In this chapter, we look at treatments for the skin and hair symptoms that my patients understandably find so troubling: acne, excess facial and body hair, and thinning scalp hair. We also talk about how to control your symptoms while you are waiting for medications to take effect.
Taking metformin to reverse infertility, as we discussed in chapter 9, lowers your insulin resistance and male hormone levels, and can be helpful for skin and hair problems, too. If you’re trying to get pregnant you’ll need to steer clear of some of the treatments I recommend in this chapter—oral contraceptives, for starters. You should also not use drugs to lower the level of male hormones (antiandrogen drugs) for four to six months before you take a fertility drug, because of the damage they can cause to a growing fetus.
As distressing as it is for many women with PCOS, acne is usually not difficult to treat. When it’s mild to moderate, a fair number of women respond to oral contraceptives, but that’s not the end of your treatment options.
Oral contraceptives are effective weapons against acne in part because they reduce male hormones secretions from your ovaries. Individual women respond differently to different contraceptives, so don’t abandon hope if the first one your doctor prescribes doesn’t work or even worsens the problem. Just move on to the next.
Sometimes switching from one oral contraceptive to another is all that is needed to improve your skin. An oral contraceptive containing 0.03 mg ethinyl estradiol (a synthetic estrogen) and 3.0 mg of the antiandrogenic progestin drospirenone (brand name Yasmin) has been effective in the treatment of cystic acne. Many women who use Yasmin for moderate or severe acne also need to take an antiandrogen, because one Yasmin tablet contains a relatively small dose of the ingredient that fights acne.
Before you start oral contraceptive therapy:
• Make sure you are not already pregnant.
• Consider your medical history. Severe varicose veins, high blood pressure, or severe migraines may mean oral contraceptives are a bad choice for you. Oral contraceptives increase the risk of phlebitis in overweight women. Also, while there is no clear evidence that women who take oral contraceptives are at higher risk of breast cancer, it may be slightly higher in women with a mother or sibling with breast cancer.
• Be prepared to quit smoking. Oral contraceptives and cigarettes are a bad combination. The clotting effect of smoking enhances the risk of heart attack, stroke, phlebitis, and the possible passage of a blood clot from the legs to the lungs.
• Consider other side effects. Oral contraceptives may promote mild weight gain, and in many women some degree of mood changes. Sometimes, switching to another oral contraceptive may be helpful. Side effects and mood changes due to contraceptives vary from person to person.
On the plus side, oral contraceptives:
• Reduce the incidence of ovarian and uterine cancers. This is important for women with PCOS, who have a higher incidence of uterine cancer than other women.
• Reduce the levels of testosterone and free testosterone by suppressing the hypothalamus and pituitary stimulation of ovarian hormone secretion.
• Reduce the incidence of ovarian and uterine cancers.
IF YOU HAVE ACNE …
Everyone these days seems to be an expert on skin care—women’s magazines, books, and Web sites all offer advice on keeping your skin young and fresh looking. Yet in spite of it all many women still harbor misconceptions about how to effectively fight acne. Part of your daily routine may actually be aggravating the problem. Here are a few things to avoid:
1. Excessive washing and scrubbing may worsen acne. It certainly won’t make blackheads go away.
2. Squeezing pimples doesn’t help acne and may even cause permanent scarring. Leave them be!
3. Sunscreens can be bad for acne. Look for products labeled non-comedogenic, which means that they are unlikely to cause whiteheads or blackheads.
For moderate to severe acne, the most commonly used antiandrogen in the United States is spironolactone (Aldactone). It is taken twice a day, often in 50 to 75 mg doses at mealtimes, for a total daily dose of 100 to 150 mg. Most women on this dosage notice improvement in cystic acne three to four months after they start taking the drug.
While spironolactone is an effective drug for severe acne, its side effects can make its benefits hard earned. Before you decided to take it, consider the following:
• Periodic blood testing required. Spironolactone has been used as a diuretic for about fifty years. It may cause increased salt excretion by blocking the effect of an adrenal hormone called aldosterone and it may cause potassium retention. If you decide to use this drug, you’ll need periodic blood tests for electrolytes, including potassium. In rare instances, the blood potassium level may rise and cause muscle cramps and discomfort. For that reason, it is best to avoid antihypertensive drugs such as angiotensin-converting enzyme (ACE) inhibitor—for example, enalapril (brand name Vasotec)—when you’re taking spironolactone. You can still eat foods containing potassium because a normal intake of the mineral does not contribute to a rise in the blood level of potassium.
