Frequently Asked Questions about Anovulatory Androgen (AAE, or PCOS)
Are women with AAE estrogen deficient since they often have skipped periods or amenorrhea?
You would think so, since many women with far-apart periods do have low estrogen levels. But surprisingly, estrogen levels are normal or high in women with AAE.
Estrogen levels are at least within the normal range in PCOS but the pattern of estrogen production is not normal. It amounts to too much estrogen exposure because levels are steady across the month. In the ideal menstrual cycle, estrogen levels go from low levels during flow, to high at midcycle, and then gradually decrease to low levels again as the next period starts. Cyclic progesterone therapy for AAE likely helps estrogen levels to re-develop a normal cyclic pattern.
Are birth control pills given to women with AAE/PCOS because doctors believe estrogen levels are too low?
Perhaps that was part of the reason for originally prescribing combined hormonal contraception (CHC, The Pill) for AAE or PCOS. CHC includes a high dose of estrogen, even with the so-called “low dose” Pills of today, because higher-than-normal estrogen levels are necessary to provide effective birth control. Today’s “low dose” Pills do have lower estrogen levels (about 20 micrograms) compared with the extremely high estrogen-doses (more than or equal to 100 micrograms) in the Pill that I tried to take in the 1960s.
Today, the main reasons for treating AAE with CHC are:
1) CHC provides reasonable contraception if this is needed/desired.
2) CHC causes more regular flow, which is important for many women with AAE.
3) The synthetic progestin that is part of CHC supresses ovarian testosterone because it slows the fast brain pulses of luteinizing hormone (LH) that stimulate increased ovarian testosterone production.
4) High estrogen levels cause greater production of a protein that binds testosterone; this makes testosterone less hormonally active.
5) CHC taken for 21 days, with 7 days of no or placebo-pills, will interfere with the steady and higher estrogen levels of AAE.
6) CHC for AAE is supported by many studies showing it improves quality of life, decreases acne and facial hair, and provides regular menstruation.
7) CHC/The Pill is something gynecologists and family doctors are comfortable prescribing, and many women are comfortable taking.
Given positive things about CHC, why do you disagree with The Pill as therapy for AAE/PCOS?
I don’t disagree with taking CHC. However, I think that women deserve choices, especially if there are therapies with the potential to curing AAE. My main reason for questioning the “treatment” of AAE with CHC is that CHC doesn’t allow womens’ own reproductive systems to recover. A very good study, for example, showed that within six months of stopping The Pill, almost all of its benefits have gone away.
I believe that it is a fundamental imbalance (partially hereditary and partially related the environment/obesity/inactivity and stress) that is causing AAE. In other words, I believe that AAE is a treatable and reversible problem that, once progesterone is present and ovulation is established, basically becomes cured.
In summary, I object to CHC as the primary AAE therapy because it prevents PCOS reproductive healing. The brain/hypothalamus needs to be free from the across-board suppression that CHC imposes in order to “learn” to ovulate and then to consistently ovulate with enough progesterone.
If women with AAE have normal/high estrogen—why do they need progesterone?
Good question, since both estrogen and progesterone are ovary-produced hormones.
There are at least three reasons why progesterone is needed for AAE:
1) Women with AAE need progesterone because progesterone solves the root cause of AAE—too rapid brain/hypothalamus pulsing of the “luteinizing hormone” (LH). Progesterone’s job is to slow rapid LH pulsing. It is this fast pulsing LH that leads to over-production of testosterone by the ovary. Testosterone then causes many of the problems of AAE such as blocking ovulation, preventing flow, causing hirsutism, acne, male-pattern balding and inappropriately steady and often high estrogen levels.
2) Women with AAE need progesterone because estrogen and progesterone are partner hormones working together to create the healthy menstrual cycle for all women. We now know that only when both are normally present in the menstrual cycle does that cycle become a fertile cycle. Plus, a normally ovulatory menstrual cycle will prevent bone loss, delay early heart attacks, and work to prevent endometrial and breast cancers.
3) Women with AAE are missing progesterone. When women have enough estrogen but lack progesterone, it leads to infertility, rapid bone loss, and a greater risk for later life heart disease, endometrial and breast cancers.
How does progesterone help with too high testosterone?
Thanks for asking me to explain.
Progesterone works against high testosterone in two main ways:
1) It prevents high levels of ovarian testosterone production by slowing the rapid pulses of LH that stimulate the ovary to make it; and
2) It blocks the enzyme that converts testosterone into its “active” hormone, called dihydrotestosterone (or DHT), that is the actual hormone stimulating facial hair growth, oily skin, acne, and the loss of head hair in a pattern similar to mens’ balding.
If progesterone helps with hirsutism and acne, why is spironolactone needed too?
That’s a great question. If one medicine is sufficient, why take two?
Spironolactone is a testosterone receptor blocker—it prevents testosterone or DHT action on hair follicles or oil glands.
The main reason women with PCOS need it plus cyclic progesterone is: most women with AAE have hair follicles and skin oil-producing glands that have been chronically, year-in and year-out, stimulated by higher testosterone levels. This greater testosterone exposure produces more testosterone receptors on hair follicles and oil glands. That means even women’s normally low levels of testosterone are high enough to maintain hirsutism and acne in a woman with AAE. Then, although progesterone may lower the testosterone levels to normal and interfere with the production of DHT, this therapy is not strong enough to break testosterone’s “vicious cycle.” Once the hirsutism is gone, spironolactone is no longer needed and can be stopped.
Will I need contraception if I take cyclic progesterone and spironolactone?
Thanks for your excellent question. Yes, YES, YES—if you are sexually active with a man, you need to actively prevent pregnancy while taking cyclic progesterone and spironolactone.
Cyclic progesterone and spironolactone therapy make it more likely that you will ovulate and thus these therapies increase your risk for an unplanned pregnancy. Spironolactone could cause hormone harm to a boy baby. Therefore, women taking it are counselled to avoid pregnancy.
However, effective contraception is a bit tricky when taking cyclic progesterone/ spironolactone because birth control needs to be non-hormonal in order to not interfere with the healing of AAE.
What are the non-hormonal birth control options for women with AAE?
There are two main options:
1) A copper intrauterine device (IUD)—this lasts 5-7 years and is nearly 100% effective. Its main unwanted effects are some increase in cramping (that frequent-dose ibuprofen will treat) and slightly heavier periods (that will be helped by low dose ibuprofen). The copper IUD also requires a health care provider visit for insertion, and has an upfront cost of $90.00 (in British Columbia, 2018) or the cost of about six months of CHC packets.
2) A vaginal barrier (condom, diaphragm or cervical cap) plus full dose vaginal spermicide applied before each intercourse. An additional advantage of this birth control method is that it prevents sexually transmitted infections. If using a diaphragm or cap plus spermicide, another good thing is that it is under a woman’s control. A woman can plan ahead by putting the diaphragm in ahead of time adding the spermicide only if sexual activity occurs. The disadvantages are that using barrier/spermicide requires planning, it requires use for every intercourse, and that a diaphragm needs to be sized to fit each woman in a one-time, health care provider visit. It is also not as fool-proof as an IUD, but used conscientiously, and every time, it will usually be without mishap.