Hyperandrogenism--what is normal?

Efficacy of second versus third generation oral contraceptives in the treatment of hirsutism

OBJECTIVE

To compare second versus third generation combination oral contraceptives (OCs) in the treatment of hirsutism.

METHODS

Women with hirsutism, as defined by a minimum Ferriman-Gallwey score of 10, were randomized in a double-blind fashion to receive an OC containing either ethinyl estradiol/desogestrel or ethinyl estradiol/levonorgestrel for 9 months of treatment. Ferriman-Gallwey scores, androgen levels and sex hormone-binding globulin were measured at baseline and every 3 months for the duration of the study. Hormones were measured in duplicate by radioimmunoassay.

RESULTS

Of the 47 women enrolled, 24 were randomized to ethinyl estradiol/desogestrel and 23 were randomized to ethinyl estradiol/levonorgestrel. Mean sex hormone-binding globulin increased significantly in subjects using the desogestrel-containing contraceptive compared with the levonorgestrel-containing contraceptive. Ten subjects completed the 9 months of treatment in the levonorgestrel group and 11 completed the study in the desogestrel group. Mean free testosterone and 3alpha-androstanediol glucuronide decreased significantly in the group receiving ethinyl estradiol/desogestrel but not in the ethinyl estradiol/levonorgestrel group. Mean Ferriman-Gallwey scores decreased significantly in both treatment groups. Improvement in mean Ferriman-Gallwey score was 35.7 +/- 38.1% (p < 0.001) for the ethinyl estradiol/desogestrel arm and 33.4 +/- 27.3% (p < 0.001) for the ethinyl estradiol/levonorgestrel arm. There were no statistically significant differences found in the improvement of Ferriman-Gallwey scores between the two treatment arms, although the power to detect a difference was limited by the small sample size.

CONCLUSIONS

Treatment of hirsute women with third generation OCs containing desogestrel results in a significant increase in sex hormone-binding globulin and decrease in free testosterone and 3alpha-androstanediol glucuronide. Both second and third generation OCs were clinically effective in treating hirsutism.

Transient hyperandrogenemia and its relation to ovulation

OBJECTIVE

To study serum androgen levels in relation to ovulation.

DESIGN

Prospective, controlled clinical study.

SETTING

Outpatient endocrine department of a public central hospital.

PATIENT(S)

Forty-eight consecutive young, nonobese, hirsute women.

INTERVENTION(S)

Endocrine evaluation between days 2 and 5 and between days 22 and 25 of a spontaneous menstrual cycle.

MAIN OUTCOME MEASURE(S)

Levels of FSH, LH, E2, P, androstenedione (A), total testosterone (T), DHEAS, and 17alpha-hydroxyprogesterone (17-OHP).

RESULT(S)

Hyperandrogenemia occurred equally in a persistent (56%) or a transient form (44%). Transient hyperandrogenemia was more common in the early follicular phase in ovulatory cycles and in the second phase in delayed or anovulatory cycles (63% and 37% versus 10% and 90%, respectively). In delayed or anovulatory cycles, A, total T, and DHEAS increased significantly during the delayed follicular phase.

CONCLUSION(S)

In delayed or anovulatory cycles, transient hyperandrogenemia occurs late in the follicular phase because of previous ineffective steroidogenesis. In contrast, in ovulatory cycles, transient hyperandrogenemia occurs mainly in the early follicular phase. After ovulation, effective aromatization attenuates the condition. During evaluation and medical treatment of hirsutism, physicians should consider the common occurrence of transient hyperandrogenemia and its relation to ovulation.

Obesity, lipids, cardiovascular risk, and androgen excess

Several lines of evidence suggest that a subset of women may be at increased risk of cardiovascular disease because of unfavorable alterations in insulin action and/or production, accompanying altered apolipoprotein metabolism and altered androgenicity and/or estrogenicity. A number of cardiovascular disease risk factors, including central obesity, insulin resistance (with associated hyperinsulinemia), dyslipidemia, and/or diabetes mellitus, tend to cluster in these women. Another common ovarian morphology in women with hyperandrogenism is polycystic ovaries, which cluster with hirsutism, anovulation, infertility, gonadotropin secretion abnormalities, android fat distribution, and many important cardiovascular disease risk factors. Studies indicate that androgen excess may be a signal of increased risk for coronary artery disease, even in younger women. If androgenicity and insulin resistance are early warning signs of increasing risk of morbidity and mortality, these patients are prime candidates for preventive medicine. It is important that primary care providers begin to recognize these androgen disorders as a clue to the existence of a complex, lifelong pattern potentially placing women at risk for premature morbidity and mortality and initiate preventive treatment before irreversible thresholds are crossed.

Clinical relevance of testosterone and dihydrotestosterone metabolism in women

Androgens are part of normal female physiology. When they are secreted in excess or when they cause unwanted symptoms such as hirsutism and male-pattern baldness, the term hyperandrogenism is used. In many hyperandrogenic women, there is no well-defined hormonal abnormality, but the women are simply on one end of a normal spectrum of androgen secretion and cutaneous androgen sensitivity. To be active in the skin, testosterone must be converted to dihydrotestosterone by the enzyme 5 alpha-reductase. Androgen sensitivity is determined, in part, by 5 alpha-reductase activity in the skin. This is a localized phenomenon, and there is no generalized increase in 5 alpha-reductase activity in these women. Dihydrotestosterone can be converted to glucuronide and sulfate conjugates, including androstanediol glucuronide. These androgen conjugates have been proposed to be serum markers of cutaneous androgen metabolism, but recent evidence indicates that they arise from adrenal precursors and are more likely to be markers of adrenal steroid production and metabolism. Antiandrogens (androgen receptor blockers) are the best medical treatment of cutaneous hyperandrogenism. 5 alpha-Reductase inhibitors have recently been approved for the treatment of benign prostatic hyperplasia, and research is currently underway to determine their effectiveness in treating hirsutism and male-pattern baldness.

Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II

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.