WEBSITE NEWSLETTER
HORMONE CENTER OF NEW YORK
Geoffrey
Redmond, MD
Issue # 3
November 2004
This newsletter is published
several times a year to provide women
with up to the minute information about common hormone conditions.
Important: Please keep in mind that the purpose of the Hormone Center of New York
and this
newsletter is to provide general information. Anyone with a medical condition
should be under the care of a physician and any changes in treatment must be
discussed with him or her.
In this issue:
Polycystic Ovary Syndrome Association Annual Conference Report
Alopecia and OCs
Update on Oral Contraceptives and Acne:
What they do and what they don’t do
POLYCYSTIC OVARY SYNDROME ASSOCIATION
ANNUAL NATIONAL MEETING
The PCOSA held its annual meeting in the New York City area two weeks ago. I
was the program chairman. We were fortunately to have several internationally
known experts including Walter Futterweit, MD (program co-chair), Samuel
Thatcher, MD from Tennessee, Ricardo Azizz, MD from Los Angeles, Michelle
Warren, MD from New York and Martha McKittrick, RD, also from New York.
The PCOSA is an extremely worthwhile organization and I recommend membership to
all women with PCOS or related conditions such as alopecia, acne and increased
facial and body hair. (www.pcosupport.org)
The organization needs everyone’s support right now
because pharmaceutical companies and other commercial sources have cut back on
funding of meetings intended for the lay public.
I was again struck by the great thirst for knowledge of the women in attendance.
Compared to a few years ago, there is much more material available but affected
women still need help in understanding their condition. Treatments continue to
improve. Unfortunately, with our unwieldy health care system, the only way to
get the care one needs is to become one’s own advocate. This means studying your
condition in advance so that you know what to ask for in regard to tests and
treatment. It shouldn’t be this way, but I don‘t see it changing anytime soon.
All we can do is educate ourselves so as to be better prepared to navigate the
maze.
ALOPECIA AND OCs
Of all the women’s hormone problems I deal with in my practice, alopecia
(hair loss) is by far the most disturbing to those affected by it. Not only does
it strike directly at self-esteem, but most doctors, dermatologists included,
offer little help. We should not blame the individual doctors because alopecia
is left out of medical training – as is PCOS and many other women’s hormonal
conditions. Despite receiving my medical and research education at leading
institutions (Columbia and Rockefeller Universities) I heard not a word about
this condition at any point during my training. It was from Wilma Bergfeld, MD,
dermatologist at the Cleveland Clinic and first woman president of the American
Academy of Dermatology that I learned about female hair loss and its hormonal
basis. She has been a pioneer in taking alopecia seriously and developing ways
to help affected women. I owe her a personal debt for all she taught me, as do
all women struggling with hair loss.
I discuss alopecia in detail in
my
website article. Here I offer an update on understanding the effects
of birth control pills (oral contraceptives, OCs) on hair.
Most current pills have two hormones, a form of estrogen called ethinyl
estradiol and a synthetic progestin. This can be a mixed bag because estrogen is
good for hair but some progestins may not be. Specifically, cetain progestins
have testosterone-like activity and so are usually best avoided by women with
alopecia or other testosterone related problems, such as unwanted hair or acne.
The newest generation of OCs such as Desogen®, Mircette®, OrthoCyclen® and
TriCyclen®, and Yasmin® are free of testosterone activity. (Some of these are
also available in generic form with different names.) Hence they are usually the
best choice if you are concerned about hair loss. There are differences between
these so it is important to discuss pill choice with your physician.
As I have just mentioned, the estrogen in OCs is good for hair. (The situation
with estrogen in OCs is different from that in menopause. OCs definitely do not
increase breast cancer risk.) Low dose OCs are ones which have between 20 and 35
mcg of ethinyl estradiol. Some are surprised to learn that within this range, 20
mcg is no safer than 30 or 35 mcg. For this reason, I usually recommend pills in
this range rather than those of 20 mcg. There are exceptions, though, especially
for women who are particularly sensitive to the estrogen in OCs.
The beneficial effect of OCs is limited by the fact most pills have 21 days of
active and 7 days of inactive pills. This means that estrogen is enhanced for
only 21 out of every 28 days. One solution is to take active pills for several
weeks continuously. This means that periods will be less often than once a month
but this is not harmful. Though one OC, Seasonale®, is set up for periods only
every 3 months, it is not one which is particularly good for hair. For
continuous use, I generally recommend Yasmin®, OrthoCyclen®, or Desogen®.
Mircette® has 26 days of estrogen but at a relatively low dose, It is a
reasonable choice, especially for women sensitive to estrogen side effects such
as nausea and breast tenderness.
