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Green Gables

Adrenal Vs. Ovary Androgens

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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 the
    pilosebaceous 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. "
Edited by Green Gables
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Interesting! I was tested for Congenital adrenal hyperplasia (CAH). I didn't have it, but the endo recommended spiro anyways. Endocrinilogy is really fascinating.

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May I ask what factors ruled out CAH for you?

Interesting! I was tested for Congenital adrenal hyperplasia (CAH). I didn't have it, but the endo recommended spiro anyways. Endocrinilogy is really fascinating.

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I don't understand how you could ever go off anti-androgen therapy. That implies that the medication makes permanent changes in your hormone levels/receptors, and I have never read that.

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May I ask what factors ruled out CAH for you?

Interesting! I was tested for Congenital adrenal hyperplasia (CAH). I didn't have it, but the endo recommended spiro anyways. Endocrinilogy is really fascinating.

I was tested for non-classical CAH because my 17OH progesterone levels were high on a routine hormonal blood test. High 17OH progesterone is a marker for CAH. Everything else was within normal range. Acne, hirutism, and early menstruation were the only suggestions for me. I was referred to an endo who did a ACTH test where they inject ACTH to spike it and then test your blood at timed intervals to see how your body processes it (this test was awful - basically a huge adrenaline spike and then sitting for several hours getting blood taken every hour). ACTH stimulates cortisol.

I can't remember exactly now, but basically if you have CAH, your body will not process cortisol in the usual way and you will end up with excessive 17OH progesterone which converts to adrenal androgens (or something like that). The test showed that I processed ACTH/cortisol normally so no CAH. This doesn't mean I don't have androgen sensitivity (either to adrenal or ovarian androgens) but only that I am not missing the particular hormone that people with CAH are missing and I am not making excessive adrenal androgens as a result of missing that hormone.

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That's very interesting. When I was in school, I had a friend who was tested for CAH because her 17OHP was high also. However, they ruled it out via an ultrasound. Apparently the adrenals would look abnormal (don't know the detailed qualifiers for 'abnormal') in an ultrasound if you have CAH. Have you heard of this?

Is there a specific/different treatment for the synptoms of acne and whatnot if you are diagnosed with CAH?

Could you explain early menstration, does that just mean multiple or more frequent periods?

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That's very interesting. When I was in school, I had a friend who was tested for CAH because her 17OHP was high also. However, they ruled it out via an ultrasound. Apparently the adrenals would look abnormal (don't know the detailed qualifiers for 'abnormal') in an ultrasound if you have CAH. Have you heard of this?

Is there a specific/different treatment for the synptoms of acne and whatnot if you are diagnosed with CAH?

Could you explain early menstration, does that just mean multiple or more frequent periods?

The ACTH test is apparently the gold standard for diagnosing CAH as a result of a genetic abnormality due to 21 hydroxylase deficiency, which is the most common reason for CAH. Never heard of using a ultrasound.

My endo told me before the ACTH test if I had it, they would recommend BCP and maybe spiro. I don't recall well, but I think they might have suggested steroids as well. Mild, non-classical CAH is not life threatening; its symptoms can look like PCOS - irregular periods, infertility, acne, excess hair, hair loss. So it is mostly about treating the symptoms and possibly doing genetic testing before having a baby. Classical CAH is very serious, and comes up in infancy.

By early menstruation, I meant I got my first period young - just before I turned 11. And signs of puberty before that - public hair and boobs at 9, awful acne by 11 or 12. (Fun!)

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Thanks for this. I wonder if PCOS is often misdiagnosed and is instead CAH?

That's very interesting. When I was in school, I had a friend who was tested for CAH because her 17OHP was high also. However, they ruled it out via an ultrasound. Apparently the adrenals would look abnormal (don't know the detailed qualifiers for 'abnormal') in an ultrasound if you have CAH. Have you heard of this?
Is there a specific/different treatment for the synptoms of acne and whatnot if you are diagnosed with CAH?
Could you explain early menstration, does that just mean multiple or more frequent periods?

The ACTH test is apparently the gold standard for diagnosing CAH as a result of a genetic abnormality due to 21 hydroxylase deficiency, which is the most common reason for CAH. Never heard of using a ultrasound.

My endo told me before the ACTH test if I had it, they would recommend BCP and maybe spiro. I don't recall well, but I think they might have suggested steroids as well. Mild, non-classical CAH is not life threatening; its symptoms can look like PCOS - irregular periods, infertility, acne, excess hair, hair loss. So it is mostly about treating the symptoms and possibly doing genetic testing before having a baby. Classical CAH is very serious, and comes up in infancy.

By early menstruation, I meant I got my first period young - just before I turned 11. And signs of puberty before that - public hair and boobs at 9, awful acne by 11 or 12. (Fun!)

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I don't understand how you could ever go off anti-androgen therapy. That implies that the medication makes permanent changes in your hormone levels/receptors, and I have never read that.

I don't understand the mechanism either. The article just suggested that some patients were able to taper off their dose and have acne not recur. The simple answer is that their body's hormone levels declined with age so medication was no longer necessary. Or it could be something different that we simply don't know the answer.

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