Anti-androgens in gynaecological practice

A review of phytotherapy of Acne vulgaris

Acne vulgaris (acne) is a cutaneous pleomorphic disorder of the pilosebaceous unit involving abnormalities in sebum production and is characterized by both inflammatory (papules, pustules and nodules) and non-inflammatory (comedones, open and closed) lesions. Propionibacterium acnes and Staphylococcus epidermidis are common pus-forming microbes responsible for the development of various forms of acne. This disease remains a common condition in industrialized societies, with many mainstream treatment options available. There are many acne products on the market, and making an appropriate selection can be daunting. Common therapies that are used for the treatment of acne include topical, systemic, hormonal, herbal and combination therapy. Topically used agents are benzoyl peroxide, antibiotics and retinoid. Systemically used agents are antibiotics and isotretinoin. However, all such treatments carry risks and none is completely satisfactory. Natural alternatives are gaining greater research support, and have much to offer clinically in this disorder. This review focuses primarily on herbal treatments for acne that show scientific evidence of clinical efficacy, as well as the more common herbs shown to be useful in the treatment of this dermatologic disorder.

Cyproterone acetate for hirsutism

BACKGROUND

Hirsutism is a distressing and relatively common endocrine problem in women which may prove difficult to manage. Cyproterone acetate, an anti-androgen, is frequently used to treat hirsutism, usually in combination with ethinyl estradiol.

OBJECTIVES

The objective of this review was to investigate the effectiveness of cyproterone acetate alone, or in combination with ethinyl estradiol, in reducing hair growth in women with hirsutism secondary to ovarian hyperandrogenism.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group trials register was searched (last search - 4 June 2002). The Cochrane Menstrual Disorders and Subfertility Group register is based on regular searches of MEDLINE (1966 to 2002), EMBASE (1980 to 2002), CINAHL (1982 to 2002), PsycINFO (1987 to 2002) and CENTRAL (Issue 2, 2002 of the Cochrane Library) the handsearching of several journals and conference proceedings, and searches of several key grey literature sources. All publications of randomised controlled trials of cyproterone acetate with or without estrogen versus placebo or other drug therapies for hirsutism were identified.

SELECTION CRITERIA

All randomised controlled studies comparing:- cyproterone acetate to placebo- cyproterone acetate with ethinyl estradiol to placebo- cyproterone acetate with ethinyl estradiol to cyproterone acetate alone- cyproterone acetate (with or without estradiol) to other medical therapies for treatment of hirsutism.

DATA COLLECTION AND ANALYSIS

Eleven studies were identified which fulfilled the inclusion criteria. Nine randomised studies were included in the review, and two were excluded because of insufficient information. Only one study had more than 100 women included in the analysis. The major outcomes included: subjective improvement in hirsutism, changes in Ferriman Gallwey scores, changes in linear hair growth and hair shaft diameter, alterations in endocrine parameters, side effects to treatment, withdrawals during therapy

MAIN RESULTS

There were no clinical trials comparing cyproterone acetate alone with placebo. There was one small study comparing cyproterone acetate in combination with ethinyl estradiol to placebo. In this study there was a significant subjective reduction in hair growth with cyproterone acetate therapy, although the confidence limits were large. There were no studies comparing cyproterone acetate alone with cyproterone acetate in combination with ethinyl estradiol to treat hirsutism. In studies where cyproterone acetate was compared to other drug modalities (ketoconazole, spironolactone, flutamide, finasteride, GnRH analogues) no difference in clinical outcome was noted. There were, however, endocrinological differences in androgen and estrogen levels between different drug therapies. There were insufficient data to assess differences in side effects between women treated with cyproterone acetate and other medical therapy.

REVIEWER'S CONCLUSIONS

Cyproterone acetate combined with estradiol results in a subjective improvement in hirsutism compared to placebo. Clinical differences in outcome between cyproterone acetate and other medical therapies were not demonstrated in the studies included in this review. This may be because of the small size of the studies, lack of standardized assessment and lack of objective determinants of improvement in hirsutism. The endocrinological effects of the different drug therapies reflect the mode of action. Larger carefully designed studies are needed to compare efficacy and safety profiles between drug therapies for hirsutism.

Role of androgens in the regulation of the human menstrual cycle

Although previous investigations have examined the importance of androgens in the regulation of the human menstrual cycle, no consensus has been reached, due to conflicting results. We have therefore used the non-steroidal anti-androgen flutamide as a pharmacological probe to evaluate the role of androgens in the control of gonadotropin secretion in normally cycling women. Eight women were studied during control and treatment cycles, during which either placebo (as control) or flutamide (750 mg orally) was given daily. Blood was sampled every other day during the follicular and luteal phases and daily around the expected midcycles for determination of luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, progesterone and androgens (testosterone, androstenedione, dehydroepiandrosterone sulfate) by radioimmunoassay and immunoradiometric assay. To establish unstimulated and gonadotropin releasing hormone (GnRH)-stimulated gonadotropin profiles, blood samples were frequently collected (every 10 min for 8 h, GnRH 25 micrograms i.v. after 7 h on day 10 in both the control and treatment cycles. Compared to control conditions, the durations of both the follicular and luteal phases did not change considerably during flutamide treatments. Serum androgen levels (testosterone, androstenedione, dehydroepiandrosterone sulfate) were significantly (p < 0.01) reduced during androgen antagonism. Daily gonadotropin and estradiol levels did not differ between control and flutamide cycles, while progesterone secretion tended to be attenuated (p = 0.2) during the luteal phases of the flutamide cycles. The LH and FSH secretory profiles and the GnRH-stimulated gonadotropin responses remained virtually unchanged during androgen antagonism.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum androstanediol glucuronide concentrations in normal and hirsute women and patients with thyroid dysfunction

There is currently much interest in measurements of 5 alpha-androstane-3 alpha, 17 beta-diol glucuronide (AdiolG) as a marker of peripheral androgen metabolism. We have therefore developed an assay to measure serum AdiolG levels and report that mean concentrations in hirsute (2.9 +/- 1.9 nmol/l, mean +/- SD, n = 15) and non-hirsute (1.9 +/- 0.6 nmol/l, n = 7) women with polycystic ovaries do not differ significantly from concentrations in normal women (2.2 +/- 0.8 nmol/l, n = 20). However, a correlation was found between serum AdiolG levels and Body Mass Index (r = 0.48, P less than 0.05) for women with polycystic ovaries, suggesting that weight may be an important factor in determining concentrations of this steroid conjugate. Serum AdiolG levels were significantly reduced in hypothyroid women (0.6 +/- 0.4 nmol/l, n = 5) and women receiving oral contraceptive therapy (0.6 +/- 0.4 nmol/l, n = 28) but increased in hyperthyroid women (4.0 +/- 0.6 nmol/l, n = 5). The results from this study do not support the hypothesis that serum AdiolG levels provide a marker of peripheral androgen metabolism in hirsute women and show that it is essential to exclude from such investigations any women with thyroid abnormalities or receiving oral contraceptive therapy.