What are the treatment options for mild adrenal hyperandrogenism?

Treatment Options for Mild Adrenal Hyperandrogenism

For mild adrenal hyperandrogenism, oral contraceptives with anti-androgenic properties are the first-line treatment option, as they effectively reduce androgen levels and improve clinical symptoms. 1, 2

Pathophysiology and Clinical Presentation

Adrenal hyperandrogenism is characterized by excessive androgen production from the adrenal glands, leading to various clinical manifestations:

• Hirsutism (excessive hair growth in a male pattern)
• Acne and seborrhea
• Androgenetic alopecia
• Irregular menstrual cycles
• Rarely, virilization (clitoral hypertrophy, deepening voice)

Diagnostic Approach

Before initiating treatment, confirm the diagnosis through:

• Measurement of circulating androgens (particularly free testosterone)
• Assessment of adrenal androgens (DHEA-S)
• Exclusion of other causes like Cushing syndrome, adrenal tumors, and congenital adrenal hyperplasia

Treatment Algorithm

First-Line Therapy:

1. Oral Contraceptives (OCs)
   • Mechanism: Reduce androgen production, increase sex hormone-binding globulin (SHBG), decrease free testosterone levels 2
   • Effectiveness: Improve hirsutism in 60-100% of women, with significant improvement in acne 2
   • Preferred options: OCs with estrogen-dominant formulations or those containing anti-androgenic progestogens 3
   • Duration: Clinical improvement typically requires 6-12 months of consistent use 3

Second-Line Therapy (for inadequate response):

1. Anti-androgens
   • Options include:
     • Spironolactone
     • Cyproterone acetate
     • Flutamide
   • These can be added to OCs for enhanced effect 1
   • Note: Cyproterone acetate can be used in higher doses (25-100 mg/day) for severe cases 3

Adjunctive Measures:

1. Weight loss for overweight/obese patients

   • Improves insulin sensitivity
   • May reduce androgen levels
   • Ameliorates metabolic consequences 4

2. Cosmetic management for hirsutism

   • Temporary hair removal methods (shaving, waxing, depilatory creams)
   • Permanent hair reduction (laser therapy, electrolysis)

Special Considerations

• Long-term management: Treatment may need to be continued indefinitely, as symptoms often recur after discontinuation 3
• Metabolic monitoring: Patients should be monitored for metabolic abnormalities, as hyperandrogenism is associated with insulin resistance and unfavorable lipid profiles 5
• Fertility concerns: For patients desiring pregnancy, clomiphene citrate is the first-line therapy for ovulation induction 4

Treatment Efficacy Timeline

• Acne and seborrhea: Improvement within 3-6 months
• Hirsutism: Noticeable improvement within 6-12 months
• Androgenetic alopecia: Requires at least 12 months for optimal effect 3

Common Pitfalls to Avoid

• Inadequate treatment duration: Expecting immediate results leads to premature discontinuation
• Overlooking metabolic complications: Hyperandrogenic women have increased risk of type 2 diabetes and adverse lipid profiles
• Failure to rule out serious causes: Adrenal tumors, though rare, require different management approaches
• Monotherapy for severe cases: Combination therapy is often needed for optimal results in moderate-to-severe cases

Remember that while mild adrenal hyperandrogenism can be effectively managed with OCs and anti-androgens, treatment response varies considerably between individuals, and patience is required as clinical improvement develops gradually over months.