Polycystic Ovary Syndrome in Dermatological Practice
Keywords:
polycystic ovary syndrome, hirsutism, hyperandrogenism, acne, obesityAbstract
Polycystic ovary syndrome (PCOS) is a malfunction of the endocrine system, which is the common cause of infertility. This condition contains of high androgen and chronic anovulation resulting in disorders such as acne, hirsutism, obesity, menstrual irregularities, and the risk of other conditions, such as metabolic syndrome, type II diabetes, dyslipidemia, etc. PCOS is common in Thailand. The exact cause of this condition is still unclear. There is evidence from genetic together with environmental factors, causing the increment of androgen level. Diagnosis is made from clinical symptoms, the serum hormonal level and ultrasonography of the ovaries. The treatment focuses on the symptoms of the patient. The main treatment is to reduce symptoms of high androgen, prevention of endometrial thickness, and weight control by promoting behavioral change. The use of medical treatment should be tailored to the individual patient. The treatment requires cooperation from the medical team and the patient.
References
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2. Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol. 2015; 73: 672-90
3. McCartney CR, Marshall JC. Polycystic ovary syndrome. N Engl J Med. 2016; 375: 54-64
4. Waldstreicher J, Santoro NF, Hall JE, Filicori M, Crowley WF Jr. Hyperfunction of the hypothalamicpituitary axis in women with polycystic ovarian disease: indirect evidence for partial gonadotroph desensitization. J Clin Endocrinol Metab 1988; 66:165-72.
5. Balen AH. Hypersecretion of luteinizing hormone and the polycystic ovary syndrome. Hum Reprod 1993;8(suppl 2): 123-8.
6. Ehrmann DA. Polycystic Ovary Syndrome. N Engl J Med. 2005; 352: 1223-36
7. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Work- shop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19-25.
8. Chang WY, Knochenhauer ES, Bartolucci AA, Azziz R. Phenotypic spectrum of polycystic ovary syndrome: clinical and biochemical characterization of the three major clinical subgroups. Fertil Steril 2005;83:1717-23.
9. Wijeyaratne CN, Balen AH, Barth JH, Belchetz PE. Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference? Clin Endocrinol 2002;57:343-50.
10. Archer JS, Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Practice & Research Clinical Obstetrics and Gynaecology. 2004; 18: 737-54
11. Wijeyaratne CN, Balen AH, Barth JH, Belchetz PE. Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference? Clin Endocrinol 2002;57:343-50.
12. Deplewski D, Rosenfield RL. Role of hormones in piloseba- ceous unit development. Endocr Rev 2000;21:363-92.
13. Carmina E, Rosato F, Janni A, Rizzo M, Longo RA. Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab 2006;91:2-6.
14. Conn JJ, Jacobs HS, Conway GS. The prevalence of polycystic ovaries in women with type 2 diabetes mellitus. Clin Endocrinol 2000;52:81-6.
15. Polson DW, Adams J, Wadsworth J, Franks S. Polycystic ovaries—a common finding in normal women. Lancet 1988; 1:870-2.
16. Farquhar CM, Birdsall M, Manning P, Mitchell JM, France JT. The prevalence of polycystic ovaries on ultrasound scanning in a population of randomly selected women. Aust N Z J Obstet Gynaecol 1994;34:67-72.
17. Dockerty MB, Jackson RL. The Stein-Leventhal syndrome: analysis of 43 cases with special reference to association with endometrial carcinoma. Am J Obstet Gynecol 1957;73: 161-73
18. Giudice LC. Endometrium in PCOS: Implantation and predisposition to endocrine CA. Best Pract Res Clin Endocrinol Metab 2006;20:235-44.
19. Solomon CG. The epidemiology of polycystic ovary syndrome. Prevalence and associated disease risks. Endocrinol Metab Clin North Am. 1999 Jun; 28: 247-63.
20. Dunaif A, Segal KR, Futterweit W, Dobrjansky A. Profound peripheral insulin resistance, independent of obesity, in polycystic ovary syndrome. Diabetes 1989;38:1165-74.
21. Lim SS, Norman RJ, Davies MJ, Moran LJ. The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Rev 2013;14:95-109.
22. Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab 1999;84:165-9.
23. Mohiyiddeen L, Watson AJ, Apostolopoulos NV, Berry R, Alexandraki KI, Jude EB. Effects of lowdose metformin and rosiglitazone on biochemical, clinical, metabolic and biophysical outcomes in polycystic ovary syndrome. J Obstet Gynaecol 2013;33:165-70.