In my experience, continuous OC use can be of substantial help in alopecia, so
long as it is part of a complete regimen.
If you want to try continuous use, it is important to have a health care
practitioner prescribe the OC and explain how to set up the schedule. For
obvious reasons, when contraception is involved, it is important to avoid
mix-ups.
ORAL CONTRACEPTIVES (OCs) AND ACNE:
WHAT THEY DO AND WHAT THEY DON’T DO
The first study definitively proving that OCs can benefit acne was on
OrthoTriCyclen®. I was the lead investigator. Since then Estrostep® has also
been shown effective, though it has been much less popular. Still, I receive
many questions from women who have had disappointing results or wonder whether
other pills, such as Diane 35®, might be better. So let’s look at the matter
more closely.
First, the studies show that on average, the OCs decrease acne by a little more
than 50%. This means half as many pimples. For many women whose acne is not very
conspicuous, this may be all they need. For women with worse acne, this limited
degree of improvement is not quite enough of a good thing.
The cause of acne Female acne is always hormonal. The triggering event is
testosterone attaching to the oil (sebaceous) glands and putting them into
overdrive so that they make much more oil. Then the pores get plugged up,
trapping the oil inside. Next, bacteria grow in the oil, causing the
inflammation and pus which makes acne more conspicuous. Most topicals act by
cutting down on plugging and bacterial growth; antibiotics also stop bacterial
growth. The problem with topicals and antibiotics is that they only work after
the acne has gotten started. Hormonal treatment works best because it cuts acne
off at the pass by preventing testosterone from stimulating the oil glands.
Treatment of the hormonal cause of acne OCs generally decreases free
testosterone by about half. However it is not possible to lower it to zero. So
when an OC by itself is not enough, or when there is reason not to take the
pill, medication to block testosterone often produces considerable improvement.
Spironolactone (Aldactone®) is still one of the best choices for this.
The benefits of testosterone-blocking for acne treatment are not as widely known
as they should be. This is unfortunate because often the improvement is
dramatic. Not only that, but there is usually an overall brightening and
smoothing of the complexion.
What about Diane 35? This pill contains a testosterone blocker called
cyproterone acetate (CPA) which is also available separately in higher doses
under the brand name Androcur®. (Diane 35 and Androcur are approved in Canada
and most of the world but not in the U.S.) I’ve never been convinced that Diane
35 works any better than TriCyclen or other non-androgenic OCs. Last year, the
Canadian Broadcasting Corporation publicized studies suggesting that Diane 35
may have a higher incidence of blood clots than many other OCs. While this may
not be conclusive, at this time I do not see any particular advantage to Diane
35.
Androcur, which contains a much higher dose of CPA, may work better for some
women than spironolactone. Side effects can include mood swings and weight gain
– though most women feel fine on it – so usually spironolactone is the best
testosterone blocker to try first.
Other OCs for acne As mentioned above, an important difference between OCs is
androgenicity. This term refers to testosterone-like effect. For a woman who is
having unwanted effects of testosterone like acne, hirsutism (increased facial
and body hair) or androgenic alopecia (loss of scalp hair) it is sensible to
avoid OCs which might add further to this. Some non-androgenic OCs are: Desogen®,
Mircette®, Cyclessa®, OrthoCyclen®, OrthoTriCyclen®, OrthoTriCyclen Lo®,
OrthoEvra® (the patch) and Yasmin®. Several of these pills have generic
equivalents. Though it is not absolutely proven that more androgenic OCs are
worse for a woman’s skin, given that there is a choice, there is usually no
reason to pick a pill that acts like testosterone in the body.
Yasmin®, has been available in the U.S. for a little more than a year. The
progestin (progesterone-like hormone) in Yasmin is very similar to
spironolactone. However the relative dose of spironolactone is quite low so
taking Yasmin is probably about the same for acne as other non-androgenic OCs.
In one study it worked just as well as Diane 35. Blood clots have been reported
with Yasmin but it is not clear that they are any more likely than with other
OCs.
There is some evidence that Yasmin may help PMS so it is often a good choice for
women with mood swings.
Yasmin can usually be taken in combination with spironolactone. Although there
are warnings regarding this because both raise potassium, this is not generally
a problem for women with normal kidneys. As with any medication regimen, this
combination should be discussed with your doctor.
For more on acne and details about treatment directed at the hormonal cause,
see my web article.
(Disclosure: I continue to work with several OC companies
including Berlex, Ortho-McNeil, and Watson.)
Here are some links to articles on The Hormone Center
Website which discuss related subjects:
Alopecia -- Female Hair Loss
Female
Acne and Hormones
PCOS (Polycystic Ovary Syndrome)
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