• Stay hydrated. Make sure you do not become dehydrated or low in salt in hot weather or during strenuous exercise. I recommend eating saltine crackers, a small sour pickle, or any other salty snack before exercise. Drinking excessive amounts of water without salt can dilute the level of sodium in your body and can lead to dizziness and in rare cases water intoxication.
• Spironolactone may make you dizzy when you bend over rapidly or stand quickly, especially if you have a tendency to low blood pressure. If this happens, have your physician check your blood pressure while sitting and then quickly standing up. A significant drop in blood pressure may indicate the need for either a reduced dosage of spironolactone or more salt in your diet.
• Use with an oral contraceptive, that is, unless an oral contraceptive is a bad choice for you because of your medical history. If you don’t use birth control and then become pregnant, you risk damaging the growing fetus. About half the women who take spironolactone without an oral contraceptive have two menstrual cycles a month. This is especially common among women who take at least two 50 mg doses a day or more.
• Some women complain of occasional headaches, mood changes, drowsiness, and breast tenderness. Some women report that their breasts become enlarged. No increased risk of breast cancer, however, has been documented.
• Frequently, a reduced sex drive occurs. A lower sex drive often accompanies lower blood testosterone levels, particularly when spironolactone is used with an oral contraceptive.
• Increased urinary frequency is an annoying symptom that can be lessened by drinking water at times that do not interfere with getting the sleep you need.
About 3 to 4 percent of women with PCOS develop small abscesses caused by blocked sweat glands under the skin. They often require the use of antibiotics. Boils under the arms, if large and recurrent, may have to be drained and removed. If left untreated, this constant source of infection may lead to immunological responses, including arthritis and a condition called amyloidosis.
• Before starting spironolactone treatment, be sure you are not pregnant and will not wish to be for six months after treatment. For the few women who use spironolactone without oral contraceptives, this is mandatory.
In instances of severe acne, dermatologists often recommend isotretinoin (Accutane), but its side effects are significant, and several treatments of four to six months are necessary. Before using Accutane, be sure you are not pregnant, and don’t become pregnant while using it. The side effects include dry lips and skin, and about one woman in ten has some shedding of scalp hair. Less common side effects include depression, feelings of aggression, skeletal and muscle discomfort, and changes and difficulties in vision due mostly to dry eyes.
To reduce the hundreds of miscarriages, birth defects, and abortions associated with Accutane each year, an FDA regulation requires that, as of December 31, 2005, patients taking Accutane and doctors prescribing it must register with manufacturers of the drug and promise to comply with instructions for its use.
The prescription drug Benzaclin topical gel is a popular initial
Women with high insulin levels and irregular periods who are distressed by severe acne, excess facial and body hair, or loss of scalp hair and who do not want to conceive have the option of triple therapy. This consists of a combination of metformin, an oral contraceptive, and spironolactone or another antiandrogen. Triple therapy is very effective for severe skin and hair symptoms in insulin resistant women with PCOS, regardless of their weight. My patients have used triple therapy successfully, but this option means my patient and I need to be extra vigilant about monitoring side effects.
treatment for acne. From 15 to 20 percent of the women who use it develop dry skin.
As a first step you can try oral contraceptives on their own to control excessive growth of facial and body hair, but chances are you’ll need some kind of combination therapy. Only 10 percent or less of women respond well, that is, notice a a significant reduction in hair growth. A combination of oral contraceptives and spironolactone (or other antiandrogen drug) is much more effective. For women with moderate to severe hirsutism, a total daily divided dosage not exceeding 200 mg of spironolactone usually brings things under control, though you may not notice significant improvement (e.g., you only need one electrolysis session a month instead of two) until you’ve been taking the drugs for four to six months. The hair that does return is also finer and lighter in color. Length of treatment varies, depending on how well you respond and whether you wish to conceive. If you do decide you want to get pregnant, stop taking spironolactone at least six months before your first attempt to conceive.
Women with severe hirsutism who do not respond to other forms of treatment have responded to an injection of gonadotropin-releasing hormone (GnRH) agonist combined with an oral contraceptive. I don’t recommend injections alone because of the risk of significant bone loss.
