I was reading some endocrinology research in AMA which specifically talks about acne and elevated androgens / androgen sensitivity in women.
It says you can have an androgen problem initiating from the adrenals or the ovary, or both.
Glucocorticoids are best for adrenal androgen suppression (spironolactone)
"[For adrenal androgen suppression] At this time, spironolactone is the most useful anti-androgen."
Birth controls with anti- or low androgenic progestins are best for ovary androgen suppression (e.g. Yaz, Diane)
Sometimes you need both.
The article also confirms what I've been saying since I started spironolactone: that androgen changes occur very slowly. It recommends a minimum of 2 years of anti-androgen therapy. It says that after 2 years with good results, some people can slowly taper off their dose in 6 month phases (so if you clear on 100mg...imagine cutting down to 75mg after 2.5years, then 50mg after 3 years, then 25mg after 3.5 years...), but recurrence is common, and some will need lifetime anti-androgen therapy.
More interesting tidbits from the article
- Ketoconazole (anti-fungal) and cimetidine (a h2 blocker) have anti-androgenic effects.
"Seborrhea occurs soon after androgen levels rise; consequently, acne is usually the first androgenic skin manifestation."
"The acne process begins when androgen action increases sebum production by thepilosebaceous unit. Without androgen action on the sebaceous gland, acne does not occur."
"Both ovary and adrenal glands secrete androgens, and it is important for diagnosis and treatment selection to determine the relative contribution of each to circulating androgen levels in an individual patient. Both are important as sources of andro-gens, but the proportion of androgens secreted by each varies in individual women. Ovarian pre-dominance is suggested by young age, oligomenorrhea, obesity, and more severe hirsutism. Because there are many exceptions to these generalizations, the relative ovarian and adrenal contributions should be determined by suppression testing. Tes-tosterone and androstenedione can be of either ori-gin, but DHEAS is almost exclusively adrenal. However, when DHEAS is elevated along with other androgens, it cannot be assumed that the ad-renal is the source of the other androgens. "