The field of androgen excess disorders has advanced substantially since the original publication of this book. The Androgen Excess Society (AES) was founded to bring together investigators in the field. A better understanding of the screening, progression, and molecular genetics of nonclassic adrenal hyperplasia (NCAH) has improved the clinical care and diagnostic accuracy of these patients. New criteria for the diagnosis of the polycystic ovary syndrome (PCOS) were proposed in Rotterdam, criteria that have resulted in controversy and, hopefully, initiation of new studies. The association of insulin resistance with PCOS has been strengthened, and the role of metformin in tre- ing the infertility of the PCOS has been validated. Risks for diabetes and, more cont- versially, cardiovascular disease in women with PCOS have received substantial investigation. Our understanding of the epidemiology and economic impact of these disorders has expanded, emphasizing their critical importance. These are but a few highlights of how the terrain has changed in a relatively brief period of time. In keeping with these advances, the title of this book has been revised to reflect the growing importance of PCOS as the most prevalent androgen excess disorder in women, and arguably, as the one that might have the most serious adverse consequences for general health. There are fewer chapters to provide a more focused elucidation of the area. Several chapters were penned by new (and young) authors who are conducting cutting-edge research in the field.
The Western ideal of beauty dictates acceptable locations for and amounts of body hair. For women, head and pubic hair are desirable, but obvious hair growth on other areas of the body is not. As many as 35 percent of white women have hair on the chest, face, or lower abdomen, and many of them consider this growth abnormal and seek a medical diagnosis. Such hair growth reflects the level of circulating androgens and tissue sensitivity to them. Many women with excess hair growth, or hirsutism, have normal levels of circulating androgens but an increased tissue sensitivity that is a characteristic of their ethnic background. For example, Hispanic women have more body hair than Asian women. Most women with excess body hair do not have a medical disease, yet they suffer from the social and psychological consequences of hirsutism.
At the other extreme of the continuum are disorders of virilization, characterized by additional masculinization -- clitoromegaly, deepening of the voice, and frontal balding -- and caused by excessive circulating androgens. The underlying cause may be life-threatening, such as adrenal cancer. Between these two extremes are female patients with hirsutism or other androgenic signs, such as acne and generalized balding, some of whom have associated problems, such as anovulation or infertility, insulin resistance, and obesity.
Thus, hirsutism may be a sign of critical illness, a marker of ethnic background, or a harbinger of metabolic problems. Because of the uncertain interpretation of a socially unacceptable feature that may also represent an adverse medical diagnosis, disorders of apparent androgen excess are challenging for internists, pediatricians, endocrinologists, and dermatologists.
Androgen Excess Disorders in Women attempts to address, in 77 chapters, many aspects of this confusing spectrum of conditions. The book is divided into sections covering physiology, clinical manifestations, causes and associations, the polycystic ovary syndrome, idiopathic hirsutism, evaluation, and treatment. The relatively short chapters have a uniform format consisting of background, discussion, synopsis and conclusions, and future avenues of investigation, which encourages the reading of just a few chapters to investigate a single issue.
This ambitious compendium both benefits and suffers from the unavoidable repetition of information. Although conflicting assertions may be disconcerting for the novice, the contrasting views provide a sense of the extent of uncertainty and controversy for the more experienced reader. Repetition also fills in the gaps of the less robust chapters. For example, an understanding of the steroidogenic pathways is needed, but the topic is not discussed until pages 202 and 316. Repetition provides a variety of information and perspectives, from the molecular biology underlying the pathophysiology of androgen excess to reminders that ethnicity and social values are important to our understanding and our patients' experience of hirsutism. Chapters advocating the use of 5(alpha)-reductase inhibitors (with cautions about their feminizing effects on a male fetus) contrast with chapters on electrolysis and dietary measures.
There are areas that may mislead the unwary reader. In particular, the discussions of ovarian regulation and insulin-like growth factors occasionally present data on rats and not on humans, ignoring important differences between species. In addition, jargon such as (Delta)4 (instead of androstenedione), abbreviations such as FOH (functional ovarian hyperactivity), and allusions to tests (dexamethasone suppression) without further explanation may be mystifying.
Balancing these blemishes are excellent treatises on current concepts of steroidogenesis, the metabolism of steroids, the vagaries of assays, the physiology of the pilosebaceous unit, and the difficulties of defining the polycystic ovary syndrome and insulin resistance. This book also contains pictures and interesting tidbits of relevant information not easily found elsewhere, such as the descriptions of the nymphomaniac cow model and threading as a treatment for hirsutism, and cartoons of steroid synthesis, steroid metabolism, and rating scores for hirsutism and balding.
Androgen Excess Disorders in Women is a compendium of current opinion from 99 expert authors. Although it lacks concise background information and chapters in which consensus discussions of standard evaluation and treatment methods are presented, it will be valuable to the investigator wishing to survey current concepts and important areas for study. It will be an often-consulted reference book for endocrinologists, internists, pediatricians, and gynecologists who care for women with hirsutism, and I recommend it for students, of all ages, with an interest in this complex field.
Reviewed by Lynnette K. Nieman, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