Other antiandrogens include 5a-reductase inhibitors and flutamide. Outside the United States, Diane (a combination of an estrogen and the antiandrogen-progestin cyproterone acetate) is reported to be equal and sometimes superior to the combination of an oral contraceptive and spironolactone. Cyproterone acetate, however, has not been approved by the FDA for use in the United States. Insulin-sensitizing agents, such as metformin, may cause some improvement in hirsutism, but in my experience it takes at least nine to twelve months for any visible improvement.
5a-reductase inhibitors. These include finasteride (Proscar) and dutasteride (Avodart), which work by suppressing 5 alphareductase, the enzyme that converts testosterone to its active form, DHT, at the site of hair growth. While the drugs have been judged safe to use for other purposes, they have not been approved by the FDA for this use in women. In other words, the studies required for approval have not been conducted, though a few reports claim that 5a-reductase inhibitors can be helpful in treating hirsutism and scalp hair loss. The dosage for effective treatment with finasteride was between 2.5 and 7.5 mg daily, while that of dutasteride is 0.5 mg daily. They are mostly used when a treatment with a combination of an oral contraceptive and spironolactone fail. Women with liver problems or abnormal liver chemistries (lab results) should not use 5a-reductase inhibitors, nor should women of reproductive age without the protection of contraceptives, because of the very serious risk of potential of birth defects of fetal male genitalia. Women I have treated with 5a-reductase inhibitors have had few side effects, and the inhibitors work well in controlling scalp hair loss. As of this writing, no large-scale study of their use and effectiveness in women with PCOS has been published. Of the two drugs, it appears to me that dutasteride may be more effective for severe hirsutism and scalp hair loss than finasteride. I have prescribed a combination of dutasteride, spironolactone, and oral contraceptives only when a woman has been very seriously affected by these symptoms.
Flutamide (Eulexin). It is considered by many endocrinologists to be the best antiandrogen available. It works by blocking the binding of testosterone to its receptors, while also affecting the hypothalamus and pituitary. The results are more regular menstrual cycles. The dosage varies, but a low dose of a 125 mg capsule twice a day is usually effective for severe skin or hair symptoms due to PCOS, though some women may need a higher dose—250 mg twice a day. Anyone with a history of liver disease or chemical liver function abnormalities should not take this drug. Like spironolactone, it has not been approved by the FDA for the treatment of hirsutism.
Unfortunately, diarrhea is a frequent side effect. Flutamide, because it can potentially damage your liver, requires careful supervision by the doctor who prescribes it for you. You should report any darkening of your urine, flu-like symptoms, or body itch to your doctor and immediately stop taking the drug. If you take this drug you’ll need regular liver function lab tests, though you may well notice something is not right before a lab test confirms it. I have prescribed flutamide reluctantly for a very small group of patients, because nothing else has been effective in treating their hair loss. The patients avoided becoming pregnant and, with full understanding, balanced its benefits against its risk of the rare but serious side effect of liver failure.
A cream made of 13.9 percent eflornithine hydrochloride (Vaniqa) has been approved by the FDA for the treatment of unwanted facial hair. You apply Vaniqa to your chin and lower portions of your face twice a day. This cream is meant to be used on your face, and on your face only. It blocks an enzyme that permits hair follicles to develop, but has no depilatory effect—that is, it won’t dissolve or get rid of the hair you already have. Generally women start to notice results about three months after they start using the cream. Vaniqa works for most women, and its main side effect is a burning sensation or rash on the skin being treated.
Most women take measures to remove unwanted facial and body hair long before they ask me for help. And they often continue doing so for some time after. It can be weeks or even months before you see visible improvement from drug therapy. The following are some of the mechanical hair removal options readily available.
Shaving. It’s a myth that shaving makes hair grow thicker and faster. Warm water, plenty of soap lather, and a sharp blade produce the best results. Electric razors eliminate nicks, but the shave is not as close and electric razors often causes skin irritation or a rash until your skin becomes accustomed to it.
Bleaching. Facial or body hairs bleached to match your skin color become almost invisible—a nice solution if your skin doesn’t react to the bleach.
Pumice. You can remove fine hair with a pumice stone. I hope I don’t need to tell you not to rub too hard or you will irritate your skin. Wash the area afterward and apply a moisturizer.
Plucking. Because it is slow and painful, plucking with tweezers is usually only for facial hair. Plucking can also irritate or infect hair follicles. The hair-free period following plucking with tweezers is much longer than that after shaving.