24. Toulis KA, Goulis DG, Mintziori G, Kintiraki E, Eukarpidis E, Mouratoglou SA, et al. Meta-analysis of cardiovascular disease risk markers in women with polycystic ovary syndrome. Hum Reprod Update 2011;17:741-60.
25. de Groot PC, Dekkers OM, Romijn JA, Dieben SW, Helmerhorst FM. PCOS, coronary heart disease, stroke and the influence of obesity: a systematic review and meta-analysis. Hum Reprod Update 2011;17:495-500.
26. Dunaif A, Graf M, Mandeli J, Laumas V, Dobrjansky A. Characterization of groups of hyperandrogenic women with acanthosis nigricans, impaired glucose tolerance, and/or hyperinsulinemia. J Clin Endocrinol Metab 1987;65:499-507.
27. Rudman SM, Philpott MP, Thomas GA, Kealey T. The role of IGF-I in human skin and its appendages: morphogen as well as mitogen? J Invest Dermatol 1997; 109: 770-7.
28. Nam SY, Lee EJ, Kim KR, Cha BS, Song YD, Lim SK, et al. Effect of obesity on total and free insulin-like growth factor (IGF)-1, and their relationship to IGFbinding protein (BP)-1, IGFBP-2, IGFBP-3, insulin, and growth hormone. Int J Obes Relat Metab Disord 1997; 21: 355-9.
29. Cruz PD Jr, Hud JA Jr. Excess insulin binding to insulin-like growth factor receptors: proposed mechanism for acanthosis nigricans. J Invest Dermatol 1992;98(6 suppl):82S-5S.
30. Ehrmann DA. Metabolic dysfunction in PCOS: Relationship to obstructive sleep apnea. Steroids 2012;77:290-4.)
31. Barry JA, Kuczmierczyk AR, Hardiman PJ. Anxiety and depression in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod 2011;26:2442-51.
32. Veltman-Verhulst SM, Boivin J, Eijkemans MJ, Fauser BJ. Emotional distress is a common risk in women with polycystic ovary syndrome: a systematic review and meta-analysis of 28 studies. Hum Reprod Update 2012;18:638-51.
33. Buzney E, Sheu J, Buzney B, Reynolds RV, Polycystic ovary syndrome: a review for dermatologists part II. treatment. J Am Acad Dermatol. 2014; 71: 859.e1-15
34. Pasquali R, Antenucci D, Casimirri F, Venturoli S, Paradisi R, Fabbri R, et al. Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol Metab 1989;68:173-9.
35. Moran LJ, Noakes M, Clifton PM, Tomlinson L, Galletly C, Norman RJ. Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003; 88:812-9.
36. Tolino A, Gambardella V, Caccavale C, D'Ettore A, Giannotti F, D'Antò V, De Falco CL. Evaluation of ovarian functionality after a dietary treatment in obese women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2005;119:87-93.
37. Wolf JE Jr, Shander D, Huber F, Jackson J, Lin CS, Mathes BM, et al. Randomized, double-blind clinical evaluation of the efficacy and safety of topical eflornithine HCl 13.9% cream in the treatment of women with facial hair. Int J Dermatol 2007; 46:94-8.
38. Hickman JG, Huber F, Palmisano M. Human dermal safety studies with eflornithine HCl 13.9% cream (Vaniqa), a novel treatment for excessive facial hair. Curr Med Res Opin 2001; 16:235-44.
39. Clayton WJ, Lipton M, Elford J, Rustin M, Sherr L. A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome. Br J Dermatol 2005; 152:986-92.
40. Rezvanian H, Adibi N, Siavash M, Kachuei A, Shojaee-Moradie F, Asilian A. Increased insulin sensitivity by metformin enhances intense-pulsedlight- assisted hair removal in patients with polycystic ovary syndrome. Dermatology 2009;218:231-6.
41. Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad Dermatol 2008;59: 547-66.
42. Blume-Peytavi U, Hillmann K, Dietz E, Canfield D, Garcia Bartels N. A randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. J Am Acad Dermatol 2011;65:1126-34.e2.
43. Yildiz BO. Oral contraceptives in polycystic ovary syn- drome: risk-benefit assessment. Semin Reprod Med 2008; 26:111-20.
44. Grossman Barr N. Managing adverse effects of hormonal contraceptives. Am Fam Physician 2010;82:1499-506.
45. Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008;93:1105-20.
46. Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev 2012;(7):CD004425.
47. Soares GM, Vieira CS, de Paula Martins W, Dos Reis RM, de Sa MF, Ferriani RA. Metabolic and cardiovascular impact of oral contraceptives in polycystic ovary syndrome. Int J Clin Pract 2009;63:160-9.
