. [PMID: 25763405 PMCID: PMC4334071 DOI: 10.1155/2014/719050] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 12/16/2013] [Accepted: 12/18/2013] [Indexed: 12/28/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine-metabolic disorder that implies various severe consequences to female health, including alarming rates of infertility. Although its exact etiology remains elusive, it is known to feature several hormonal disturbances, including hyperandrogenemia, insulin resistance (IR), and hyperinsulinemia. Insulin appears to disrupt all components of the hypothalamus-hypophysis-ovary axis, and ovarian tissue insulin resistance results in impaired metabolic signaling but intact mitogenic and steroidogenic activity, favoring hyperandrogenemia, which appears to be the main culprit of the clinical picture in PCOS. In turn, androgens may lead back to IR by increasing levels of free fatty acids and modifying muscle tissue composition and functionality, perpetuating this IR-hyperinsulinemia-hyperandrogenemia cycle. Nonobese women with PCOS showcase several differential features, with unique biochemical and hormonal profiles. Nevertheless, lean and obese patients have chronic inflammation mediating the long term cardiometabolic complications and comorbidities observed in women with PCOS, including dyslipidemia, metabolic syndrome, type 2 diabetes mellitus, and cardiovascular disease. Given these severe implications, it is important to thoroughly understand the pathophysiologic interconnections underlying PCOS, in order to provide superior therapeutic strategies and warrant improved quality of life to women with this syndrome.
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Chhabra S, Gautam RK, Kulshreshtha B, Prasad A, Sharma N. Hirsutism: A Clinico-investigative Study. Int J Trichology 2013; 4:246-50. [PMID: 23766607 PMCID: PMC3681104 DOI: 10.4103/0974-7753.111204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Hirsutism is a common clinical condition characterized by presence of terminal hair at body sites under androgenic influence. Inspite of the significant worldwide prevalence of hirsutism, studies on hirsutism from India are not many. OBJECTIVE To assess the etiology of hirsutism and correlate its severity with underlying causes and various hormone levels. MATERIALS AND METHODS In this prospective study, 40 patients of hirsutism enrolled on first come basis were included. All patients underwent detailed clinical assessment and transabdominal ultrasonography. Free and total testosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, luteinizing hormone, follicle stimulating hormone, prolactin, free tri-iodothyronine, free tetra-iodothyronine, and thyroid stimulating hormone, and sex hormone binding globulin were estimated. Forty age-matched controls without features of hyperandrogenemia were included for the comparison. RESULTS Thirteen (32.5%) patients had mild, 52.5% had moderate whereas 15% had severe hirsutism. Positive family history was documented in 42.5% patients. The clinical features found to be associated with hirsutism included acne (55%), menstrual irregularities (40%), acanthosis nigricans (37.5%), obesity (37.5%), and androgenetic alopecia in 27.5% of patients. Polycystic ovarian syndrome (PCOS) was the underlying cause in 70%, non-classical congenital adrenal hyperplasia and hypothyroidism in 7.5% each whereas idiopathic hirsutism was found in 15% patients. CONCLUSION PCOS was the most common cause of hirsutism found in the instant study. Further, there was positive correlation between severity of hirsutism and free testosterone levels.
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Affiliation(s)
- Sunny Chhabra
- Department of Dermatology, STD and Leprosy, Dr. RML Hospital and PGIMER, Baba Kharak Singh Marg, New Delhi, India
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Sharma D, Shanker V, Tegta G, Gupta M, Verma GK. Clinico-investigative Profile of Patients of Hirsutism in a Tertiary Level Institution. Int J Trichology 2012. [PMID: 23180912 PMCID: PMC3500076 DOI: 10.4103/0974-7753.96904] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction: Hirsutism has a significant impact on the quality of life and serves as a marker of underlying hormonal and systemic conditions. The aim of this study was to study the clinical, biochemical characteristics of these patients and other associations. Materials and Methods: Fifty (n=50) consecutive newly diagnosed patients of hirsutism were assessed during a period from August 2009 to July 2010 using modified Ferriman Gallwey (mF-G) score. Results: Idiopathic hirsutism (IH) was found in 30 (60%) patients followed by polycystic ovarian syndrome (PCOS) in 19 (38%) patients. Other causes included late-onset classic adrenal hyperplasia in two (4%) and hypothyroidism in four (8%) patients. The mean age at presentation was 23.8±6.657 years. Total (T) and free testosterone (fT), 17-hydroxyprogesterone was significantly higher in PCOS than IH. Conclusion: The present data show IH as the commonest cause of hirsutism in our study population. Face, chest, and lower abdomen have a higher impact on the hirsutism score while upper back, abdomen, and lower back are rarely involved.
