Hirsutism with oral contraceptives

It has become apparent that reduction in the dose of the constituents of oral contraceptives has markedly reduced mild and severe adverse effects, providing a relatively safe and convenient method of contraception for many young women. Treatment with oral contraceptives has also been shown to be associated with many benefits unrelated to contraception. These include a reduced risk of ovarian cysts, ovarian and endometrial cancer, and benign breast disease. There is a lower incidence of ectopic pregnancy. Iron deficiency and rheumatoid arthritis are less common, and premenstrual symptoms, dysmenorrhea, endometriosis, acne, and hirsutism may be ameliorated with their use. 

A woman with Wilson s disease treated with penicillamine developed severe hirsutism (257). After treatment with oral contraceptives, her breasts enlarged rapidly, and she had cyclic mastodynia. Around the same time she also developed gingival hyperplasia. 

Cyproterone acetate in combination with ethinylestra-diol is indicated for the treatment of women with severe acne and moderately severe hirsutism. This product has been associated with a greater risk of venous thromboembolism than oral contraceptives. However, in a rigorous case-control study the risk of venous thromboembolism with cyproterone acetate + ethinylestradiol was not significantly greater than the risk in women who took conventional oral contraceptives (25). 

There were mild increases in serum triglyceride and cholesterol concentrations in 13 hirsute women treated with triptorelin and a triphasic oral contraceptive, in a randomized comparison of triptorelin with flutamide + cypro-terone acetate (85). Altered lipid profiles have not been described before in patients receiving gonadorelin agonists and oral contraceptives. 

Pazos F, Escobar-Morreale HF, Balsa J, Sancho JM, Varela C. Prospective randomized study comparing the long-acting gonadotropin-releasing hormone agonist triptorelin, flutamide, and cyproterone acetate, used in combination with an oral contraceptive, in the treatment of hirsutism. Fertil Steril 1999 71(l) 122-8. 

Normal sexual activity is associated with ovulation in most female mammals. Compounds affecting this process can adversely affect female libido. Ovarian failure induced by xenobiotic compounds has been associated with a decrease in libido in women. Certain types of oral contraceptives as well as drugs of abuse (methadone, cannabis, alcohol) cause decreases in female libido. The treatment for hirsutism, excessive growth of hair in both normal and abnormal locations, is the compound cyproterone acetate. It is an antiandrogen that has the side effect of severely decreasing libido in women. 

In a 25-year-old woman with Wilson s disease, treatment with penicillamine (1.5 g/day) was first followed by the development of hirsutism, mainly of the face (255). After she started to use an oral contraceptive, her breasts enlarged rapidly and she experienced cyclic mastodynia in addition, gingival hyperplasia developed. All symptoms improved on withdrawal of penicillamine, but additional mammoplasty was needed. 

D. Combined Oral Contraceptives Combined oral contraceptives exert an antiandrogenic effect when they are used in women with hirsutism that is due to excess production of androgenic steroids. The estrogen in the contraceptive acts in the liver to increase the production of sex hormone binding globulin (SHBG), which in turn acts to reduce the concentration of free androgen in the blood. 

Co-cyprindiol is a mixture of the anti-androgenic progestogen, cyproter-one acetate 2 mg, with ethinylestradiol 35 micrograms. It is used for the treatment of acne and moderately severe hirsutism in women who may also wish to use it as an oral contraceptive, and its contraceptive efficacy is expected to be reduced by the same hepatic enzyme inducers (see Table 28. r, (p.975)) that interact with conventional combined oral contraceptives. The precautions described in this section for the combined hormonal contraceptives with the various drugs listed in Table 28.1 , (p.975), should therefore be followed, see Hormonal contraceptives + Antiepileptics Barbiturates or Phenytoin , p.985. 

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