48. Van der Spuy ZM, le Roux PA. Cyproterone acetate for hirsutism. Cochrane Database Syst Rev 2003;(4):CD001125.
49. Batukan C, Muderris II. Efficacy of a new oral contraceptive containing drospirenone and ethinyl estradiol in the long-term treatment of hirsutism. Fertil Steril 2006;85:436-40.
50. US Food and Drug Administration web site. Updated infor- mation about the risk of blood clots in women taking birth control pills containing drospirenone. Available at: http:// www.fda.gov/drugs/drugsafety/ucm299305.htm. Accessed February 8, 2014.
51. Moghetti P, Tosi F, Tosti A, Negri C, Misciali C, Perrone F, et al. Comparison of spironolactone, flutamide, and finasteride efficacy in the treatment of hirsutism: a randomized, double blind, placebocontrolled trial. J Clin Endocrinol Metab 2000; 85:89-94.
52. Christy NA, Franks AS, Cross LB. Spironolactone for hirsutism in polycystic ovary syndrome. Ann Pharmacother 2005;39:1517-21.
53. Brown J, Farquhar C, Lee O, Toomath R, Jepson RG. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev 2009;(2):CD000194.
54. Mazza A, Fruci B, Guzzi P, D’Orrico B, Malaguarnera R, Veltri P, et al. In PCOS patients the addition of low-dose spironolac- tone induces a more marked reduction of clinical and biochemical hyperandrogenism than metformin alone. Nutr Metab Cardiovasc Dis 2014;24:132-9.
55. Ganie MA, Khurana ML, Nisar S, Shah PA, Shah ZA, Kulshrestha B, et al. Improved efficacy of low dose spironolactone and metformin combination than either drug alone in the management of women with polycystic ovary syndrome (PCOS): a six month, open label randomized study. J Clin Endocrinol Metab 2013;98:3599-607.
56. Katsiki N, Hatzitolios AI. Insulin-sensitizing agents in the treatment of polycystic ovary syndrome: an update. Curr Opin Obstet Gynecol 2010;22:466.
57. Fux Otta C, Wior M, Iraci GS, Kaplan R, Torres D, Gaido MI, et al. Clinical, metabolic, and endocrine parameters in response to metformin and lifestyle intervention in women with polycystic ovary syndrome: a randomized, double-blind, and placebo control trial. Gynecol Endocrinol 2010;26:173-8.
58. Dunaif A. Drug insight: insulin-sensitizing drugs in the treatment of polycystic ovary syndromeo_a reappraisal. Nat Clin Pract Endocrinol Metab 2008;4:272-83.
2. Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol. 2015; 73: 672-90
3. McCartney CR, Marshall JC. Polycystic ovary syndrome. N Engl J Med. 2016; 375: 54-64
4. Waldstreicher J, Santoro NF, Hall JE, Filicori M, Crowley WF Jr. Hyperfunction of the hypothalamicpituitary axis in women with polycystic ovarian disease: indirect evidence for partial gonadotroph desensitization. J Clin Endocrinol Metab 1988; 66:165-72.
5. Balen AH. Hypersecretion of luteinizing hormone and the polycystic ovary syndrome. Hum Reprod 1993;8(suppl 2): 123-8.
6. Ehrmann DA. Polycystic Ovary Syndrome. N Engl J Med. 2005; 352: 1223-36
7. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Work- shop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19-25.
8. Chang WY, Knochenhauer ES, Bartolucci AA, Azziz R. Phenotypic spectrum of polycystic ovary syndrome: clinical and biochemical characterization of the three major clinical subgroups. Fertil Steril 2005;83:1717-23.
9. Wijeyaratne CN, Balen AH, Barth JH, Belchetz PE. Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference? Clin Endocrinol 2002;57:343-50.
10. Archer JS, Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Practice & Research Clinical Obstetrics and Gynaecology. 2004; 18: 737-54
11. Wijeyaratne CN, Balen AH, Barth JH, Belchetz PE. Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference? Clin Endocrinol 2002;57:343-50.
12. Deplewski D, Rosenfield RL. Role of hormones in piloseba- ceous unit development. Endocr Rev 2000;21:363-92.
13. Carmina E, Rosato F, Janni A, Rizzo M, Longo RA. Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab 2006;91:2-6.
14. Conn JJ, Jacobs HS, Conway GS. The prevalence of polycystic ovaries in women with type 2 diabetes mellitus. Clin Endocrinol 2000;52:81-6.
15. Polson DW, Adams J, Wadsworth J, Franks S. Polycystic ovaries—a common finding in normal women. Lancet 1988; 1:870-2.
