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Azziz, L. Sanchez, E. Knochenhauer, C. Moran, J. Lazenby, K. Stephens, K. Taylor, L. All patients presenting for evaluation of symptoms potentially related to androgen excess between October and June were evaluated, and the data were maintained prospectively in a computerized database. For the assessment of therapeutic response, a retrospective review of the medical chart was performed, after the exclusion of those patients seeking fertility therapy only, or with inadequate follow-up or poor compliance.
A total of consecutive patients were seen during the study period. Excluded from analysis were patients in whom we were unable to evaluate hormonal status, determine ovulatory status, or find any evidence of androgen excess. In the remaining population of patients, the unbiased prevalence of androgen-secreting neoplasms was 0. Fifty-nine 6. A total of patients were included in the assessment of the response to hormonal therapy. The mean duration of follow-up was The major side effects noted were irregular vaginal bleeding Androgen excess in the development of androgenic features in the women affected, with the development of hirsutism, androgenic alopecia, acne, ovulatory dysfunction, and, if extreme and prolonged, even virilization and masculinization.
Disorders that result in androgen excess include specific identifiable disorders i. Alternatively, a of androgen excess disorders are diagnosed by exclusion, such as the polycystic ovary syndrome PCOS and idiopathic hirsutism IH , termed disorders of functional androgen excess FAE. Notwithstanding their clinical importance, the prevalence of the different pathological conditions causing or associated with androgen excess remains unclear. Although the most recognizable clinical feature of androgen excess may be hirsutism, it should be noted that not all patients with hirsutism have overt evidence of androgen excess, with some women suffering from what we understand to be IH 4.
Alternatively, not all patients with an androgen excess disorder have hirsutism, as in the Asian patient with PCOS 5. This has made it difficult to accurately assess the frequency of the lesser common androgen excess disorders. The response of hirsutism, ovulatory dysfunction, and other features of androgen excess to hormonal therapy is important to determine but has been studied primarily with the use of individual agents.
However, combination therapy including oral contraceptives OCs , antiandrogens, or metformin has been suggested to be superior to monotherapy 7 — 9. Unfortunately, reports evaluating the of these regimens have generally included 50 or fewer patients 7 — 13 , limiting our assessment of the efficacy of this therapeutic regimen. The objective of the present study was to report on our experience evaluating over consecutive patients consulting for symptoms potentially related to androgen excess. All patients presenting for the evaluation of symptoms potentially related to androgen excess to the reproductive endocrinology clinic to R.
The data were recorded and maintained prospectively in a computerized database Alpha Four version 6. All patients completed a uniform history form and underwent a complete physical examination. The body mass index BMI was calculated as kilograms per square meter.
Beginning January , the abdominal and hip circumferences were assessed as published ly 14 , and the waist to hip ratio WHR was calculated. The presence of acne was recorded, but the severity was not generally scored.
Excess body and facial terminal hair growth was assessed using a modified Ferriman-Gallwey mF-G hirsutism score The interval between bleeding episodes was assessed prospectively and classified as less than 26 d, 27—34 d, 35—44 d, 45 d to 3 months, and more than 3 months duration. This classification was established per the reported variations in menstrual cycle length observed by Treloar et al. In addition, beginning January , ovulatory function was confirmed in all eumenorrheic i.
A level of P4 greater than In patients who had not received hormonal therapy for 3 months before their initial visit, the serum levels of total testosterone T , free T, dehydroepiandrosterone sulfate DHEAS , and hydroxyprogesterone HP were obtained and recorded. Blood sampling for androgens was performed without regard to the time of the cycle or the day, although an effort was made to measure the HP in the preovulatory phase of the menstrual cycle Hyperandrogenemia was defined as an androgen value above the 95th percentile of 98 healthy control women [ i.
Patients with a basal level of HP greater than 6. If the repeat HP was 6. Patients with levels of total T above 8. Patients with evidence of ovulatory dysfunction also underwent measurements of serum prolactin and thyroid-stimulating hormone levels to exclude a prolactin-secreting adenoma and thyroid dysfunction, respectively. When indicated see above , the acute ACTH stimulation test was performed as described ly Dexamethasone was not administered before the study.
Three baseline samples were obtained 15 min apart and mixed 0-min sample. Immediately afterward, 0. Both the 0- and min samples were assayed for HP levels. Based on the above evaluation, two distinct types of androgen excess disorders, those with specific diagnoses ascertained by inclusion and those diagnosed by exclusion defined as FAE disorders , were identified:.
To determine the response to suppressive hormonal therapy in patients with androgen excess, we retrospectively reviewed the charts of all androgen excess patients seen initially between October and June Using a uniform form, the documented treatment outcome and side effects as assessed by the patient were recorded. We excluded those patients: 1 seeking infertility therapy; 2 with inadequate follow-up i. All patients with menstrual or ovulatory dysfunction received OCs when possible.
SPA was rarely used alone, except in the occasional hirsute patient who had ly undergone a hysterectomy or tubal ligation. Other treatment regimens were occasionally used, including glucocorticoids, insulin sensitizers, GnRH analogs, flutamide, finasteride, and other estrogen-progestin combinations, alone or in combination; the majority of these were used as part of clinical trials 24 — When side effects were identified, they were managed as follows.
On occasion, the SPA was changed to flutamide or finasteride. Third, if other side effects attributable to the OC occurred e. Two-group comparison of continuous variables was performed using a two-sample t test with adjustment for nonconstancy of variance, when necessary. More than two group means were compared using the ANOVA with post hoc least squares means pairwise comparisons.
A total of consecutive patients were seen during the time period of the study. Of these, In In 8. In total, subjects were included in the study. Hysterectomized, and without information regarding menstrual or ovulatory function. All with regular menses, d 26—34 in length, but without having ovulation verified by luteal progesterone level. Patients who were excluded from the study were slightly older There was no difference in racial composition between the two groups, with subjects that were excluded being Of the patients included in the study 5.
Clinically, Patients with hirsutism or infertility were slightly older [ Patients with infertility were also more obese than their non-infertile counterparts Alternatively, women with acne were younger and less overweight than those patients than non-acneic patients [ Oligo-ovulation was present in One hundred five Of hirsute women, 35 5. Of the patients with acne, Overall, Total T was elevated inExtreme hirsute women
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