Polycystic ovarian syndrome is
accompanied by insulin resistance.
Elevated insulin levels enhance ovarian
and adrenal androgen production
as well as increase the bioavailability of androgens which
are related to a reduction in sex hormone binding globulin.
Polycystic ovary syndrome is associated with an
increase incidence of the metabolic syndrome,
prediabetes, type 2 diabetes,
hypercholesterolemia and obesity.
Exposure to exogenous testosterone
which may be topical, oral or injected
can also be assessed as a possible cause
of hyperandrogenism and virilization.
This particular case manifest clinically as patients whose
partners are using topical testosterone replacements
and whose skin comes into contact with them,
usually at night when they lie together in bed
and the testosterone cream then rubs off unto
the female partner, causing hirsutism.
These patients should be worked up by having a total
testosterone and sex hormone binding globulin measured.
Morning 17-hydroxyprogesterone should be done
to screen for congenital adrenal hyperplasia.
Evaluation for oligomenorrhea
or amenorrhea should be done
by checking a HCG, a prolactin, an
FSH, a TSH and a free thyroxine level.
sulfate or DHEAs measurement
is obtained in cases of recent onset or rapidly
progressive hirsutism and/or virilization
Mechanical hair removal to treat the hirsutism involves
threading, depilatories, electrolysis and laser
and may be adequate for most cosmesis
in women with idiopathic hirsutism.
First line pharmacological management
of hirsutism with the above findings,
with the above treatments
have not worked,
is combined hormonal estrogen and
progesterone oral contraceptive agents.
If the oral contraceptives
do not work,
antiandrogen therapy with spironolactone can
often be added for better cosmetic response.
Please note to beware of prescribing
spironolactone to females of reproductive age
because this medication can
be quite teratogenic.
The management of hyperandrogenism should primarily
consist of weight loss as the first line intervention
for patients with a
BMI of 25 or greater.
Sustained weight loss of
up to 5-10%
will improve androgen levels, menstrual
function and possibly fertility.
The oral contraceptive is a first
line pharmacologic therapy
for hirsutism and menstrual dysfunction
unless fertility is desired.
If a fertility is required, clomiphene citrate or
letrozole can be used to correct oligo- and anovulation.
Finally, metformin reduces
hyperinsulinemia and androgen levels
but it doesn't improve the
hirsutism or the fertility.