HIRSUTISM AND ACNE

Women's Health Center 555 Midtowne St. Suite 300 Grand Rapids, MI 49503 (800) 695-5941 (616) 774-2030

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Hirustism (excessive sexual hair) and Acne do not occur in isolation. They are nearly always associated with other medical conditions. Treatment needs to be directed at all the underlying condition if the treatment of the excess hair and acne is to be successful.

Anovulation, Infertility, Obesity, Insulin Resistance, Metabolic Syndrome, “PCOS”, Elevated Cholesterol, and Heart Disease are associated symptoms and conditions that often require treatment.

Effective treatment for Hirsutism and Facial Acne starts with an understanding of how excess sexual hair occurs and what it may be telling us about overall health. Effective treatment includes the control of the causes of excess sexual hair growth before the removal of the existing hair.

This brochure will help you understand your condition. It will help you formulate a total prevention and treatment approach to hirsutism and facial acne.

Definitions and a little medical information

Hirsutism: The maturation to a male hair pattern of sexual hair to a degree not desirable for the woman

Ovulation: The growth and release of an oocyte (egg). Most women with regular cycles ovulate. A woman starts many oocytes each month but only ovulates one. The rest die.

Follicle: The structure in the ovary where an oocyte matures or dies. It is fluid filled (a cyst) normal structure.

Estradiol: The primary female hormone, it blocks the activity of Testosterone and DHT.

Progesterone: The other female hormone, but only after ovulation. It does not impact testosterone or DHT action.

Testosterone: The primary male sex hormone. Excess testosterone in a woman leads to sexual hair maturation and facial acne. Androgen is the term for all male hormones.

DHT (DiHydroTestosterone): The metabolite of Testosterone that causes sexual hair maturation and facial acne.

Obesity: A ratio of weight to height that exceeds 150% or a BMI of 30.

Central Obesity: Tendency for obesity in the abdomen instead of the hips and thighs.

Insulin Resistance: The cells in the body respond inadequately to Insulin. This may be genetic and/or physiologic (Obesity), causes Adult Onset Diabetes Mellitus (AODM).

Polyfollicular Ovaries: The presence of an elevated number of early follicles. Common in younger woman, it decreases with age.

Anovulation: The ovaries are not being stimulated to mature an oocyte. This results in irregular cycles and infertility. There are many causes. An evaluation by a doctor is indicated. All anovulatory women have an elevated ratio of testosterone to estradiol.

Metabolic Syndrome: Inherited condition with varying components. Unifying triad is Insulin resistance, elevated cholesterol, and a propensity to Central Obesity. Predisposes to anovulation and hirsutism, AODM (type 2), and vascular heart disease.

Polycystic Ovary Syndrome (PCOS): Term applied to anovulatory woman with Metabolic Syndrome. It is important to realize that PCOS is a result of the underlying problems, not the cause of the problems.

Cholesterol: A protein – lipid complex, Low Density (LDL) cholesterol predisposes to heart disease. High Density (HDL) cholesterol helps prevent heart disease.

Hypertension: High blood pressure, a common complication of Obesity and AODM. Hypertension, elevated cholesterol, and AODM increase the risk of Heart Disease.

Sexual Hair

Sexual Hair maturation begins at puberty with the increase in male hormones (androgens) from the adrenal gland and ovary. The hair follicles in the Axillary and Pubic area are the initial hair follicles to respond to androgens because they are the most sensitive to DHT. There are genetic and ethnic differences in the sensitivity of the hair follicles. Mediterranean and Africans are more sensitive than Asians and Scandinavians. In most ethnic populations facial, breast, chest, back, and abdominal sexual hair maturation requires levels of DHT that do not occur in healthy ovulatory woman without metabolic syndrome. The presence of mature sexual hair outside of the axillary and pubic regions warrants evaluation of ethnic background, ovulation status, and metabolic syndrome risk before a treatment plan is established. Treatment of mature sexual hair without treatment of the underlying cause for the maturation of sexual hair will NOT be effective in permanently resolving the problem.

Facts about hair follicles:
• There is NO difference in the number of hair follicles between sexes
• There is a difference based on race/ethnicity
• There are genetic/ethnic differences in production of DHT
• There are genetic/ethnic difference in receptors for DHT
• Not all hair follicles mature at the same pace. At any location there will be sexually immature hair follicles that will mature if given the opportunity.

The maturation of the hair follicle or the Pilosebaceous apparatus includes not only the hair follicle itself but also the sebaceous glands, and arrector pili muscles. Therefore sexual maturation of a hair follicle is linked to the maturation of the accompanying sebaceous gland and the predisposition to acne. Acne tends to occur in regions of the body that have enough androgen stimulation to cause sexual hair maturation.

Factors that cause excessive Sexual Hair Maturation

Some factors are in your genes. The genetic ethnic component determines the activity of the enzyme that converts testosterone to DHT and the activity of the DHT receptor. This activity is “preprogrammed” and can not be changed. There are medications that can block these activities.