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Affiliation(s)
- Divya Sharma
- Department of Dermatology, Venereology and Leprosy, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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Affiliation(s)
- Kisalay Ghosh
- Department of Dermatology, Mata Gujri Memorial Medical College, Kishanganj, Bihar, India. E-mail:
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Bergfeld WF. Hirsutism in Women: Effective Therapy that is Safe for Long-Term Use. Postgrad Med 2000. [DOI: 10.1080/19419260.2000.12277434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Affiliation(s)
- Wilma F. Bergfeld
- Dr Bergfeld is head of clinical research, department of dermatology, The Cleveland Clinic, Cleveland
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Affiliation(s)
- R E Watson
- Michigan State University College of Human Medicine, East Lansing, USA
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Abstract
BACKGROUND Early-onset acne before obvious signs of puberty is an uncommon phenomenon. OBJECTIVE The aim of this study was to determine if prepubertal acne is associated with an excess of androgens. METHODS Basal and adrenocorticotrophic hormone-stimulated plasma androgen levels were measured and bone age was determined in 15 children with early-onset acne. RESULTS A late-onset adrenogenital syndrome caused by 21-hydroxylase deficiency was diagnosed in two children. These children had early pubic hair development and advanced bone maturation. Heterozygosity for 21-hydroxylase deficiency was found in three other children. CONCLUSION We recommend hormonal evaluation in children with prepubertal acne, especially those with associated advanced bone maturation and early pubarche.
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Affiliation(s)
- L De Raeve
- Department of Dermatology, Free University of Brussels, Belgium
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Abstract
A hereditary, androgen-driven disorder, androgenetic alopecia is the most common form of alopecia in humans: its prevalence is 23-87%. Central alopecia is more severe in men; women are more likely to experience diffuse thinning. The acute onset of alopecia in those with inflammatory diseases of the scalp suggests a variety of etiologies, including the impact of inflammatory cells, release of cytokines, presence of growth factors, and increased interaction of stromal cells. Therapeutic modalities, which are most effective when used in combinations, utilize hair growth promoters, antiandrogens, and androgen blockade agents.
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Affiliation(s)
- W F Bergfeld
- Department of Dermatology, Cleveland Clinic Foundation, Ohio 44195-5032
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Blondell RD. Selected Disorders of the Endocrine and Metabolic System. Fam Med 1994. [DOI: 10.1007/978-1-4757-4005-9_125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sperling LC, Heimer WL. Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II. J Am Acad Dermatol 1993; 28:901-16. [PMID: 8496453 DOI: 10.1016/0190-9622(93)70129-h] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In the May 1993 issue of the Journal we reviewed the basic science of androgen biology in women. We now discuss the evaluation of suspected hyperandrogenism and the therapeutic modalities available.
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Affiliation(s)
- L C Sperling
- Dermatology Service, Walter Reed Army Medical Center, Washington, D.C
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Sperling LC, Heimer WL. Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. I. J Am Acad Dermatol 1993; 28:669-83. [PMID: 8496411 DOI: 10.1016/0190-9622(93)70092-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Disorders of androgen excess in women are common in the practice of dermatology. The literature regarding the evaluation and treatment of women with cutaneous hyperandrogenism (acne, hirsutism, and alopecia) is vast and is contained in numerous subspecialty journals. At first glance, the basic science knowledge required to understand androgen biology appears exceedingly complex. However, an understanding of androgen physiology and a familiarity with the relevant literature are the basis of appropriate evaluations and treatment recommendations. In the first of this two-part series, we review the basic science of androgen biology and pathophysiology in women. The second part of this series will cover the evaluation of suspected hyperandrogenic women and the therapeutic modalities that are available.
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Affiliation(s)
- L C Sperling
- Dermatology Service, Walter Reed Army Medical Center, Washington, D.C
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