16. Farquhar CM, Birdsall M, Manning P, Mitchell JM, France JT. The prevalence of polycystic ovaries on ultrasound scanning in a population of randomly selected women. Aust N Z J Obstet Gynaecol 1994;34:67-72.
17. Dockerty MB, Jackson RL. The Stein-Leventhal syndrome: analysis of 43 cases with special reference to association with endometrial carcinoma. Am J Obstet Gynecol 1957;73: 161-73
18. Giudice LC. Endometrium in PCOS: Implantation and predisposition to endocrine CA. Best Pract Res Clin Endocrinol Metab 2006;20:235-44.
19. Solomon CG. The epidemiology of polycystic ovary syndrome. Prevalence and associated disease risks. Endocrinol Metab Clin North Am. 1999 Jun; 28: 247-63.
20. Dunaif A, Segal KR, Futterweit W, Dobrjansky A. Profound peripheral insulin resistance, independent of obesity, in polycystic ovary syndrome. Diabetes 1989;38:1165-74.
21. Lim SS, Norman RJ, Davies MJ, Moran LJ. The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Rev 2013;14:95-109.
22. Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab 1999;84:165-9.
23. Mohiyiddeen L, Watson AJ, Apostolopoulos NV, Berry R, Alexandraki KI, Jude EB. Effects of lowdose metformin and rosiglitazone on biochemical, clinical, metabolic and biophysical outcomes in polycystic ovary syndrome. J Obstet Gynaecol 2013;33:165-70.
24. Toulis KA, Goulis DG, Mintziori G, Kintiraki E, Eukarpidis E, Mouratoglou SA, et al. Meta-analysis of cardiovascular disease risk markers in women with polycystic ovary syndrome. Hum Reprod Update 2011;17:741-60.
25. de Groot PC, Dekkers OM, Romijn JA, Dieben SW, Helmerhorst FM. PCOS, coronary heart disease, stroke and the influence of obesity: a systematic review and meta-analysis. Hum Reprod Update 2011;17:495-500.
26. Dunaif A, Graf M, Mandeli J, Laumas V, Dobrjansky A. Characterization of groups of hyperandrogenic women with acanthosis nigricans, impaired glucose tolerance, and/or hyperinsulinemia. J Clin Endocrinol Metab 1987;65:499-507.
27. Rudman SM, Philpott MP, Thomas GA, Kealey T. The role of IGF-I in human skin and its appendages: morphogen as well as mitogen? J Invest Dermatol 1997; 109: 770-7.
28. Nam SY, Lee EJ, Kim KR, Cha BS, Song YD, Lim SK, et al. Effect of obesity on total and free insulin-like growth factor (IGF)-1, and their relationship to IGFbinding protein (BP)-1, IGFBP-2, IGFBP-3, insulin, and growth hormone. Int J Obes Relat Metab Disord 1997; 21: 355-9.
29. Cruz PD Jr, Hud JA Jr. Excess insulin binding to insulin-like growth factor receptors: proposed mechanism for acanthosis nigricans. J Invest Dermatol 1992;98(6 suppl):82S-5S.
30. Ehrmann DA. Metabolic dysfunction in PCOS: Relationship to obstructive sleep apnea. Steroids 2012;77:290-4.)
31. Barry JA, Kuczmierczyk AR, Hardiman PJ. Anxiety and depression in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod 2011;26:2442-51.
32. Veltman-Verhulst SM, Boivin J, Eijkemans MJ, Fauser BJ. Emotional distress is a common risk in women with polycystic ovary syndrome: a systematic review and meta-analysis of 28 studies. Hum Reprod Update 2012;18:638-51.
33. Buzney E, Sheu J, Buzney B, Reynolds RV, Polycystic ovary syndrome: a review for dermatologists part II. treatment. J Am Acad Dermatol. 2014; 71: 859.e1-15
34. Pasquali R, Antenucci D, Casimirri F, Venturoli S, Paradisi R, Fabbri R, et al. Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol Metab 1989;68:173-9.
35. Moran LJ, Noakes M, Clifton PM, Tomlinson L, Galletly C, Norman RJ. Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003; 88:812-9.
36. Tolino A, Gambardella V, Caccavale C, D'Ettore A, Giannotti F, D'Antò V, De Falco CL. Evaluation of ovarian functionality after a dietary treatment in obese women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2005;119:87-93.
37. Wolf JE Jr, Shander D, Huber F, Jackson J, Lin CS, Mathes BM, et al. Randomized, double-blind clinical evaluation of the efficacy and safety of topical eflornithine HCl 13.9% cream in the treatment of women with facial hair. Int J Dermatol 2007; 46:94-8.
