Hyperandrogenism - Causes, Symptoms and Treatment .MF .
Hyperandrogenism - a condition associated with excessive secretion of androgens and / or enhance their impact on the body that women most often seen virilization (the appearance of male characteristics), male gynecomastia (breast enlargement) and impotence.
Androgens - the name of the group of steroid hormones, produced mainly by the testes in men and ovaries in women, as well as the adrenal cortex.To include androgens, such as testosterone, 17-OH-progesterone (oksiprogesteron), DHEA-sulfate, etc.
Of all endocrine diseases in gynecological practice most common thyroid disease and considered us hyperandrogenism.To understand this problem, a little diagram to describe the synthesis of androgens, as much as possible to simplify it:
The whole process is controlled by hormones of the pituitary gland - ACTH (adenokortikotropnym hormone) and LH (luteinizing hormone).
synthesis of steroid hormones begins with the conversion of cholesterol to pregnenolone.It is important to understand the following - this p
Other processes in varying degrees occurs in all organs related to steroidogenesis, but the output in different organs are produced as the same or different steroid hormones.You can figure it out in this simplified scheme:
This scheme is simplified.There does not appear much of the data produced by steroids authorities.It draws only the most important and final products.
In addition, it is necessary to add that the production of steroid hormones can occur not only in these bodies, but also in the periphery.In particular, for the important role of women in the production of steroids plays subcutaneous fat.
symptoms of hyperandrogenism
Among all the symptoms of hyperandrogenism prevail following:
- Hirsutism - excessive hair growth in women, the so-called body hair male pattern, is the most common sign of hyperandrogenism.On it you can talk with the appearance of hair on the abdomen at the midline, on the face, chest.However, the color may be a receding hairline.
should distinguish between the symptom of hypertrichosis - excessive hair growth is not dependent on androgens, which can be either congenital or acquired (in various diseases, such as porphyria).It should also pay attention to the racial affiliation of the patient - so eskimosok women and immigrants from Central Asian body hair is more pronounced than in women in Europe or North America.
- Acne, skin peeling - cosmetic defect, which usually is concomitant with other, more serious symptoms.
- Opsooligomenoreya (shortened and separated by long periods of monthly), amenorrhea (absence of menstruation) and infertility - often this symptom occurs with polycystic ovaries, accompanied by hyperandrogenism.
- Obesity - characteristic for ovarian pathology, and for the pathology of the adrenal glands.
- atrophy of muscles, abdominal muscles, osteoparoz, atrophy of the skin - the most characteristic of Cushing's syndrome (or Cushing's in Russian literature).
- high risk of infections - is associated with a reduced immune response of the body, due to inadequate gormonproduktsiey.
- Impaired glucose tolerance - mainly in lesions of the adrenal glands, often the same and pathology of the ovaries.
- Formation of the external genitalia of intermediate type (hypertrophy of the clitoris, urogenital sinus, partial fusion of the labia majora) - is detected immediately after birth or in early childhood period;often in congenital adrenal hyperplasia.
- Arterial hypertension, myocardial hypertrophy, retinopathy (nevospolitelnoe retinal damage).
- Depression, drowsiness, fatigue - is due above all to the fact that impaired secretion of adrenal glucocorticoids.
Causes of hyperandrogenism
State, accompanied by hyperandrogenism:
Polycystic ovary syndrome (Stein-Leventhal syndrome) - a combination of amenorrhea and bilateral multiple ovarian cysts.This is most common: menstrual disorders, infertility, hirsutism and obesity.Diagnosis is made by the presence of hyperandrogenism and chronic anovulation.Increased risk of insulin resistance and giperinsulinemii, diabetes occurs in 20% of patients.
ultrasound in PCOS
Cushing's Syndrome - condition characterized by an excess production of glucocorticoids by the adrenal glands.Most patients have an increase in weight with the deposition of fat on the face (moon face), neck, torso.Characteristic: hirsutism;menstrual dysfunction, infertility;atrophy of muscles, osteoporosis;immunoresistance reduction;impaired glucose tolerance;depression and psychosis;male - possibly gynecomastia and impotence.
syndrome have the following options:
A. ACTH (a hormone produced by the pituitary gland adenokortikotropny) dependence syndrome:
Pituitary - most pituitary tumor lesion
Ectopic - ACTH secretion (or corticotropin) a tumor of any localization
B. independent of ACTH syndrome:
adrenal -cancer, adenoma or hyperplasia of the adrenal cortex
Exogenous - self glucocorticoid drugs or treatment other pathologies, the forced taking of these drugs
Congenital adrenal hyperplasia cortex - inherited genetic disorder.Are important the following forms:
- deficiency of 21-hydroxylase (90-95% of cases) - a common cause of failure is the aldosterone.Characterized by: acidosis (shift of acid-base balance in the body in the direction of increasing acidity);pathology of the external genitalia.
