Polycystic Ovary Syndrome (PCOS), Acne, and Hirsutism: Pathogenesis, Clinical Presentation, and Treatment

Polycystic Ovary Syndrome (PCOS) is a prevalent endocrine disorder that primarily affects women of reproductive age. PCOS is characterized by a cluster of clinical features, including hyperandrogenism, chronic anovulation, insulin resistance, and infertility. However, in this article, we will focus on the manifestations and management of hirsutism and acne, two common and distressing clinical symptoms associated with PCOS.

Understanding Hyperandrogenism in PCOS

Hyperandrogenism, a hallmark of PCOS, is the excessive production of androgens, the male sex hormones, in women. This hormonal imbalance can lead to various clinical symptoms, with hirsutism and acne being the most noticeable. Hirsutism refers to the excessive growth of coarse, dark hair in a male pattern, often observed on the face, chest, and back. Acne, on the other hand, involves the development of persistent and often severe pimples on the face, chest, and back.

1. PCOS Overview:

• PCOS is a common endocrine disorder in women, leading to various clinical manifestations affecting reproductive, dermatological, metabolic, psychological, and sometimes neoplastic aspects from adolescence to menopause.

• Common dermatological manifestations of PCOS include hirsutism, acne, alopecia, and acanthosis nigricans.

2. Diagnostic Criteria for PCOS:

• Diagnostic criteria have evolved over time, with various sets proposed by different groups such as NIH, Rotterdam ESHRE/ASRM, Androgen Excess and PCOS Society, and a broader consensus recommended by NIH and ESHRE/ASRM in 2012.

• Generally, the diagnosis involves combinations of hyperandrogenemia, ovulatory dysfunction, and polycystic ovarian morphology (PCOM).

3. Etiopathogenesis:

• PCOS is a multifactorial disorder influenced by genetic, endocrine, and environmental factors, involving genetic predisposition, androgen overproduction, insulin resistance, and various associated abnormalities like obesity, hypertension, dyslipidemia, and more.

4. Cutaneous Manifestations in PCOS:

• Hirsutism: Excessive hair growth, particularly in androgen-sensitive areas, often evaluated using the Ferriman Gallwey (FG) score.

• Acne: Notable in many women with PCOS, particularly involving the face, neck, chest, and upper back, potentially due to increased androgen sensitivity.

• Acanthosis Nigricans: Characterized by velvety, hyperpigmented skin, linked to insulin resistance and observed in a smaller percentage of PCOS cases.

• Alopecia: Hair thinning or loss, typically at the vertex or similar to androgenic alopecia, resulting from hormonal influences and alteration in the hair growth cycle.

• Seborrhea: Oily and shiny skin, commonly found in women with hyperandrogenism and hyperinsulinemia.

5. Evaluation of Cutaneous Manifestations:

• Diagnosis and management focus on confirming PCOS and early intervention to prevent long-term health issues. Clinical history and examination are crucial due to varying presentations.

6. Management Approach:

• A multidisciplinary team involving a reproductive endocrinologist, dermatologist, psychologist/psychiatrist, dietician, and occasionally a bariatric surgeon is recommended for comprehensive and long-term management.

• Addressing underlying endocrine and metabolic issues alongside lifestyle modifications is crucial for effective and long-lasting treatment rather than relying solely on cosmetic treatments.
  

The Importance of Detailed Clinical History

When diagnosing PCOS, obtaining a detailed clinical history is paramount due to the wide variations in its clinical presentation. The history should encompass various aspects, including:

• Duration of Cutaneous Manifestation: Understanding how long the symptoms have been present.

• Menstrual History: Exploring irregularities in the menstrual cycle.

• History of Infertility: Assessing any difficulties in conceiving.

• Diet History: Examining dietary habits and their impact on the condition.

• Family History: Identifying any genetic predispositions.

Comprehensive Clinical Examination

A thorough clinical examination is crucial in diagnosing PCOS and should include the following elements:

• Grading of Hirsutism: Using the Ferriman-Gallwey (FG) scale to assess the severity of excessive hair growth.

• Assessment of Acne: Examining the location and type of lesions.

• Seborrhea Evaluation: Identifying the presence of excessive skin oiliness.

• Alopecia Examination: Assessing for signs of hair loss.

• Genital Region Evaluation: Checking for signs of virilization, such as clitoromegaly.

• BMI, Waist Circumference, and Blood Pressure Measurements: Determining these vital health parameters.

Laboratory Evaluation

Diagnosing PCOS is not straightforward and typically involves a combination of clinical features, physical findings, and specific laboratory investigations. Key tests and considerations include:

Androgens and Hyperandrogenism

• Measurement of common androgens, such as testosterone (total or free), androstenedione, DHEA, and DHEAS.

• Preferably, tests should be conducted early in the morning between the 4th and 10th day of the menstrual cycle.

• Elevated free testosterone is often preferred for diagnosis due to variations in SHBG levels in hyperandrogenism.

• Note that not all women with PCOS exhibit elevated androgen levels.

Other Biochemical Tests

• Thyroid stimulating hormone (TSH), prolactin, 17 hydroxy progesterone, dexamethasone suppression test, and 24-hour urinary cortisol to exclude other potential causes.

• Gonadotropin Abnormalities: Increased LH secretion, increased GnRH/LH pulsatility, and normal FSH levels are common but not used as diagnostic criteria due to assay variations and obesity-related influences.