38. Hickman JG, Huber F, Palmisano M. Human dermal safety studies with eflornithine HCl 13.9% cream (Vaniqa), a novel treatment for excessive facial hair. Curr Med Res Opin 2001; 16:235-44.
39. Clayton WJ, Lipton M, Elford J, Rustin M, Sherr L. A randomized controlled trial of laser treatment among hirsute women with polycystic ovary syndrome. Br J Dermatol 2005; 152:986-92.
40. Rezvanian H, Adibi N, Siavash M, Kachuei A, Shojaee-Moradie F, Asilian A. Increased insulin sensitivity by metformin enhances intense-pulsedlight- assisted hair removal in patients with polycystic ovary syndrome. Dermatology 2009;218:231-6.
41. Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad Dermatol 2008;59: 547-66.
42. Blume-Peytavi U, Hillmann K, Dietz E, Canfield D, Garcia Bartels N. A randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. J Am Acad Dermatol 2011;65:1126-34.e2.
43. Yildiz BO. Oral contraceptives in polycystic ovary syn- drome: risk-benefit assessment. Semin Reprod Med 2008; 26:111-20.
44. Grossman Barr N. Managing adverse effects of hormonal contraceptives. Am Fam Physician 2010;82:1499-506.
45. Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008;93:1105-20.
46. Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev 2012;(7):CD004425.
47. Soares GM, Vieira CS, de Paula Martins W, Dos Reis RM, de Sa MF, Ferriani RA. Metabolic and cardiovascular impact of oral contraceptives in polycystic ovary syndrome. Int J Clin Pract 2009;63:160-9.
48. Van der Spuy ZM, le Roux PA. Cyproterone acetate for hirsutism. Cochrane Database Syst Rev 2003;(4):CD001125.
49. Batukan C, Muderris II. Efficacy of a new oral contraceptive containing drospirenone and ethinyl estradiol in the long-term treatment of hirsutism. Fertil Steril 2006;85:436-40.
50. US Food and Drug Administration web site. Updated infor- mation about the risk of blood clots in women taking birth control pills containing drospirenone. Available at: http:// www.fda.gov/drugs/drugsafety/ucm299305.htm. Accessed February 8, 2014.
51. Moghetti P, Tosi F, Tosti A, Negri C, Misciali C, Perrone F, et al. Comparison of spironolactone, flutamide, and finasteride efficacy in the treatment of hirsutism: a randomized, double blind, placebocontrolled trial. J Clin Endocrinol Metab 2000; 85:89-94.
52. Christy NA, Franks AS, Cross LB. Spironolactone for hirsutism in polycystic ovary syndrome. Ann Pharmacother 2005;39:1517-21.
53. Brown J, Farquhar C, Lee O, Toomath R, Jepson RG. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev 2009;(2):CD000194.
54. Mazza A, Fruci B, Guzzi P, D’Orrico B, Malaguarnera R, Veltri P, et al. In PCOS patients the addition of low-dose spironolac- tone induces a more marked reduction of clinical and biochemical hyperandrogenism than metformin alone. Nutr Metab Cardiovasc Dis 2014;24:132-9.
55. Ganie MA, Khurana ML, Nisar S, Shah PA, Shah ZA, Kulshrestha B, et al. Improved efficacy of low dose spironolactone and metformin combination than either drug alone in the management of women with polycystic ovary syndrome (PCOS): a six month, open label randomized study. J Clin Endocrinol Metab 2013;98:3599-607.
56. Katsiki N, Hatzitolios AI. Insulin-sensitizing agents in the treatment of polycystic ovary syndrome: an update. Curr Opin Obstet Gynecol 2010;22:466.
57. Fux Otta C, Wior M, Iraci GS, Kaplan R, Torres D, Gaido MI, et al. Clinical, metabolic, and endocrine parameters in response to metformin and lifestyle intervention in women with polycystic ovary syndrome: a randomized, double-blind, and placebo control trial. Gynecol Endocrinol 2010;26:173-8.
58. Dunaif A. Drug insight: insulin-sensitizing drugs in the treatment of polycystic ovary syndromeo_a reappraisal. Nat Clin Pract Endocrinol Metab 2008;4:272-83.
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2016-12-01
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Pakornphadungsit, K., Suchonwanit, P., & Sriphojanart, T. (2016). Polycystic Ovary Syndrome in Dermatological Practice. Thai Journal of Dermatology, 32(4), 240–254. Retrieved from https://he02.tci-thaijo.org/index.php/TJD/article/view/159201
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