СПКЯ — тестовый контроль по американски

СПКЯ — тестовый контроль по американски

Написано 09.04.2015
Галина Афанасьевна Мельниченко

Простенькая задачка с очевидным диагностическим ответом , но с любопытными разъяснениями по лечению ( это рассылка Essential Endocrinology )

Девушке 19 лет, жалуется на нерегулярные менструации и гирсутизм, менархе с 11 лет,цикл 45 — 60 дней, акне с 11 лет, с пубертата избыточный рост на лице ,по белой линии живота , чем пациентка обеспокоена и планирует лечение . Половая жизнь с предохранением ( презерватив ) Прием лекарств и какие -либо серьезные заболевания отрицает

АД 124/70 mm Hg, вес 68.2 kg, рост 168 cm(BMI = 24.2 kg/m2). Умеренно выраженные акне , Ferriman-Gallwey шкала 19 (normal ≤9). Acanthosis в области шеи и подмышек . Молочные железы и живот без особенностей .

TSH = 2.12 mIU/L

Prolactin = 8.2 ng/mL (0.36 nmol/L)

FSH = 6.2 mIU/mL (6.2 IU/L)

Testosterone = 112 ng/dL (3.9 nmol/L)

17-Hydroxyprogesterone (8 AM) = 127 ng/dL (3.8 nmol/L)

Total cholesterol = 197 mg/dL (5.10 mmol/L)

Triglycerides = 134 mg/dL (1.51 mmol/L)

HDL cholesterol = 43 mg/dL (1.11 mmol/L)

LDL cholesterol = 140 mg/dL (3.63 mmol/L)

Hemoglobin A1c = 5.1% (0.051)

УЗИ органов малого таза : объем яичников более 10 mL с обеих сторон и более 12 фолликулов 2 to 10 mm в каждом яичнике .

Which one of the following is the best treatment for control of this patient’s hirsutism?

A. Spironolactone

B. Finasteride

C. Metformin

D. Hormonal contraceptives containing ethinyl estradiol and drospirenone

E. Hormonal contraceptives containing ethinyl estradiol and norethindrone

Ответ : E был для меня не вполне понятен — знаю , что у дроспиренона невелик антиандрогенный эффект ( что речь идет о СПКЯ , понятно ) , но объяснение было покруче

This patient has polycystic ovary syndrome (PCOS) causing hirsutism. Hormonal contraceptives are the treatment of choice in women with PCOS and hirsutism that causes distress. The hormonal contraception acts by suppressing LH levels and therefore suppressing ovarian androgen production from the ovarian theca cells. In addition, the estrogen increases SHBG, decreasing the bioavailable androgens in serum. The progestins in hormonal contraceptives are derived from testosterone and have some androgenic activity in laboratory assays. The choice of a hormonal contraceptive with ethinyl estradiol and norethindrone, a less androgenic progestin, is a good choice for the patient (Answer E). However, it should be noted that there is no evidence that contraceptives with less androgenic activity are better for treatment of hirsutism.

Drospirenone is an analogue of spironolactone and acts as a competitive antagonist at the androgen receptor; it inhibits LH and increases sex hormone–binding globulin. Based on this antiandrogenic activity, hormonal contraceptives containing drospirenone are often favored for treatment of hirsutism. However, the antiandrogenic activity in drospirenone is very weak, equivalent to 25 mg of spironolactone. Furthermore, the largest randomized controlled study in Indian women demonstrated a similar improvement in Ferriman-Gallwey score with drospirenone-containing hormonal contraceptives compared with desogestrel-containing hormonal contraceptives. In contrast, treatment with cyproterone acetate, which is not available in the United States, resulted in the greatest improvement in Ferriman-Gallwey scores. A recent meta-analysis published in the British Journal of Obstetrics and Gynaecology demonstrated that drospirenone is associated with a higher risk for thromboembolism than other progestin-containing contraceptives. Therefore, drospirenone-containing contraceptives (Answer D) would not be the treatment of choice.

Metformin (Answer C) is not effective in the treatment of hirsutism, which is this patient’s main concern. In the absence of diabetes or impaired glucose tolerance, there is no indication for metformin for the treatment of hirsutism in PCOS. Spironolactone (Answer A) acts as a competitive inhibitor of the androgen receptor and inhibits 5α-reductase activity. Finasteride (Answer B) blocks 5α-reductase activity in the skin. Although both are effective in the treatment of hirsutism, neither treatment is considered first-line therapy. Further, both spironolactone and finasteride must be used in combination with birth control because they can cause anomalies of genitourinary development in a male fetus. Of note, metformin, spironolactone, and finasteride are all used off-label for treatment of PCOS.