Newswise — An occasional facial wax or bikini wax is the only treatment most women need to control unwanted hair. But those who find themselves in a constant battle with coarse, dark hairs that grow in patterns typical of men may be dealing with a common symptom of an often-overlooked but usually treatable hormone imbalance.
Androgens are known as male hormones but they also circulate in lesser levels in women's bloodstreams. In fact, several necessary male hormones are produced by the ovaries and other organs and glands. If they exist in lower-than-normal amounts, a woman may experience decreased sex drive and fatigue and be vulnerable to osteoporosis. In excess, androgens often lead to acne, balding or thinning hair on the scalp, irregular or absent menstrual periods, fatigue, decreased sex drive, and the abnormal hair growth called hirsutism.
The intricate mechanisms producing androgens and other hormones that impact androgen availability and strength are the first links in an entwined chain of events that ultimately affect individual sites such as hair follicles, skin pores and eggs in the ovaries. The effectiveness of treatment, therefore, depends on finding and addressing the defective point or points in the sequence while providing therapy for bothersome symptoms.
To offer in-depth testing, comprehensive treatments and support, and research into molecular mechanisms and future therapies, Cedars-Sinai Medical Center has launched the Center for Androgen-Related Disorders. It is believe to be the only program of its kind in the country to specialize in both up- and down-regulation of androgen levels in women.
Ricardo Azziz, M.D., who holds the Helping Hand of Los Angeles Chair in Obstetrics and Gynecology, directs the new center and its programs in androgen-excess disorders. Director of Cedars-Sinai's Department of Obstetrics and Gynecology, Dr. Azziz joined the medical center in late 2002 after serving for 15 years at the University of Alabama at Birmingham. In addition to his role at Cedars-Sinai, Dr. Azziz also serves as Executive Director of The Androgen Excess Society, an organization dedicated to offering recommendations for therapy, identifying research priorities, and helping to provide education on this often-misunderstood and misdiagnosed disorder.
Glenn Braunstein, M.D., holder of the James R. Klinenberg, M.D., Chair in Medicine at Cedars-Sinai, offers expertise in causes and complications of androgen deficiencies. Board-certified in internal medicine with a subspecialty in endocrinology, diabetes and metabolism, Dr. Braunstein has conducted extensive research in reproductive endocrinology. Currently, three Phase III clinical trials are underway to assess the effectiveness of testosterone replacement therapy in women.
Although androgen excess " which typically is seen in the years from adolescence to menopause " causes many symptoms that are readily visible, underlying causes are more challenging to detect. The inability to become pregnant, for example, may stem from a variety of causes, and many women who suffer from hirsutism believe they are destined for a life of plucking, tweezing or paying for expensive treatments, never knowing that a serious medical condition may be responsible.
"The overwhelming majority of women with hirsutism have an underlying androgen disorder," says Dr. Azziz. Because hair overgrowth is so common to the disorder and so problematic to the sufferer, Dr. Azziz and several of his colleagues have made a concerted effort to inform electrologists about the medical implications of hirsutism.
"Electrologists tend to be the front line for patients with hirsutism," he says. "When electrologists recognize that they are treating a symptom that is part of a larger disorder, they are able to give appropriate referrals, which enables patients to find the diagnostic and treatment help they need."
Although adrenal gland disorders and certain tumors occasionally contribute to excessive androgen levels, about 80 percent of patients will be found to suffer from an endocrine disorder called polycystic ovary syndrome (PCOS), according to Dr. Azziz.
Women with PCOS have numerous small cysts on the periphery of their ovaries and experience a variety of symptoms, such as menstrual irregularities, skin problems, and excess weight. Many are found to have insulin resistance, a condition that allows excessive levels of insulin to circulate in the blood. Risks of developing Type II diabetes, hypertension and heart disease are increased.
Maricarmen Ornelas has struggled with weight, excessive facial hair, and an uncooperative and unpredictable menstrual cycle since first entering puberty.