Depilatories. Over-the-counter depilatories are available as creams, lotions, gels, roll-ons, and sprays. You leave a depilatory on your skin for a few minutes (check individual product labels for instructions) and then wipe it off, removing unwanted hair with it. Follow the instructions carefully. Depilatories suitable for your body or legs may not be so for your face. They can cause skin irritation and should not be used on skin cuts or rashes.
Waxing. Salons and spas offer this hair removal treatment, though you can do it yourself at home. You apply melted wax on your skin, let it cool, then pull it off, removing embedded hairs with it. As in plucking with tweezers, irritated or infected follicles can result.
Electrolysis. An electrologist inserts a probe at each hair root and kills the hair follicle with a small electrical charge. Electrologists may use one of three methods: (1) direct-current electrolysis; (2) alternating-current thermolysis; or (3) a blend of both. If this sounds like a risky procedure, you’re not far off: In the hands of anyone but a skilled professional, it is. Skin scars, electric shock, and infections can result if it not done properly. It is worthwhile to check the qualifications of anyone who is treating you with electrolysis and determine if she or he is a member of the major professional electrology group, such as the American Electrology Association (AEA). Look into whether your state has a licensing procedure for electrologists. The AEA has voluntary tests and continuing education for professionals. Ask him or her directly about qualifications, experience, and references and rely on your own observations as to whether the person is responsible and clean, has sterile instruments, wears surgical gloves, and so forth. Professionals should use sterilized, single-use disposable needles and practice other precautions, including hand washing and disposable gloves for each treatment.
Hair does not grow back after successful electrolysis, though hair roots not exactly under the hair follicle openings cannot be successfully treated with electrolysis (at least initially). So while it’s a slow and expensive process, it’s worthwhile for many women.
Only a small area of skin is treated on each visit. The number of treatments will vary with hair growth cycles, the quantity and structure of hair being removed, hormonal function, and certain medications. Often some scabbing occurs—a normal and healthy part of the healing process. If you become pregnant, discuss with your physician whether you should continue the use of electrolysis. I recommend that my patients stop.
Home kits for electrolysis are available, but their results do not compare with those achievable by a skilled professional.
Laser hair removal. The FDA has approved laser hair removal, but not claims that the hair removal is “permanent.” That said, laser treatment for a year and a half may produce a 90 percent reduction in hair growth. Initially, for each skin area, you have to have three to five treatments about a month apart. To achieve optimal results, you may need up to eight treatments or more for each skin area. Although laser therapy is more expensive than electrolysis, the skin area treated on each visit is larger and treatment is less time-consuming.
Lasers work on actively growing hair. At any given time, up to a third of the hair follicles in a given area may be dormant and thus unaffected by the treatment. Do not pluck or wax a skin area before laser treatment, because this removes hairs from follicles; it is okay to shave. Lasers work best on women with light skin. It can be helpful to dye blond hairs dark and to wait for deep tans to fade before you have a treatment.
Laser hair removal doesn’t hurt. Some women describe it as akin to having a rubber band snapped against your skin. A topical anesthetic cream can be given in advance if you’re highly sensitive. The area is cleaned and shaved prior to laser treatment. The laser energy passes through the skin and is absorbed by the pigment in the hair follicle. The skin area treated may become slightly reddened or irritated for a day or so. Women with dark skin or a deep tan may have some temporary lightening of skin color. For at least a week before each treatment, avoid medications that make your skin more sensitive to light (tetracycline, St. John’s wort) or lasers (skin care products such as Retin A, Renova cream, and other glycolic or alpha-hydroxy acid preparations). Sun screens are recommended for any area that is to be treated.
Perhaps 7 percent of women with PCOS complain of nipple discharge (galactorrhea), usually in association with infrequent menstrual cycles and hirsutism. The nipple discharge is usually caused by an elevated prolactin blood level, which is due to overactivity of prolactin-secreting pituitary cells (lactotropes) and the presence of pituitary microadenoma that may or may not be found on MRI testing. Some drugs may cause a milky white discharge from the breasts as well. These include a variety of psychotropic drugs, which may increase the prolactin level to some extent. Thorazine, Compazine, and, to a lesser extent, Prozac and verapamil may increase the prolactin blood level. Stopping the drugs, when possible, will cause the nipple discharge to lessen or disappear.