- 11β-hydroxylase deficiency - a violation of the formation of cortisol.It is characterized by: a classic form - virilization, hypertension, myocardial hypertrophy, retinopathy, pathology of external genital organs;non-classical form - hirsutism, acne, menstrual disorders.
- Insufficiency 3 β-hydroxysteroid - it can be suspected with an increase in the levels of dehydroepiandrosterone and dehydroepiandrosterone sulfate under normal or slightly elevated levels of testosterone and androstenedione.
Androgensekretiruyuschie ovarian tumors and adrenal - often this pathology is characteristic of people with severe virilization or with its sharp appearance and rapid progression.This increase in testosterone levels more typical of ovarian cancer, and increase the level of dehydroepiandrosterone sulfate - for adrenal tumors.The most common in:
ovarian granulosa tumors,
Steroidokletochnyh ovarian tumors (lyuteoma beermennosti, leydigoma),
Adeome adrenal glands - 90% of all ovarian tumors, which are characterized by production of androgens only.
stromal hyperplasia and ovarian gipertekoz - occurs most often after 60-80 years.Increased ratio of estradiol and estrone.Characterized
: hyperandrogenism, obesity, hypertension, glucose violation tolerantnostik and endometrial cancer.
The above pathology often accompanied by hyperandrogenism, but this list is significantly extended.Since it is impossible to describe all in one article, we considered it prudent to introduce the basic pathology.
Diagnosis of hyperandrogenism
The first and foremost method in the diagnosis of hyperandrogenic conditions is a laboratory blood test on the content of the level of steroid hormones.Retreating not for long aside, give performance standards for steroid hormones in the blood:
standards for women:
Testosterone - 0.2-1.0 ng / ml or 0.45 - 3.75 nmol / L
Estradiol -0.17 ± 0,1nmol / l - follicular phase, 1,2 ± 0,13nmol / l-ovulation, 0.57 ± 0,01 nmol / l - luteal phase.
Progesterone - 1.59 ± 0,3 nmol / l - follicular phase, 4.77 ± 0.8 nmol / n- ovulation, 29.6 ± 5.8 nmol / l - luteal phase
Cortisol - 190-750 nmol / L
Aldosterone - 4-15 ng /ml
In addition, it is necessary to know the rules of hormones that affect the production of steroids:
LH - follicular phase - 1.1 - 11.6 mIU / l, ovulation 17 - 77 mIU / l, luteal phase 0 14.7 mIU /l
ACTH - 0 - 46 pg / mL FSH
- follicular phase-2,8-11,3 mIU / l, ovulation - 5.8 - 21 mIU / l, luteal phase - 1.2 - 9.0 mIU /l
a variety of diseases, which are accompanied by hyperandrogenic conditions, predisposes consideration diagonstiki methods (as well as treatment) for each disease.Consider the diagnostic methods described above pathologies:
Polycystic Ovary Syndrome (PCOS):
data history and exam (see above.)
blood test for hormones - usually observed alignment of testosterone and LH ratio;the ability to change the level of FSH;in 25% of cases giperprolaktinemiya;increase the level of glucose
US - enlargement of the ovaries and bilateral multiple cysts
Laparoscopy - rarely used, usually with pain syndrome of unknown origin, when for some reason it is not possible to perform ultrasound
The general analysis of blood - leukocytosis;lymphopenia and hypoeosinophilia.
blood test for hormones simultaneous excess of hormones synthesized by the adrenal glands.
ultrasound study - perhaps for the diagnosis of ectopic forms (detection of tumors located outside the adrenal gland), adrenal and shapes (for diagnosis of large adrenal tumors).
MRI (magnetic resonance imaging) - a suspected oncology, with uninformative ultrasound.
craniography - X-ray of the skull in 2 projections for the diagnosis of abnormalities of the pituitary (sella deformation - a place pituitary location in the sphenoid bone of the skull).
Congenital adrenal hyperplasia:
Increase 17-hydroxyprogesterone serum with 21-hydroxylase deficiency (above 800 ng%);possible to carry out tests with ACTH.It is important to note that this state can be detected in fetuses before birth and to begin treatment in the womb - diagnostics at high risk of this pathology is the study of amniotic fluid in the levels of progesterone and androstenedione.
the ACTH stimulation test as conducted for the diagnosis of disease and 11β-hydroxylase and 3 β-hydroxysteroid dehydrogenase.
blood test for hormones - raising the level of androgens - testosterone for ovarian tumors;dehydroepiandrosterone - for
adrenal tumors pelvic ultrasound - for ovarian tumors.
