Issues for Women with CAH
For those women who find coping with the medical, surgical,
psychological or sexual problems of CAH difficult, support and counselling
should be made available. Sensitive
discussion with specialists, general practitioners, fertility specialists,
gynaecologists, counsellors, psychologists and CAH support groups can all be
helpful. The difficulties
experienced by some women with CAH arise because of decisions made many years
ago when less was known about medical and surgical care.
Young adults now should not have to face many of the problems addressed
in this section.
Unwanted hair growth
high androgen levels that occur when cortisol treatment is too low, commonly
cause problems for women with CAH. For
many women acne and excess hair growth, 'hairiness' or hirsutism are the first features of high androgen levels.
The aim of changing the dose of cortisol treatment is to reverse this
process and it can be a very fine line between keeping free of unwanted hair and
suffering the side effects of cortisol treatment - in particular weight gain.
Because of these difficulties, many women with CAH require additional
treatment for excess hair growth to oppose the action of androgens. The 'anti-androgen'
treatments available in the United Kingdom are cyproterone acetate,
spironolactone, flutamide and finasteride. Cyproterone acetate is the only one
of these to be in common usage and it works by competing with testosterone at
the hair follicle to block the stimulation of hair growth.
Anti-androgens are often given together with the combined oral
contraceptive pill which reduces the amount of testosterone made by the ovary. Hirsutism takes several months to respond to treatment but
cosmetic methods of treating excess hair such as waxing, shaving, creams or
electrolysis are perfectly acceptable options which in no way cause hair to
is no restriction for the use of different contraceptives for women with CAH.
The choices of contraception include the sheath, the diaphragm, the coil
and oral contraceptive pills. The combined oral contraceptive pill may have the added
benefit of making irregular periods regular.
Some women, however, find that the pill makes it more difficult to lose
weight although a low dose pill might get around this problem.
Dianette is commonly advised for women with CAH because it is
particularly effective in suppressing unwanted hair growth.
Progesterone only pills - 'mini-pills' can be used by women with CAH but
they can cause difficulties with irregular periods.
women with CAH have polycystic ovaries when pictured by an ultrasound machine.
In fact, one in four of women without CAH also have polycystic ovaries,
so this in itself is not a worrying feature though, of course, a concern to the
individual. Polycystic ovaries are slightly larger than average and
contain more small follicles, where the eggs develop, than average.
Polycystic ovaries are associated with irregular periods and infertility
which are both common in women with CAH.
It may be that high levels of testosterone in childhood cause the
development of polycystic ovaries in some women but this is far from certain.
High levels of testosterone from the adrenal gland cause irregular
periods and failure to produce an egg, ovulation.
Irregular periods and failure to ovulate can improve with higher
doses of cortisol treatment but the balance of treatment in this instance can be
periods occur in about one third of women with non-salt losing CAH and one half
of women with salt-losing CAH compared to one in ten of women without CAH.
There is surprisingly little information about fertility in women with
CAH and most of our knowledge on this subject comes from a time before modern
fertility treatments. This 'historical' information says that two thirds of women
with non-salt losing CAH are fertile without the need for treatment whereas only
one in ten of women with salt-losing CAH are fertile. Most specialists feel that the prospects for fertility are
better than these figures would indicate nowadays.
If a woman with CAH has very irregular periods, then it is likely that
specialist fertility treatment will be required. On the whole, fertility treatments will be the same as
for women without CAH where a fertility tablet, clomiphene citrate, can be
given. If tablet treatment is
not successful then hormone injections (gonadotrophins, LH and FSH) can be used
to bring about ovulation. If all of
these treatments fail then in vitro
fertilisation (IVF) might be needed but a specialist fertility clinic with
experience in CAH should be consulted at this stage.
women with late onset CAH fertility problems are usually less marked.
In the mildest forms, steroid treatment might be necessary in order to
conceive but it may be able to be stopped in pregnancy.
pregnant, both the mother with CAH and her child should expect to be healthy in
every way. There is discussion as
to whether there should be a slight increase in dosage of cortisol replacement
treatment in late pregnancy but high dose treatment should be avoided.
The placenta protects the baby from any hormone imbalance in the mother
and destroys any excess hydrocortisone in the circulation.
In a recent review of 46 children born to mothers with CAH, all babies
were healthy and normal. Two thirds
of babies were delivered by caesarean section and only one third by vaginal
delivery. There are many reasons
why caesarean sections might be common in women with CAH but one worry is that earlier genital surgery might make normal
labour difficult. Pain relief and
the use of epidurals is the same in CAH as normal.
© Dr G. S. Conway 1999
This Page was updated 30-Apr-2006
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© 1999 - 2006 Adrenal Hyperplasia Network