Indirect genetic influences are “controllable”. They are related to the predisposition to Metabolic Syndrome. A woman with metabolic syndrome “genetics” who becomes overweight is less likely to ovulate, will have higher androgen levels, will have insulin resistance, may be hypertensive, and may have high LDL cholesterol. As a result her hirsutism and acne will be more severe. She will be more likely to develop heart disease. All of these conditions occur at a younger age with smoking. Smoking cessation, weight control, regular exercise, and medications all will improve the hirsutism and acne. Some of the medications will also lower the risk of heart disease and peripheral vascular disease.

With proper treatment good complexion and good health go together.

(Page 4)Evaluating Your Risk

1) I have excessive hair growth in the following areas of my body:

A) _______ Facial ______Abdomen _______Thighs ______ Breasts

B) _______ Chest ______ Back _______ Buttocks ______ Arms/Legs

Height _______ Weight _______

2) My excess weight is:

A) More in Thighs/Hips ______ B) More Abdominal _____ C) Both ________

My cycles: A) Have always been Regular______ Irregular in past - now regular ______

B) Used to be regular / not now _______ Never have been regular________

I have: Elevated Cholesterol: A) No ______ B) Yes _____ C) Don’t know ________

High blood pressure: A) No ______ B) Yes _____ C) Don’t know ________

Diabetes: A) No _____ B) Yes ______ C) Don’t know ________

I never smoked_________ B) Still smoke _____pack/day C) I Quit _____ yrs ago

Family History

My mother has: Central Obesity____ Hypertension____ AODM____ Heart disease____

My father has: Central Obesity____ Hypertension____ AODM ____ Heart disease____

My grandparents have the following health issues (1 check for each grandparent):

Central Obese _______ Hypertensive _______ AODM ______ Heart Disease ______

Other women in my family have excess sexual hair: A) No ________ B) Yes________

I am presently on the following medicines:__________________________________________


Medicines I have used in the past for this problem but don’t like – reason:



If you have checked any of the “B” or “C” answers above or have more than 4 checks in the family history section (2 checks if you only know your parents history) then you are at risk for additional health problems. You should make an appointment with one of the physicians affiliated with the Women’s Health Center, and listed on the brochure, before embarking on a specific treatment to remove sexual hair or treat acne or acne scarring. Even if you only checked the “A” boxes you may wish to seek an opinion from one of the physicians before proceeding.

Adjunctive treatments for Hirsutism (page 5)

Treatment of hirsutism and Metabolic Syndrome is multifaceted. It is aimed at the production of the androgens, at the receptors that respond to the androgens, or at the underlying “drivers” of androgen. It is the “drivers” that impact your long term health.

Obesity: Nothing is as important for the long term health of a woman with obesity as weight loss and weight loss maintenance, especially for central obesity. Losing weight lowers LDL- cholesterol, improves hypertension, decreases insulin resistance, and decreases the peripheral conversion of weak sex steroids to testosterone and estrone. Weight loss may even restore ovulation. In women with anovulation and obesity there is a “double drive” to androgen production from the ovary and from peripheral conversion of weak sex steroids. Only weight loss has the potential to decrease both. Weight Watchers or a similar program is a good option. A 30 pound weight loss is excellent adjunctive therapy to electrolysis or laser for hair removal or to microdermabrasion or Obagi Blue peel treatment for acne scarring.

Elevated cholesterol: LDL cholesterol is the main “driver” of atherosclerotic vessel disease leading to heart disease and stroke. A woman with metabolic syndrome and insulin resistance may require medications to lower LDL-Cholesterol. The medication should be discussed with your physician. “Statin” drugs may also lower androgens by decreasing the availability of LDL-cholesterol to the adrenal gland.

Insulin resistance: The link between insulin resistance, metabolic syndrome, and anovulation is well established. There may be benefits to treating insulin resistance with Metformin® or other medications in ovulatory women. Once a weight loss program has been established Metformin® augments diet control. Insulin resistance is associated with high production of androgens and increased androgen receptor activity. Lowering insulin resistance improves symptoms of hirsutism.

Hypertension: Hypertension does not lead to hirsutism but is a common companion to metabolic syndrome and obesity. If blood pressure is elevated then treatment is warranted. Starting with the “old fashion” Hydroclorothyazide - spironolactone diuretics is an appropriate treatment. Spironolactone is a good anti-androgen.

Cigarettes: Cigarettes contribute to hirsutism symptoms in a variety of ways. A 30 year, 1 pack per day smoker will have menopause 3-5 years earlier than a non-smoker. Acceleration of vascular disease after menopause is a risk for any woman, but a woman with metabolic syndrome, central obesity, elevated cholesterol, and hirsutism is at far greater risk and may develop heart/vascular disease before menopause. Cigarettes and nicotine accelerate microvascular disease of the skin leading to premature skin aging, loss of normal elasticity, and abnormal Pilosebaceous function which can lead to either hirsutism and alopecia (hair loss). Smoking cessation should always be part of treatment.




