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Toronto,
ON-- Why should dermatologists prescribe oral contraceptives?
Because reducing circulating androgen has beneficial effects for
mild acne, hirsutism and polycystic ovarian syndrome (PCOS), James
C. Shaw, MD, associate professor of dermatology, University of Toronto,
said.
Dr. Shaw discussed the androgen/ovarian link between the three conditions
at the annual meeting of the Atlantic Dermatological Society meeting.
Although there is uncertainty in how the three cross over, the treatments
commonly boil down to oral contraceptives, androgen receptor blockers,
or insulin sensitizers and risk monitoring.
Of particular interest to Dr. Shaw is the question of how many adult
women with acne have PCOS. Large studies have shown that 25 to 35
per cent of PCOS patients complain of mild acne and 70 per cent
complain of hirsutism. Thus, a dermatologist may well ask: "When
is a full evaluation indicated?" and "Are the therapies
within our jurisdiction?" The overall prevalence of PCOS is
approximately six per cent (J Clin Endocrinol Metab 1998 Sep;83(9):3078-82).
A select
group
Adult females with persistent or new, but not severe, acne, who
have irregular menstrual cycles, premenstrual acne flares, seborrhea,
hirsutism, and perhaps androgenetic alopecia may be considered for
a full work up. The main goal of evaluation is to exclude other
diseases such as tumour, adrenal hyperplasia, thyroid and Cushing's
syndrome.
One-half to two-thirds of women with PCOS have BMIs higher than
25, Dr. Shaw noted.
Treatment
choices
Ovarian suppression: oral contraceptives, GnRH agonists
Adrenal suppression: corticosteroids
Androgen receptor blockade: spironolactone, flutamide cyproterone
acetate
5-alpha reductase inhibition: finasteride
Insulin sensitizing agents: metformin, thiazolidinediones
Recommended
reading:
Stewart FH et al: Clinical Breast and Pelvic Examination Requirements
for Hormonal Contraception: Current Practice vs Evidence JAMA 2001;285:2232-2239.
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