Hyperandrogenism. Dr Jack Biko. MB. BCh (Wits), MMED O & G (Pret), FCOG (SA), Dip Advanced Endoscopic Surgery(Kiel, Germany)
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1 Hyperandrogenism Dr Jack Biko MB. BCh (Wits), MMED O & G (Pret), FCOG (SA), Dip Advanced Endoscopic Surgery(Kiel, Germany) 2012
2 Hyperandrogenism Excessive production of androgens Adrenal glands main source of androgens Ovaries also produce androgens Men manifest few symptoms Occur in postmenopausal women as well
3 Hyperandrogenism Androgens are a byproduct of cortisol synthesis ACTH a major determinant of androgen production
4 Cortisol production
5 Adrenal androgens Dehydroepiandrosterone (DHEA) Dehydroepiandrosterone sulphate (DHEAS) 90% produced by adrenal glands 10% by ovaries / Testis
6 Hyperandrogenism DHEA and DHEAS do not have androgenic activity Converted to Testosterone in adrenal gland and peripheral tissue: Hair follicles, Sebaceous glands, External genitalia, Adipose tissue
7 Clinical features General appearance Mascular male body habitus Android obesity Skin changes Hirsutism (face, chin, chest, perineum) Alopecia Oily skin Acne vulgaris Male sweat changes Acanthosis nigrans
8 Clinical features Menstrual irregularities Amenorrhea Infertility Endocrine changes Hypertension Hyperlipidemia Impaired glucose tolerance
9 Clinical features Deepening of voice Clitoromegally Increased libido Associated conditions Hashimoto s thyroiditis Graves disease
10 Clinical features Skin changes Hirsutism Alopecia Acanthosis nigrans Oily skin Acne vulgaris Male sweat changes Hyperandrogenic syndromes PCOS HAIR-AN syndrome
11 Clinical features Pubertal boys Increased rate of progression of puberty Rapid skeletal maturation Premature epiphyseal fusion Pubertal girls Virilization Amenorrhea Rapid skeletal maturation Premature epiphyseal fusion
12 Clinical features Adult male Minimal clinical changes Inhibition of GNRH secretion testis atrophy leading to: (1) low testosterone levels and (2) low sperm count Infertility!! Adult females Hirsutism Acne Male pattern baldness Menstrual problems Ovulatory dysfunction infertility
13 Causes of hyperandrogenism Medications: Anabolic steroids Danazol Metoclopramide Phenothiazines COC s (ovral, nordette, triphasil Resepine Endogenous overproduction: CAH: 21 and 11 hydroxylase deficiency Cushing s syndrome Ovarian cause: PCOS, Hyperthecosis, HAIR AN syndrome
14 Non-tumour related causes Adrenal causes CAH 21 hydroxylase deficiency 11 hydroxylase deficiency. Cushing syndrome Ovarian causes PCOS Hyperthecosis HAIR-AN syndrome
15 Tumour related causes Adrenal tumours Adrenocortical tumour Adrenal adenoma Adrenal carcinoma Ovarian tumours Arrhenoblastoma Hilar cell ovarian tumour Krukenberg tumour
16 Congenital adrenal hyperplasia Several autosomal recessive disorders Defect in cortisol synthesis Defect in aldosterone synthesis Accumulation of precursors
17 HAIR-AN syndrome Hyperandrogenism Insulin resistance Acanthosis nigrans
18 Gestational hyperandrogenism Changes in pregnancy: hirsutism, acne, temporal balding, clitoromegally, deepening voice. Palpable solid or cystic mass may be present Luteoma, Theca lutean cysts, Ovarian tumour, Adrenal tumour, Placental aromatase deficiency, Exogenous androgens/ progestogens
19 Ambiguous genitalia
20 Ambiguous genitalia
21 Investigations Pelvic ultrasound FSH, LH, Oestradiol, DHEA, DHEAS, Testosterone, SHBG,FBC, TSH, Prolactin UKE, Fasting glucose and insulin CT scan MRI
22 Management Lifestyle changes Metformin (reduction in testosterone) COC Anti-androgens (aldactone, proscar) Refer to endocrine / gynaecologist Follow up patient
23 Management Reduce androgens Manage the cosmetic effects Manage infertility Treatment is life long
24 Management COC s: must contain 30 35ug E3 and less androgenic progestin Inhibit LH, stimulate SHBG production % improvement in hirsutism Must use for at-least 6months before improvement can be noted Hirsutism recurs if Rx stopped
25 Management Anti-androgens: not recommended as first line or as monotherapy. Use as add-on to COC Spironolactone, Finesteride, Cyprosterone acetate, Flutamide(hepatotoxic) Metformin: no effect on hirsutism
26 Management Cosmetic therapy: Shaving, Plucking, Waxing Fertility: ovulation induction with clomid
27 Thanks
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