Directed Treatments prior to electrolysis or laser therapy (page 6)

Control of anovulation – ovulation function: Weight loss and Metformin® may help a woman regain ovulation but some woman will remain anovulatory. Frequently these women have polyfollicular ovaries, ie too many oocytes. Since anovulation leads to excessive androgen production a patient with anovulation needs additional treatment. The traditional birth control pill is a good treatment, but if this leads to excessive calorie intake and weight gain it can be counter productive. A sequential estradiol – estradiol & progesterone treatment program is an option. The evaluation and treatment of anovulation should be made by a physician.

Androgen & Androgen receptor blockage: Many medications are available in the USA and even more overseas. All anti-androgen medications can feminize a male fetus and therefore should be used with effective contraception. The combination of the BCP and one of these medications is the treatment of choice. Spironolactone 50mg three times a day is as effective as the newer medications and considerably less expensive. The only negative is the three times a day dosing. As a diuretic it helps prevent water retention in women who are dieting and on BCP. Combined with hydrochlorthiazide, spironolactone can be an effective treatment for hypertension. The decision to use spironolactone or another anti-androgen is made by the patient and her physician.

Summary:

To maximize the benefit of electrolysis or laser hair removal it is important to treat the underlying “drivers” of androgen activity for 2- 4 months. Even 1 month of treatment with caloric control and an anti-androgen will give better results than electrolysis or laser hair removal alone. The treatment of hirsutism is most effective when there is a multidiscipline approach to ALL the factors leading to sexual hair maturation. Treating the hirsutism and the underlying causes can change your life.



You can be evaluated at Grand Rapids Fertility by calling 1-800-695-5941 or 616-774-2030












Electrolysis and Laser Hair Removal(page 7)

There are two treatment options for hair removal; electrolysis (permanent hair removal) and laser hair reduction. Both offer relief and can be useful in specific settings. If the underlying causes of hirsutism remain untreated new hair follicle maturation will occur after either treatment.

Laser hair reduction has been approved by the FDA for permanent hair reduction on most areas of the body. The term reduction is applied because research has not proven conclusively that hair growth is permanently prevented. The laser creates a monochromatic beam of high energy light. When this beam is applied to hair that is a color similar to that monochromatic amplification a thermal effect occurs. Heat is absorbed by the hair and conducted down the hair shaft destroying the germination cells. The laser is only effective on dark hair and light skin. Light blond, gray and light red hair is untouched by the laser beam. Dark or tan skin absorbs the amplified light and results in removal of pigmentation and possibly tissue burn. The laser is not recommended for skin types III or IV on the Fitzpatrick scale without pretreatment with skin bleach. Types V and VI are not recommended for laser treatment because of the high risk of damage.

Electrolysis is FDA approved for permanent hair removal. It is effective on all skin types and all types of hair. Electrolysis was developed in 1869 by an ophthalmologist for the treatment of trichiasis. It is accomplished by inserting a fine probe, matching the diameter of the hair, beside the hair and into the follicle. A very small amount of direct electric current is applied. This causes a chemical reaction that creates a microscopic pool of sodium hydroxide within the follicle. This pH imbalance causes a denaturing of the cells lining the follicle wall, including the growth germination cells in the lower half of the follicle. The skin normalizes this pH imbalance and there is no permanent effect to surrounding tissue.

Both laser and electrolysis treatments require the completion of at least one growth cycle in the area of treatment. These cycles have been documented from as short as 16 weeks on the upper lip to as long as eight months on the chin. If androgen suppressive treatment is not given in future growth cycles new androgen hair growth may occur.

As these descriptions imply laser can treat large areas of growth in short periods of time in appropriately selected patients. While electrolysis is an exact treatment often taking hours to complete but can be used regardless of the skin or hair characteristics. Each serves a purpose in the treatment of hirsutism. Assessment by a qualified professional will determine which treatment or combinations of treatments will serve the patient best.






Treatment of acne and post acne scarring (page 8)
Information provided by Pending



 

DOUGLAS C. DALY, M.D.

Douglas C. Daly, M.D., is a graduate of the University of Connecticut School of Medicine and completed his Reproductive Endocrinology Fellowship in 1982 at the same institution.  Board Certified in Obstetrics, Gynecology and Reproductive Endocrinology, Dr. Daly is a Fellow of the American College of Obstetrics and Gynecology (F.A.C.O.G.) and a member of the American Society of Reproductive Medicine (ASRM).  In 1991 he assumed leadership of the Assisted Reproductive Program at Blodgett Memorial Medical Center, now known as Spectrum Health East. This program maintains membership in the Society for Assisted Reproductive Technology (S.A.R.T.) and abides by the regulations and guidelines of this organization.  Dr. Daly is also a Clinical Associate Professor in Obstetrics and Gynecology at Michigan State University (MSU). He is an active staff member of Spectrum Health Downtown (Butterworth) and St. Mary's Hospital.

CONCLUSION

We hope this brochure has been helpful in providing basic information about our practice. If you need additional information, any of our staff will be happy to help you.  Our goal is to provide you with the highest quality care available.