Hormone-Related Disorders and Treatments
Introduction to Hormonal Influences
- Normal physiological increase in progesterone levels during pregnancy, with levels rising 10-fold compared to non-pregnant state, as stated by the American Psychological Association 1
- Thyroid disorders may alter hormone levels, including progesterone, according to the American Psychological Association 2
Contraception and Fertility Treatments
- Oral contraceptives contain synthetic progestins that can affect progesterone levels, as stated by the American Association for the Study of Liver Diseases 3
- Women with elevated progesterone due to certain conditions may require specialized care during pregnancy, and the American Association for the Study of Liver Diseases recommends careful planning 3
- Women with conditions like acute hepatic porphyrias should avoid contraceptive methods involving only progesterone or progestins, as advised by the American Association for the Study of Liver Diseases 3
Diagnostic Testing for Hormonal Disorders
- Elevated levels of 17-hydroxyprogesterone (17-OHP) >200 ng/dl, androstenedione above the upper limit of normal, and DHEAS >100 μg/dl are considered elevated and clinically significant in patients, according to The Journal of Urology guidelines 4
- Normal range for 17-OHP is generally <50 nmol/L (or <200 ng/dl), as stated by the Annals of Oncology and The Journal of Urology guidelines 4, 5
- Androstenedione levels are considered elevated when above the upper limit of normal, with clinical significance in conditions like PCOS, non-classical CAH, and adrenocortical tumors, as per the Annals of Oncology and The Journal of Urology guidelines 4, 5
- The following table summarizes the diagnostic testing for hirsutism:
| Test | Indication |
|---|---|
| Testosterone (total and free) | Initial testing |
| DHEAS | Initial testing |
| 17-hydroxyprogesterone | Initial testing |
| LH/FSH ratio | Initial testing |
| Morning cortisol and ACTH | Clinical suspicion of Cushing syndrome |
| Prolactin levels | Clinical suspicion of prolactinoma |
| Thyroid function tests | Clinical suspicion of thyroid dysfunction |
| Fasting glucose and insulin | Clinical suspicion of insulin resistance |
Conditions Associated with Hormonal Imbalances
- Adrenocortical tumors are characterized by elevated DHEAS (often >3800 ng/ml in younger women), elevated androstenedione, and variable 17-OHP levels, as indicated by the Annals of Oncology and The Journal of Urology guidelines 4, 5
- Polycystic Ovary Syndrome (PCOS) is associated with mildly elevated androstenedione, mildly elevated DHEAS, and normal to slightly elevated 17-OHP, according to the Human Reproduction Update guidelines 6
- Non-classical congenital adrenal hyperplasia (NCAH) is most commonly due to 21-hydroxylase deficiency, and is characterized by elevated 17-hydroxyprogesterone levels, modest elevation of testosterone, and may have elevated DHEAS levels 7
- Cushing syndrome is a rare cause of hirsutism, associated with cortisol excess, central obesity, purple striae, buffalo hump, hypertension, hyperglycemia, and hypokalemia 8
Treatment and Management of Hormonal Disorders
- Initial testing should include testosterone (total and free), DHEAS, 17-hydroxyprogesterone, and LH/FSH ratio (>2 suggests PCOS) 7
- The American College of Obstetricians and Gynecologists recommends that clinicians identify the underlying cause of hirsutism and implement appropriate treatment strategies to address both cosmetic concerns and associated health risks 7
- The American Academy of Family Physicians recommends assessing fasting glucose, insulin levels, and lipid profile in patients with hirsutism, particularly those with polycystic ovary syndrome (PCOS) and insulin resistance 9
- Anti-androgens, such as spironolactone, flutamide, finasteride, and cyproterone acetate, can be used to treat hirsutism, with spironolactone being a common choice, dosed at 25-100 mg daily 9
- The American Academy of Dermatology recommends combined oral contraceptives (COCs) as a first-line treatment for hyperandrogenism, which suppress ovarian androgen production, increase sex hormone-binding globulin (SHBG), and reduce free testosterone levels in women with hyperandrogenism 10
- Lifestyle modifications, including weight loss if overweight or obese, regular exercise, and stress reduction, are recommended as part of the management plan for hyperandrogenism 10
Special Considerations and Precautions
- Women with epilepsy have a higher prevalence of PCOS (10-25%) than the general population (4-6%) 7
- The American Academy of Allergy and Clinical Immunology advises against the use of ACE inhibitors in patients with hyperandrogenism, as they may worsen the condition 11
- The American Academy of Allergy and Clinical Immunology recommends discussing alternative treatments with women planning pregnancy, as androgens are contraindicated during pregnancy due to the risk of fetal virilization 11
- Reducing hydrocortisone below 10mg total daily dose significantly increases the risk of adrenal crisis, as reported by the Journal of Internal Medicine 12
- Discontinuing hydrocortisone despite side effects could be life-threatening, as warned by the Journal of Clinical Oncology 13
- During illness, surgery, or significant physical stress, hydrocortisone dose should be increased, as recommended by the Journal of Clinical Oncology 13