The treatment of hyperandrogenism in women with PCOS aims at interrupting androgen production and/or action. Suppression of ovarian function with oral contraceptives is usually the first line of therapy. It will arrest progression of hirsutism but does not lead to substantial improvement. This treatment lowers free T levels by reducing serum gonadotropin levels, increasing SHBG levels, and modestly lowering DHEAS levels. One of the new generations of pills containing a non-androgenic progestin such as desogestrel, gestodene or norgestimate is advisable. Cyproterone acetate is the major antiandrogen available outside the USA. It is a potent progestin taken up by fat and released slowly.
When given for 21 days every 4 weeks at a 50-mg daily dose, it inhibits pituitary gonadotropin secretion and acts as a potent antiandrogen upon the pilosebaceous unit. An excellent response of hirsutism is seen in up to 90% of cases. It must be administered with an estrogen to avoid irregular bleeding or amenorrhea due to endometrial atrophy.
Natural estradiol (either percutaneously or orally, 2mg/day for 1 - 21 days) is preferable to ethinyl estradiol, which has more metabolic effects. Spironolactone, 50 - 100 mg bid, has been shown to be effective and is the most potent and safest antiandrogen available in the USA. It is potentially teratogenic to fetal male genital development and may cause menstrual disturbance. Therefore, it should be prescribed with an oral contraceptive. Corticosteroid therapy is seldom useful.
In obese subjects, weight loss is very important, having beneficial effects on most aspects of the syndrome, such as subjective symptoms, infertility, hyperinsulinemia and related metabolic aberrations, and long-term health risks. Whether a long-term treatment with insulin-sensitizing drugs should be undertaken as soon as adolescence starts is an unsolved issue, until long-term studies demonstrate that the benefit/risk or cost ratio is favorable.
As in classic forms, the conventional treatment of NCAH is glucocorticoid therapy. This aims mainly to reduce adrenal hyperandrogenism, while the necessity for cortisol replacement is less evident. Our opinion is that DXM should be used rather than less potent ACTH-inhibiting compounds such as hydrocortisone or prednisone. Very low doses of DXM are needed (0.25 - 0.5 mg at night). Physicians should not aim to normalize the morning 17-HP plasma level, since it has been shown that adrenal androgens are more sensitive to the glucocorticoid-suppressive effect than are the C-21 steroids. Therefore, the T or A plasma levels, rather than 17-HP, should be monitored.
The fact that much of the intra-adrenal abnormalities in NCAH may be ACTH-independent may explain why 17-HP serum levels are frequently not completely normalized by glucocorticoid treatment despite adequate ACTH suppression.
Cyproterone acetate instead of DXM or hydrocortisone has been suggested for the treatment of hirsutism due to NCAH. Although we did not perform such a prospective and randomized study, our personal data agree fully with this proposal, providing the patient has no or only mild adrenal hyperplasia on CT scan. Despite the increased levels of androgens, cyproterone acetate has a powerful antiandrogen effect on peripheral receptors that allows a more rapid and sustained improvement of hirsutism than does hydrocortisone or DXM alone. Furthermore, adverse effects with cyproterone acetate are less than with glucocorticoids. The same remarks apply to spironolactone.
These treatments should be encouraged since they complete the effect of antiandrogen therapy. Temporary methods of hair removal include bleaching, depilation (hair shaft destruction), and epilation (removal of the hair by the root). The only permanent method of hair removal currently in use is electrolysis, which can either be galvanic electrolysis, thermolysis, or a blend of the two.
Laser epilation is a relatively new technique which may be promising for the future.
Revision date: July 5, 2011
Last revised: by Jorge P. Ribeiro, MD