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PCOS, acne link: presence of polycystic ovaries not required for diagnosis. (Special report: gender-specific dermatology).

Dermatology Times, Feb, 2003, by Liz Meszaros

Toronto -- Polycystic ovary syndrome (PCOS) may be linked to acne in adult women, but its prevalence in these women and the specifics of which of these women may need more extensive work-ups and referrals are still largely an unknown.

Dermatologists should be aware of the link and the treatment modalities available for PCOS, said James C. Shaw, M.D., associate professor, division of dermatology, University of Toronto, Toronto Western Hospital.

"A knowledge of PCOS is important for clinicians to have so they are not worried about each case of an adult women with acne or hirsutism. They may not all have PCOS," said Dr. Shaw.

The definition of PCOS has been updated to include the presence of a triad of the following:

* Ovulatory dysfunction, defined as more than six menstrual cycles that are longer than 35 days per year or fewer than eight menstrual cycles per year;

* Hyperandrogenism, as evidenced by clinical findings of hirsutism, acne, or androgenetic alopecia, or laboratory evidence of elevated androgen levels;

*Exclusion of other endocrine diseases that can present with hyperandrogenism. These diseases include but are not limited to adrenal hyperplasia, thyroid disorders, hyperprolactinemia, and Cushing's syndrome.

Of value to dermatologists is that the presence of polycystic ovaries is not required for the diagnosis, and the LH/FSH ratio is no longer used routinely in making the diagnosis because of its unreliability.

According to Dr. Shaw, although acne has not traditionally been viewed as a typical sign of PCOS, as significant hirsutism has, clinicians must be aware that there is a hormonal link with acne in adult women.

The difficulty for clinicians in diagnosing or even suspecting PCOS is that the prevalence of PCOS in women with adult acne is uncertain. Some studies have suggested that up to 38 percent of adult women with acne have PCOS.

"Further, the larger question of whether or how extensive a work-up we should do on a 27-year-old with some acne is unanswered," said Dr. Shaw. Some laboratory tests, such as testosterone, free testosterone, DHEA sulfate, and 17-hydroxyprogesterone, may be wise in such women, but Dr. Shaw refrained from making any strong recommendations until more research is available that "allows us NOT to do those studies," he noted.

Occasionally, laboratory tests in women presenting to dermatologists may be abnormal (i.e., highly elevated prolactin levels). In these cases, the dermatologist would probably be better off referring the patient to an endocrinologist for management. Women who would benefit most from a referral to an endocrinologist for a full work-up include those with a strong family history of diabetes, those with any signs of severe insulin resistance such as acanthosis nigracans and obesity. Other referral options may include the ob/gyn if there are fertility or surgical issues.

Treatment options for PCOS

Dr. Shaw discussed the treatment options of hormonal therapies for acne, hirsutism, and androgenetic alopecia with or without PCOS. "These valuable treatments have been around for a while, but I think dermatologists are still learning about them," he said.

Oral contraceptives are the first line of treatment for women with PCOS, and dermatologists can, if they choose, be the ones to initiate this treatment. Recently, several new oral contraceptives that include newer progestins or lower doses of estrogen have been studied or have become approved for use in acne in North America. Examples include Ortho Tri-Cyclen, Diane-35 (Canada), Estrostep (United States), Alesse, and Yasmin(United States). Oral contraceptives containing low doses of estrogen (less than 35 mcg) are thought to have a higher safety profile than those with 35 mcg or higher, and new progestins are less androgenic and have improved safety over earlier progestins.

Androgen receptor blockers (ARBs) are the second line of treatment. According to Dr. Shaw, these agents are probably the most effective medications in women with PCOS for the treatment of hyperandrogenism, or the triad of acne, hirsutism, and androgenetic alopecia. They include spironolactone (Aldactone), flutamide (Eulexin), and cyproterone acetate (Androcur/Cyprostat). Not much has changed over the past few years with this class of agents, which have a high safety profile, although dermatologists express continued concern about the safety of the ARBs. Dr. Shaw reported that a recent long-term safety study has shown spironolactone to have an excellent safety record (Shaw JC, White L. J Cutaneous Med Surg. Nov-Dec 2002).

Finally, insulin sensitizers, including metformin (Glucophage) and the glitizones are the third line of treatment. These are given with a goal of correcting insulin sensitivity in patients with PCOS, which can reduce androgen production secondarily. Typically, dermatologists are not involved in such care, but, according to Dr. Shaw, if the dermatologist is comfortable with drugs such as methotrexate (Rheumatrex), acetretin (Soriatane), and the immunosuppressives, the glitizones, as a class, can be mastered as well.

For more information

Dr. Shaw will speak on the topic Sunday, March 23, at 3 p.m. during the "Polycystic Ovary Syndrome" forum session in room 270 at the annual meeting of the American Academy of Dermatology in San Francisco.

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