"After I got married, the problem kept getting worse. I started gaining more weight. I couldn't get pregnant," says the 31-year-old Pico Rivera resident, who did manage to have a son nearly nine years ago. "My son is a miracle, he's totally a miracle, and I've been trying ever since then."
Visits to several physicians were not beneficial. Although one suspected that Ornelas had PCOS, he and others simply prescribed fertility treatments, which were ineffective. Some suggested that if she lost weight, her cycle and fertility might return. Finally, after researching PCOS on the Internet and reading of other women's experiences, she determined to find a specialist who might offer a more comprehensive evaluation.
Her search led to Sanjay K. Agarwal, M.D., director of the Center for Reproductive Medicine and acting director of the Division of Reproductive Endocrinology at Cedars-Sinai. With board certification in obstetrics and gynecology, reproductive endocrinology and infertility, Dr. Agarwal has conducted extensive research in several areas, including polycystic ovary syndrome.
"The first day we spoke, before he did all of the exams, I told him that I suspected that that's what I had. He said it could be a possibility but he wanted to rule other things out," recalls Ornelas.
After examining her ovaries, ordering extensive blood work, and reviewing her personal and family medical histories, Dr. Agarwal confirmed that Ornelas had PCOS as well as excessive insulin levels. He prescribed medications to regulate insulin and initiate ovulation.
A secretary during the day who goes to school at night, Ornelas has not found time to support the medical intervention with diet and exercise, which she believes will provide better results. But she already has lost a few pounds and the rapid growth of hair on her face has slowed as her body responds to the proper balance of hormones. More importantly, her menstrual cycle has returned, which she hopes will enable her to have another baby.
"It takes at least six months to begin to observe a change in hair growth, and for pregnancy it may take a little bit longer," suggests Dr. Azziz. "It usually takes three to six months for a person to actually begin to ovulate regularly, and it may be necessary to make additional medication adjustments. That's one of the benefits of a comprehensive center and our staff that provides follow-up and support."
According to Dr. Braunstein, while it is recognized that five or six percent of women in their reproductive years will have polycystic ovary syndrome and androgen excess, such precise statistics are not available for the population of women with androgen insufficiency syndrome, for two reasons.
"There have not yet been widespread epidemiologic studies on androgen insufficiency, and the assays for measuring androgens in women have been relatively insensitive. They have been optimized for measuring the androgens of males, while the levels in women are normally 1/10th to 1/20th of those in males," says Dr. Braunstein. "It is important to have a very good, sensitive assay to measure the levels in women."
Women with androgen insufficiency syndrome typically experience a constellation of symptoms that warrant further investigation: decrease in libido, decline in sense of well-being or quality of life, fatigue, possibly a slower-than-normal growth rate of pubic hair, and a likelihood of bone density problems.
To progress toward a diagnosis, physicians will evaluate the signs and symptoms and find out if a clinical situation exists " such as removal of ovaries, adrenal or pituitary disorders, or menopause " that is known to be a factor in androgen deficiency.
"In the premenopausal woman, about a quarter of the androgens are produced directly by the ovaries and about a quarter by the adrenal glands. About half comes from the conversion in various tissues " such as the skin and liver " of precursors, "prohormones" from the ovaries and the adrenals, into more potent androgens. When a woman has her ovaries removed, about half of the androgen production actually decreases. The same is not true for someone going through natural menopause because the androgen production continues from the ovaries," says Dr. Braunstein.
"Many women who have had their ovaries removed, those with adrenal or pituitary diseases, and some individuals with natural menopause may have a low libido that is part and parcel of a low testosterone level," he adds. "We're doing trials of testosterone replacement therapy in these women, and there have been some very positive responses."
Cedars-Sinai is one of the largest nonprofit academic medical centers in the Western United States. For the fifth straight two-year period, it has been named Southern California's gold standard in health care in an independent survey. Cedars-Sinai is internationally renowned for its diagnostic and treatment capabilities and its broad spectrum of programs and services, as well as breakthroughs in biomedical research and superlative medical education. Named one of the 100 "Most Wired" hospitals in health care in 2001, the Medical Center ranks among the top 10 non-university hospitals in the nation for its research activities.
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