CT (computed tomography) and MRI - especially for tumors of the adrenal glands.
adrenal vein catheterization with the definition of the level of testosterone - a controversial method, because of the large number of complications.
scintigraphy the abdomen and pelvis with I-cholesterol.
stromal hyperplasia and ovarian gipertekoz:
blood test for hormones - the levels of ovarian androgens are usually the male norm.
level of gonadotropins is usually normal - differential diagnosis of PCOS
Treatment of hyperandrogenism
A. Medroxyprogesterone - effective for hirsutism.20-40 mg / day or 150 mg INT intramuscularly 1 every 6-12 weeks.
B. Combined perooralnye contraceptives - reduce the secretion of steroid hormones, reduce hair growth in 70% of patients with hirsutism, acne cure, utsranyayut dysfunctional uterine bleeding.Preference is given to the PC with a weak androgenic action: desogestrel, gestodene and norgestimate.
B. Glucocorticoids - deksametozon - 0.25 mg / day (no more than 0.5 mg / day).
G. Ketoconazole - 200 mg / day - inhibits steroidogenesis.
D. Spironalakton 200 mg / day for 6 months.- Improvement in 70-80% of patients - with hirsutism;possible violation of the menstrual cycle
Surgical treatment - the ineffectiveness of drug treatment:
A wedge resection of the once popular, now this method is not so often used in hospitals
B. Laparoscopic ovarian electrocoagulation - coagulate (cauterize) the ovary in 4-8 points electrode
A. Drug treatment - unfortunately, in many cases, diagnosis is made very late.Medication is increasingly seen as a preparation for the operation, rather than as an independent method of treatment.Apply steroidogenesis inhibitors ketoconazole often - 600-800 mg / day
B. Surgical treatment - produce a prostatectomy, which, when microadenomas (less than 1 cm tumor size) positive results were observed in 80% of patients;for macroadenomas - 50%.
B. Radiation therapy - usually with pituitary disease.Positive results in adults in 15-25% of cases.
ACTH independent - often the only radiukalny treatment for tumors of the adrenal glands - operation with the subsequent appointment of glucocorticoids in the postoperative period, and mitotane, to prevent recurrence.
Congenital adrenal hyperplasia:
Deksametozon - to suppress ACTH secretion in a dose of 0.25 - 0.5 mg / day orally.Were treated under the control of cortisol (if the level of not less than 2 mg%, the treatment is effective without further complications in the hypothalamic-pituitary axis).
mentioned above that the identification of disease and its treatment is possible even in the womb (for 21-hydroxylase deficiency).Deksametozon applied in a dose of 20 mg / kg / day in 3 divided doses.At high risk of formation of pathology in the child's treatment begins with the detection of pregnancy.If the fetus is a male - treatment is stopped if the female - continue.If treatment is started before 9 weeks of pregnancy and before delivery - the risk of the formation of the pathology of genitals is much less.This treatment regimen is a matter of dispute experts pointing out that a large number of possible complications to the mother at a rather low efficiency of the treatment.
Androgensekretiruyuschie ovarian tumors and adrenal
Treatment only cancer hospital, most often surgery in combination with chemotherapy, radiotherapy or hormone therapy.Forecast of treatment depends on the diagnosis of the time and nature of the tumor itself.
stromal hyperplasia and ovarian gipertekoz:
In mild effective wedge resection of the ovaries.Perhaps the use of GnRH analogues.In severe disease - possibly bilateral amputation of the ovaries in order to normalize blood pressure and correction of impaired glucose tolerance.
With the emergence of symptoms of hyperandrogenism obligatory visit to a doctor.Most often - endocrinologist or gynecologist, the therapist often.Be sure to thoroughly understand the causes of hirsutism and other symptoms, and, if necessary, to send a specialized hospital.
Any self completely and absolutely contraindicated!Valid only hair removal cosmetics.
Hyperandrogenism has no specific preventive measures.The main include adherence to a healthy diet and lifestyle.Every woman must remember that excessive weight loss contributes to hormonal disorders and can lead to both described as well as many others.In addition, we should not get involved in sports activities, that too (especially when taking steroids) can lead to hyperandrogenism.
Rehabilitation require patients with hyperandrogenism tumor genesis, have undergone surgical treatment and chemotherapy.In addition, mandatory consultation with a psychologist, especially for young girls with severe hirsutism and gynecological problems.
spectrum of possible complications in all diseases is very large as described above.It may be noted only some of the most important:
- In congenital pathology of possible anomalies, the most common of them - the abnormal development of reproductive organs.