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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

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.

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.

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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