A 22-year-old woman consults you for treatment of hirsutism. She is obese and has facial acne and hirsutism on her face and periareolar regions and a male escutcheon. Serum LH level is 35 mIU/mL and FSH is 9 mIU/mL. Androstenedione and testosterone levels are mildly elevated, but serum DHAS is normal. The patient does not wish to conceive at this time. Which of the following single agents is the most appropriate treatment of her condition?
Correct Answer: Oral contraceptives
Description: This patient has polycystic ovarian syndrome (PCOS), diagnosed by the clinical picture, abnormally high LH-to-FSH ratio (which should normally be approximately 1:1), and elevated androgen but normal DHAS. DHAS is a marker of adrenal androgen production; when normal, it essentially excludes adrenal sources of hyperandrogenism. Several medications have been used to treat hirsutism associated with PCOS. For many years contraceptives were the most frequently used agents; they can suppress hair growth in up to two-thirds of treated patients. They act by directly suppressing ovarian steroid production and increasing hepatic binding globulin production, which binds circulating hormone and lowers the concentration of metabolically active (free unbound) androgen. However, clinical improvement can take as long as 6 months to manifest. Other medications that have shown promise include medroxyprogesterone acetate, spironolactone, cimetidine, and GnRH agonists, which suppress ovarian steroid production. However, GnRH analogues are expensive and have been associated with significant bone demineralization after only 6 months of therapy in some patients. Surgical wedge resection is no longer considered an appropriate therapy for PCOS given the success of pharmacologic agents and the ovarian adhesions that were frequently associated with this surgery.
Category:
Gynaecology & Obstetrics
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