Bromocriptine (Parlodel) is the best treatment. Bromocriptine lowers the prolactin blood level, improves menstrual function, and lightens mood disturbances. After two to three months of treatment, its effectiveness should be assessed. Bromocriptine can be taken at meals in combination with ovulation-promoting medications. Nipple discharge does not always occur when a woman’s prolactin blood level is high. Normal levels of prolactin may occur in association with a milky breast discharge. If a woman is unable to tolerate the initial nausea and light-headedness of bromocriptine, she may tolerate dostinex (Cabergoline) better.
Thinning scalp hair (alopecia) is a traumatic event for any woman. As I mentioned in chapter 1, your scalp becomes visible through your hair after about 20 percent of your scalp hair has been lost. The incidence of alopecia in PCOS varies from 40 to 67 percent. It’s most visible toward the front and top of the head.
Before you hold PCOS responsible, you and your doctor should consider other possible causes. For example, vegetarians who have not eaten any red meat for a relatively long period may have a reduced zinc blood level and consequent hair loss. Genetic, local, age-related, nutritional, chronic diseases, and hormonal factors have to be taken into account. Androgen excess diseases, thyroid diseases (including hypo- and hyperthyroidism), and anemias have to be excluded. Hair loss can be due to a protein deficiency, or deficiencies in folic acid, B-12, or other B-complex vitamins caused by a poor diet or an associated medical condition. An iron deficiency, due to lack of red meat in the diet or heavy menstrual bleeding, may also cause hair loss.
• Corticosteroids (cortisone-like drugs) taken orally, and sometimes the chronic use of topical cortisone preparations for skin conditions
• Lithium carbonate
• Levodopa
• Propranolol or atenolol (brand names Inderal and Tenormin)
• Anti-neoplastic agents
• Cyclosporine
• Propylthioracil (PTU) and another antithyroid drug, methimazole (brand name Tapazole)
• Cimetidine (brand name Tagamet)
• Danazol (used in the treatment of endometriosis)
• Accutane
Of all the skin and hair problems women with PCOS struggle with, scalp hair loss is probably the most difficult to treat. There are drugs that can help reduce loss—specifically a daily dose of spironolactone (no more than 200 mg) and an oral contraceptive.
When scalp hair loss is caused by elevated male hormone levels, it’s difficult to regrow. Sometimes fine hair comes back, but unfortunately that’s uncommon. The best thing you can to is catch it early and get treatment to prevent further loss as soon as possible.
Other treatments for women with PCOS and scalp hair loss involve combining an oral contraceptive with finasteride (Proscar) or dutasteride (Avodart), to which spironolactone may sometimes be added.
Outside the United States, women with alopecia, hirsutism, or acne can use cyproterone acetate, which has not been approved by the FDA, though it’s been used elsewhere for more than thirty years. The FDA may have concerns regarding an increased incidence of phlebitis and thrombotic tendencies and, rarely, adrenal insufficiency. It is combined with ethinyl estradiol in different drugs (Dianette, Diane-35) for women with elevated male hormone levels and alopecia. Diane-35 has resulted in modest improvements in more than half of thirty patients with scalp hair loss that I have followed up. Most of these women went to Canada, where I referred them to an endocrinologist who uses this drug. Experts disagree on the comparative antiandrogenic effects of cyproterone acetate and spironolactone. Generally they seem about equally effective, with cyproterone acetate being minimally more effective in the treatment of scalp hair loss in women with elevated male hormone levels.
The use of minoxidil (brand name Rogaine) in the treatment of alopecia is modestly useful. It must be used daily, however. Take great care with this product—you don’t want any of the solution to drip onto your face. Remember, it promotes hair growth!
Keep in mind that heredity often plays a major role in determining the degree of hair loss and its response to treatment. Normal daily scalp hair loss is between 100 and 150 hairs, and cutting back on the number of times you wash your hair a week won’t affect your hair loss problems.
Some women lose hair seasonally—that is, they shed more hair in the spring and fall months. Also, a woman starts losing some scalp hair as she approaches menopause. This onset of hair loss is visible in many women after the age of forty.
I recommend the following for the care of thinning scalp hair:
• Avoid tugging your hair or anything that causes tugging, such as a headband, braids, or ponytail.
• Don’t play with your hair or curls.
• Don’t use hot or fairly warm blow dryers.
• Eat a balanced diet.