Androgen excess: investigations and management

• Published in: Best practice & research. Clinical obstetrics & gynaecology 2016-11, Vol.37, p.98-118
• Main Authors: Lizneva, Daria, Gavrilova-Jordan, Larisa, Walker, Walidah, Azziz, Ricardo
• Format: Article
• Language: English
• Subjects: 5-alpha Reductase Inhibitors - therapeutic use; acne; Acne Vulgaris - drug therapy; Acne Vulgaris - etiology; Acne Vulgaris - metabolism; Alopecia - drug therapy; Alopecia - etiology; Alopecia - metabolism; Androgen Antagonists - therapeutic use; Androstenedione - metabolism; Contraceptives, Oral, Combined - therapeutic use; Contraceptives, Oral, Hormonal - therapeutic use; Dehydroepiandrosterone Sulfate - metabolism; Eflornithine - therapeutic use; Female; female pattern hair loss; Hair Removal; hirsutism; Hirsutism - drug therapy; Hirsutism - etiology; Hirsutism - metabolism; Humans; hyperandrogenism; Hyperandrogenism - drug therapy; Hyperandrogenism - etiology; Hyperandrogenism - metabolism; Obstetrics and Gynecology; Ornithine Decarboxylase Inhibitors - therapeutic use; PCOS; Polycystic Ovary Syndrome - complications; Polycystic Ovary Syndrome - metabolism; Testosterone - metabolism
• ISSN: 1521-6934; 1532-1932
• DOI: 10.1016/j.bpobgyn.2016.05.003

Abstract Androgen excess (AE) is a key feature of polycystic ovary syndrome (PCOS) and results in or contributes to the clinical phenotype of these patients. While AE will contribute to the ovulatory and menstrual dysfunction of these patients the most recognizable sign of AE includes hirsutism, acne and androgenic alopecia or female pattern hair loss (FPHL). Evaluation not includes scoring facial and body terminal hair growth using the modified Ferriman-Gallwey method, but also recording and possibly scoring acne and alopecia. Assessment of biochemical hyperandrogenism is also necessary, particularly in patients with unclear or absent hirsutism, and will include assessing total and free testosterone (T), and possibly DHEAS and androstenedione, although these latter add a limited amount to the diagnosis. Assessment of T requires use of the highest quality assays available, generally radioimmunoassays with extraction and chromatography, or mass spectrometry preceded by liquid or gas chromatography. Management of clinical hyperandrogenism involves primarily either androgen suppression, with a hormonal combination contraceptive, or androgen blockade, as with an androgen receptor blocker or a 5α-reductase inhibitor, or a combination of the above. Medical treatment should be combined with cosmetic treatment including the use of topical eflornithine hydrochloride, and short-term (shaving, chemical depilation, plucking, threading, waxing, and bleaching) and long-term (electrolysis, laser therapy, and intense pulse light therapy) mechanical treatments. Generally acne responds to therapy relatively rapidly, while hirsutism is slower to respond, with improvements observed as early as three months, but generally only after 6 or 8 months of therapy. Finally, FHLP is the slowest to respond to therapy, if it will at all, and it may take 12 to 18 months of therapy before response is begun to be observed.