Insulin Resistance

• PCOS is often associated with insulin resistance and hyperinsulinism.

• The 2-hour oral glucose tolerance test (OGTT) is recommended to assess insulin and glucose levels.

• OGTT should be performed when fasting blood glucose levels are normal or impaired.

• Evaluation of DHEAS levels may be useful in cases of rapid virilization.

Management Strategies

The management of PCOS should align with the Rotterdam criteria, and several key approaches are vital for effectively addressing the condition:

Lifestyle Modification

• The initial step in managing PCOS involves lifestyle adjustments, including dietary changes, exercise, and weight loss.

• A 5% reduction in total body weight has been shown to improve insulin resistance and testosterone levels, benefiting overall health.

Medical Therapy

Oral Contraceptive Pills (OCPs)

• COCPs are commonly prescribed to alleviate clinical symptoms associated with PCOS.

• They contain estrogen, which suppresses LH, increases SHBG, and reduces ovarian androgen production, leading to improved skin conditions.

• The choice of OCP should consider efficacy, metabolic risk, side effects, cost, and availability.

• OCPs should be continued for at least 6-9 months before significant improvement in hirsutism is observed.

Antiandrogens

• Antiandrogens inhibit androgen action through various mechanisms.

• Spironolactone is effective for hirsutism, acne, and alopecia, but may cause minor side effects.

• Cyproterone acetate and finasteride are alternative options for addressing androgen excess.

Insulin Sensitizers

• While metformin may not directly impact hirsutism or acne, it can be beneficial for women with insulin resistance or deranged blood glucose levels.

Cosmetic and Local Therapy

• Various methods for hair removal are available, including threading, waxing, plucking, bleaching, and shaving.

• Permanent hair reduction techniques like electrolysis and photoepilation can also be considered.

Psychological Support

• PCOS can lead to psychological and behavioral challenges, necessitating counseling and intervention to address the emotional impact on patients.

1. Topical Agents for Mild Acne

   For milder forms of acne, dermatologists often start with topical agents. These can include benzoyl peroxide, which is a common choice, provided it is well-tolerated. Topical antibiotics can also be effective but should be used cautiously due to the risk of bacterial resistance. To counter comedonal acne, retinoids like adapalene, tretinoin, and tazarotene are recommended, with a gradual progression from the least potent to the most potent.

2. Combination Therapy for Moderate Acne

   In moderate cases, oral antibiotics like doxycycline, lymecycline, or minocycline may be prescribed, but their use should be limited to 3 to 6 months. Topical retinoids can complement the treatment by targeting comedones. If androgen excess or other hormonal issues are present, combined oral contraceptives and antiandrogens, such as spironolactone, might be used in conjunction with antibiotics, always with the necessary contraception.

3. Oral Retinoids for Severe Acne

   Severe female adult acne often warrants the use of oral retinoids, primarily isotretinoin. However, it's essential to consider the potential side effects and teratogenicity before prescribing this medication.

4. Alternative Approaches

   Some experts suggest that antiandrogens, combined with topical therapy, can be a valuable alternative for both moderate and severe acne. Spironolactone, in particular, has gained popularity in some regions. However, the use of antiandrogens, including spironolactone, should always involve contraception due to their teratogenic effects. In selected cases, radiofrequency, laser, and light treatments are options, but they come with cost considerations and limited long-term efficacy data.

5. The American Academy of Dermatology recommends oral estroprogestin or antiandrogen therapy as a second-line treatment for moderate to severe adult acne in women who don't respond to other treatments. However, there's no requirement to measure androgens in these patients.

6. European dermatologists often employ hormonal treatments, even for mild cases, when there's evidence of hyperandrogenism. In moderate acne, hormonal therapy may be used without evidence of androgen excess.

7. The AE-PCOS task force suggests treating hyperandrogenism when clinical or biological evidence exists. These patients will also receive topical and, if needed, systemic acne treatments.

Recommendations

1. Diagnosis should be mainly clinical, but a grading tool can optimize treatment.

2. Serum androgen values should be measured in all women with adult acne.

3. Oral combined estroprogestins should be considered for patients with hyperandrogenism, regardless of the severity of their acne.

4. Estroprogestins should be chosen based on individual factors such as age, body mass index, and cardiovascular risk.

5. Spironolactone can be added when moderate to severe adult acne does not respond to usual treatments.

Conclusion

In conclusion, PCOS is a complex condition that requires a holistic approach to diagnosis and management. Early diagnosis and intervention are crucial in preventing long-term complications. A combination of endocrine and metabolic treatments, lifestyle modifications, and laser therapy for hirsutism can significantly improve the quality of life for individuals with PCOS.

Related

https://healthnewstrend.com/advances-in-pcos-management-whats-new-in-2023-and-beyond

https://healthnewstrend.com/revolutionizing-acne-care-unveiling-the-power-of-spironolactone-for-women

References

Archer JS, Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2004 Oct;18(5):737-54. doi: 10.1016/j.bpobgyn.2004.05.007. PMID: 15380144.

Gainder S, Sharma B. Update on Management of Polycystic Ovarian Syndrome for Dermatologists. Indian Dermatol Online J. 2019 Mar-Apr;10(2):97-105. doi: 10.4103/idoj.IDOJ_249_17. PMID: 30984582; PMCID: PMC6434760.

Image: Wikimedia Commons

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