Male hormones in women: norm and pathology

There are very clear gender differences between the female and male body, primarily due to the influence of hormones. If a woman's body works correctly and smoothly, all hormones are released on time and in the right amount – then her appearance will be a pleasant reflection of such a physiological "order." If there are certain hormonal disorders – the appearance of such a woman will deteriorate. The levels of male hormones in women play a particularly important role.

Especially for readers of estet-portal.com, gynecologist-endocrinologist Krasovskaya Alexandra Vladimirovna spoke about the normal and pathological content of male sex hormones in the female body, as well as about the symptoms and methods for correcting the pathological condition.

Why is the issue of male hormones in women relevant for aesthetic medicine specialists?

Male sex hormones (androgens) are normally present in the blood of every woman. They perform important functions, without which the body could not grow and exist properly. For example, androgens stimulate the growth of muscle tissue, increase brain activity, improve memory and attention, are natural antidepressants, etc. But with hyperandrogenism (hyperandrogenism - increased activity of male sex hormones and / or increased receptor sensitivity to androgens), the patient has complaints that take her to a specialist in aesthetic medicine. First of all, it is, of course, acne, as well as hypertrichosis and hirsutism.

What specific hormones are we talking about, and what is their norm in the female body?

There are many male hormones, and, depending on the symptoms and complaints of the patient, it is necessary to develop an algorithm for her examination.

Of course, for a dermatologist and cosmetologist, the levels of such indicators will be of interest: Total testosterone (Ttot), Free testosterone (Tsv), Dihydrotestosterone, sexsteroid-binding globulin (SSBG).

Testosterone – one of the most significant male hormones in women.

It is known that 50% of testosterone in a woman's body is produced by the adrenal glands and ovaries, and another 50% is formed by peripheral conversion from androstenedione. The content of testosterone in the blood may not reflect the true degree of androgenization, which depends, to a greater extent, on the degree  testosterone relatedness:

• 80% of testosterone binds to globulins (SHBG)
• 18% of testosterone binds to albumin (CCCA)
• 2% testosterone remains free and active.

And it is Tsv that is able to penetrate into the sebaceous gland and hair follicle, where, under the action of the 5α-reductase enzyme, it turns into Dihydrotestosterone (a hormone that is 3 times more active than testosterone itself).

SSSG is synthesized in the liver, respectively, the level of this indicator will depend on the state of the liver. Women with hyperandrogenism tend to have lower concentrations of SHBG than healthy women.

When a patient has any complaints or symptoms, an esthetician may suspect hyperandrogenism in a woman?

Androgens stimulate the function of the sebaceous glands and hair follicles, with  hyperandrogenism, hyperfunction of these skin derivatives will be noted. Patients, in this case, will complain of acne, seborrhea, hypertrichosis, hirsutism (excessive hair growth), alopecia.

Pathogenetic factors for acne:

1. Androgen-mediated hypertrophy of the sebaceous glands with hyperproduction of sebum, hyperreception of target organ cells to androgens, increased activity of 5α-reductase;
2. Reduction of bactericidal activity of sebum;
3. Follicular hyperkeratosis;
4. Microbial hypercolonization;
5. Inflammation and immune response.

Hirsutism – this is excessive hair growth in women according to the male pattern, namely: on the chest, face in the form of sideburns, in the beard area and above the upper lip, along the white line of the abdomen, on the sacrum, buttocks, inner thighs.

Causes of hirsutism:

• increased androgen production;
• increased activity of the 5α-reductase enzyme.

Androgenetic alopecia  - loss of hair in women in the central parietal region with oval outlines, while there is no baldness on the temples and above the forehead.

Why can female hormone levels rise and cause the above symptoms?

There are many reasons for hyperandrogenism. And it is very important to understand that hyperandrogenism is not always an increased level of male sex hormones.

Pathogenetic forms of hyperandrogenism (HA):

1. True GA:

• adrenal:

- AGS (adrenogenital syndrome);

- tumor of the adrenal gland;

• ovarian:

- PCOS (polycystic ovary syndrome);

- ovarian tumor.

2. Other forms of hyperandrogenism:

• transport:

-↓ SSSG;

• peripheral:

- receptor (increase in the number or activity of androgen receptors);

     - metabolic (increased activity of 5α-reductase);

• iatrogenic;

• secondary:

- hypothalamic-pituitary syndrome with gonadotropic dysfunction;

- hyperprolactinemia;

- acromegaly;

- Itsenko-Cushing's disease;

- anorexia;

- hypothyroidism;

- type II diabetes mellitus, obesity;

- hepatic dysfunction.

Quite often we see a patient with acne, and her levels of male sex hormones are normal. In this case, the cause of hyperandrogenism may be transport, peripheral, iatrogenic or secondary hyperandrogenism.

What methods do you, as a gynecologist-endocrinologist, recommend to normalize the level of male sex hormones?

Undoubtedly, the treatment of the patient must be individualized. We have already found out that there are many causes of hyperandrogenism, and therefore the patient must be properly examined and the cause that provokes the symptoms of hyperandrogenism must be eliminated.

Hormonal treatment is not always necessary, since with hyperandrogenism we do not always meet with an increased level of male hormones in women.

Drugs that are used in the treatment of hyperandrogenism are called antiandrogens. Their action can be directed to:

• decreased secretion of androgens in the ovaries;
• decreased secretion of androgens in the adrenal glands;
• androgen and antiandrogen competition for the receptor;
• blocking 5-.alpha. reductase (testosterone is NOT converted to dihydrotestosterone);
• increase in SHSH production (decrease in active free testosterone fractions).

There are simple antiandrogens – These are non-hormonal drugs, the mechanism of action of which is to compete for the androgen receptor. That is, their appointment is advisable in the presence of increased receptor sensitivity and / or an increase in the number of androgen receptors, as well as with a normal level of androgens. Well-known representatives of this group of drugs – flutapharm and flutamide.

We also have steroid antiandrogens in our arsenal:

• antiandrogen-progestins (cyproterone acetate and chlormadinone),
• combined oral contraceptives (COCs),
• corticosteroid hormones.

COCs and antiandrogens-progestins affect several links in the pathogenesis of hyperandrogenism, namely:

• have a local antiandrogenic effect,
• suppress androgen production,
• have an antigonadotropic effect (suppress the production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)).

Corticosterides - suppress androgen production.

For polycystic ovary syndrome (PCOS) – ovarian form of hyperandrogenism – Worldwide, the gold standard of care is COCs (combined oral contraceptives). However, you need to remember that not all contraceptives are the same. And you can’t use COCs on the principle of “helped a neighbor / girlfriend - it will help me too.”

Each group of contraceptives has its own niche of patients. Only a doctor at a consultation can choose the right COC, taking into account all the complaints and the results of the examination of the patient.

Can a doctor of aesthetic medicine himself recommend certain drugs to a patient to normalize hormone levels, or is a consultation with a gynecologist necessary?

Hormonal homeostasis of a woman – a fragile system that depends on many factors (nutrition, work and rest, stress, the presence of diseases), which is why treatment with hormonal drugs should be clearly justified. I would say that the main principle of treatment in such situations comes down to the oldest principle of medical ethics – "Do no harm!".

Since with an increase in the level of male hormones in women, in addition to aesthetic problems, there are problems with the cycle, infertility, miscarriage, I think that these patients should consult a gynecologist. And it is precisely with the joint management of such patients by a gynecologist and an esthetician, we will be able to quickly and efficiently help them.