Women's Health Community

Dear SarahRoss: Among younger women with polycystic ovarian syndrome ("PCOS") the increased levels of male hormones can prompt increased facial hair, acne, and thinning hair over the crown of the head. While this is often referred to as "male pattern baldness" it does not progress to the usual shiny bald head one sees in men. Rather, the involved hair follicle replaces a lost long hair with a much shorter, finer hair. This can give a fuzzy appearance with the scalp clearly visible.

Treatments can include Rogaine 2% applied to the scalp. This is the only FDA approved medication for androgenic alopecia. A less expensive prescriptive option, spironolactone (Aldactone), pills may tried. Spironolactone 100-200 mg per day is given in divided doses to block the effects of androgens at the level of the hair follicle. Estrogen containing birth control pills may be tried as estrogen works to bind male hormones so they are less biologically active. Flutamide (Eulexin) is an anti-androgen drug that was found to be helpful in younger women (Cusan, 1994 & Carmina, 2003), yet it is not FDA approved for treating androgenic alopecia in women.

In terms of the spotting, you are correct, spironolactone can be tied to menstrual irregularities. Yet you mention that stopping the drug did not improve the spotting. It is also true that spotting is very common with the progestin only minipill. Estrogen, even in low doses, can improved cycle control. Because of its super low dose the minipill tends to have a low incidence of side effects (except spotting). Generally spotting on progestin only contraceptives arises because the lining of the uterus becomes thinned out. While a thin lining is a healthy lining it is also more prone to breakthrough bleeding (BTB). BTB is not a health problem per se but it is a major nuisance side effect! So your BTB treatment choices might be limited to every few months doing a withdrawal bleed with Provera, revisiting an estrogen containing birth control pill. Honestly, it sounds like your GYN is doing a thorough job by trying to avoid androgen type birth control pills and trying other approaches.

Some women with PCOS are lean. Studies have found increased markers of inflammation (suggestive of early damage inside blood vessels) in lean young PCOS women (Atabekoglu, 2011). Perhaps only 12% of lean PCOS women will develop glucose abnormalities (Norman, 2001). If one can stay normal weight it might buffer or slow some of the unfavorable changes. For example, 78 women with carefully documented PCOS were divided into two groups. Only those who had a BMI of more than 28 (i.e., overweight or obese) had insulin resistance and/or abnormal values on a fasting blood sugar blood test (Stovall, 2011). So Sarah you are doing a lot for your health by staying slim.

There is something different about PCOS which can make women more vulnerable to early onset diabetes and heart disease risks. Some of the major suspects are: higher levels of male hormones, and problems with elevated insulin levels. These two factors may be at work in thin PCOS women as well. Lean women with PCOS were given metformin, or a placebo pill, for 4-6 weeks. As expected, insulin levels decreased in the metformin group. More surprisingly, blood levels of free testosterone decreased by 70% in the metformin group as well (Nestler, 1997). I'm sorry that you had the GI issues with metformin.

Sarah, I don't have any advice on the depression medication regimen. Your current regimen of Wellbutrin has some major advantages, but if you seem to not be deriving enough benefit you should see a psychiatrist/psych NP for a med discussion. Lit searches at the National Library of Medicine site did not yield case reports or studies on Wellbutrin caused hair loss.

It's got to be incredibly frustrating to have to deal with problems at every turn. Alas, we know so much less about "thin PCOS". Much more research is needed to be able to help women such as yourself.

In Support,
Jane