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The choice of a specific oral contraceptive should be predicated on the progestational component, as progestins vary in their suppressive effect on SHBG levels and in their androgenic potential. Ethynodiol diacetate has relatively low androgenic potential, whereas progestins such as norgestrel and levonorgestrel are particularly androgenic, as judged from their attenuation of the estrogen-induced increase in SHBG. Norgestimate exemplifies the newer generation of progestins that are virtually nonandrogenic. Drospirenone, an analogue of spironolactone that has both antimineralocorticoid and antiandrogenic activities, has been approved for use as a progestational agent in combination with ethinyl estradiol. Its properties suggest that it should. | Chapter 050. Hirsutism and Virilization Part 5 The choice of a specific oral contraceptive should be predicated on the progestational component as progestins vary in their suppressive effect on SHBG levels and in their androgenic potential. Ethynodiol diacetate has relatively low androgenic potential whereas progestins such as norgestrel and levonorgestrel are particularly androgenic as judged from their attenuation of the estrogen-induced increase in SHBG. Norgestimate exemplifies the newer generation of progestins that are virtually nonandrogenic. Drospirenone an analogue of spironolactone that has both antimineralocorticoid and antiandrogenic activities has been approved for use as a progestational agent in combination with ethinyl estradiol. Its properties suggest that it should be the preferred choice for the treatment of hirsutism. Oral contraceptives are contraindicated in women with a history of thromboembolic disease or in women with increased risk of breast or other estrogen-dependent cancers Chap. 342 . There is a relative contraindication to the use of oral contraceptives in smokers or in those with hypertension or a history of migraine headaches. In most trials estrogen-progestin therapy alone improves the extent of acne by a maximum of 50-70 . The effect on hair growth may not be evident for 6 months and the maximum effect may require 9-12 months owing to the length of the hair growth cycle. Improvements in hirsutism are typically in the range of 20 but there may be an arrest of further progression of hair growth. Adrenal androgens are more sensitive than cortisol to the suppressive effects of glucocorticoids. Therefore glucocorticoids are the mainstay of treatment in patients with CAH. Although glucocorticoids have been reported to restore ovulatory function in some women with PCOS this effect is highly variable. Because of side effects from excessive glucocorticoids low doses should be used. Dexamethasone 0.2-0.5 mg or prednisone 5-10 mg should be .
