It is not normal for a woman who is over 20 years of age to have acne. Similarly, a woman experiencing coarse hair growth involving her chin, cheeks, neck, sternum, abdomen, and lower back is not normal. These are all signs of an overproduction of androgens or male hormones.
In women, male hormones are normally produced from two sources, the adrenal glands and the ovaries. If one or both of these glands becomes overactive in their androgen production, then the woman develops the classic signs of acne, dark, coarse hair growth, irregular menses, infertility, and occasionally, gain weight.
The key to successfully treating women with androgen overproduction involves accurately determining the source of the overproduction. One must first determine if the adrenals, the ovaries, or both glands are overactive. Once the source of the overproduction is determined, then one must determine what is stimulating the over activity of the gland. Only after this has been accurately determined can the patient be presented with her treatment options to determine the most appropriate and effective therapeutic course for her individually.
The main reason why so many women have continued problems with acne and hirsutism once therapy has been initiated by a physician is that they were never properly diagnosed. Instead of specific therapy directed to lower the androgen production and optimize the results for each person, they are treated with a random, “shot gun” approach. Non-specific treatments are started and continued with the hope for resolution of the acne and/or hair growth. There is no systematic plan for treatment and then evaluating the results of that treatment, with the intention of making therapeutic changes as the response and resolution of the acne and/or hair growth resolves. Frequently, this approach results in a very disappointing outcome with the patient becoming discouraged and feeling that there is no hope of alleviating her problem.
Knowing the specific causes of androgen overproduction and how to identify each one is crucial in developing a successful treatment program.
Common causes for the ovary to overproduce male hormones are classic polycystic ovarian syndrome (PCOS), caused by abnormal hormonal stimulation to the ovaries by the pituitary gland. A second cause of direct stimulation of androgen production in the ovaries is insulin. This condition of overproduction of insulin with elevated blood levels of insulin and normal blood sugars is known as insulin resistance. This results in a persistent stimulation of certain cells in the ovary (stromal cells and theca cells) to overproduce testosterone that then spills out of the ovary into the circulation where it causes effects all over the body. A much less frequent cause of ovarian overproduction of androgens is a mild defect in one of the enzymes in the ovary that are required for the normal conversion of androgens to estrogens. It is also important to be able to identify these individuals for their long-term treatment and health.
Adrenal over activity resulting in male hormone production most frequently is caused by environmental stresses. These may be stresses that the individual is aware of or they may be subliminal. Additional but significantly less frequent causes adrenal overproduction of androgens are a mild enzyme defect in the adrenal gland and, very rarely, adrenal tumors.
The first step in evaluating acne or coarse hair growth is to establish that there is an overproduction of androgens present. This involves getting baseline hormonal studies and, if indicated, a 3-hour glucose tolerance test with insulin levels. This will establish the presence or absence of elevated insulin levels stimulating the ovaries production of testosterone.
Once these initial studies are done, the source of the overproduction of the androgens, either the adrenals or the ovaries, is determined by a 4 week Decadron suppression test. This involves taking 0.5 mg on the medication on the medication, Decadron, at bedtime for 4 weeks followed by repeating the DHEA-sulfate and testosterone levels at the end of the 4 weeks.
Once all this data is obtained, one can generally accurately determine the source of the androgen excess and the optimal therapeutic options to treat this condition. Treatment decisions ultimately are the patient’s after a thorough discussion of her condition and the advantages and disadvantages of these therapeutic options with Dr. Burke.
Once treatment is initiated, Dr. Burke monitors the patient’s progress with hormonal studies and physical evaluation of the acne and hirsutism to assure that the patient is getting a good cosmetic response.