Non-fertility Treatments
A. Acne and Hirsutism.
B. Metabolism; Lipids and cardiovascular concerns.
C. Adolescent patient.
A. Acne and Hirsutism.
Patients with PCOS often have acne or excessive hair growth or even alopecia due to elevated androgens. Androgens are precursors of estrogen and so all women have androgens. The over-production of androgens by the ovaries stimulates hair follicle growth leading to the classic cutaneous signs of PCOS. Androgens (i.e. Testosterone) circulate in the bloodstream largely bound up in a protein called sex-hormone binding globulin (SHBG). SHBG is produced in the liver and secreted into the bloodstream where it acts. SHBG is basically a sponge that sops up the testosterone. It is only free testosterone that is able to leave the blood stream and cause hirsutism. Insulin actually lowers the SHBG by its action on the liver, leaving more free testosterone to cause problems. One of our hormonal treatments is basically 2 pronged. It is well known that birth control pills will increase SHBG when they go to the liver (i.e. 1st pass effect) after being digested, and thus bind up free testosterone. They also suppress luteinizing hormone (LH stimulates the ovaries to make more androgens). This leads to an overall decrease in free hormonally active testosterone.
When combined with a medicine that actually acts on the hair follicles to block the effects of testosterone like spironolactone, BCPs improve acne and hirsutism. Spironolactone is structurally very similar to testosterone. Of course, the addition of insulin sensitizers may improve the outcome as mentioned above and a number of studies have shown beneficial effects of adding these medicines. Due to the life cycle of the hair follicle, it may take 3-6 months for the effects of these drugs to be seen on the hair growth and acne. Mechanical or cosmetic treatments may be used in combination with the suppressive therapies mentioned above. It is of note that plucking and waxing probably do little. Electrolysis, lasers, shaving, and bleaching have been used successfully. Over 80% of patients that are compliant with therapy will have improvement. Eflornithine 13.9 % cream (Vaniqua) has been shown inn clinical studies to improve facial hair in PCOS patients and as an adjunct to the treatments above. We are able to coordinate laser therapy or electolysis. The cost is reasonable and only a few treatments are needed, in the case of laser hair removal.
B. Metabolism; Lipids and cardiovascular concerns.
From our discussion on the metabolic aspects of PCOS elsewhere on our site, it is clear that we can help our patients as they age and potentially reduce their risk of cardiovascular disease. Clearly addressing their insulin resistance will improve this.
C. Adolescent patient.
It is important not to avoid treating the adolescent patient. These patients are at a very important time both physically and emotionally and benefit greatly from appropriate diagnosis and treatment. Other pages on our site discuss PCOS and the adolescent in more detail. These patients are most concerned with correction of menstrual abnormalities, correction of hyperandrogenism, and weight control. We are able to help our patients with all of these. Please see our page on weight management.
