Ep 127: Spironolactone Use and its Effect on Fertility with Dr. Kimberley Thornton & Dr. Atoosa Ghofranian
Fertility Forward Episode 127:
Today on Fertility Forward, we will discuss another research abstract presented at this year’s American Society for Reproductive Medicine (ASRM) Conference, titled ‘Spironolactone use in oocyte maturation in patients undergoing oocyte cryopreservation.’ Here to join us in conversation about it are two of the authors, who are also endocrinologists at RMA of New York, Dr. Atoosa Ghofranian and Dr. Kimberley Thornton. Tune in now to hear more about Spironolactone and its uses, where their research question stemmed from including the story behind the interest in this project, highlights from the study’s findings, and more.
Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Dara: Today on Fertility Forward, we will be discussing another research abstract that will be presented at this year's ASRM conference. The abstract is titled, Spironolactone Use and Oocyte Maturation in Patients Undergoing Oocyte Cryopreservation and today to share with us this research, we have two of the authors here who are also reproductive endocrinologists at RMA of New York. We have Dr. Atoosa Ghofranian and Dr. Kimberly Thornton. Thank you both for being here.
Dr. Thornton: Hi. Thank you for having us. So we sort of started studying this with Spironolactone is a a medication. It, it's actually a medication that's a diuretic. It's sometimes used for high blood pressure, but we often, reproductive aged women are on it because it has some anti-androgen properties, so it can help treat acne and it can help treat what we call hirsutism, which is women who can, you know, sometimes have, can develop hair on the lip, abdomen, belly, or sometimes hair thinning on our, our on our head. And so those typically, those symptoms come from high, what we call androgens, which are like testosterone. DHEs are, are male hormones. And one of the subgroup of women that very commonly have high androgens is our patients with PCOS or polycystic ovarian syndrome. But other women don't have PCOS and isolated, have these symptoms and, and may be on these medications. So we always take patients off these medications when they want to get pregnant because there is concern that by lowering these male hormone levels that there can be some feminization of any male embryos. But we don't, you know, it was always a question, well, if someone's freezing their eggs, they're not trying to get pregnant now, do we need to take them off of this medication before doing an egg freezing cycle? And overwhelmingly, there really hasn't been good data or, or evidence one way or the other. One of the big side effects of spironolactone is it does cause irregular menstrual cycles in a lot of women. We know it has some weak progestin effects. And so there is concern would this affect, you know, the number of eggs retrieved, the number of mature eggs, the ones that are gonna have the ability to, to fertilize? And so that is sort of what led to the interest of this project.
Rena: How did you even come up with this to study?
Dr. Thornton: So we came up with it last year at… Dr. Ghofronian and I were actually working on a project where we were looking at high levels of testosterone for transgender males who were on testosterone prior to egg freezing and wondering if that was gonna increase or in affect, sorry, outcomes. And so that got us thinking, well, if we're looking at what higher levels are doing, what about the reverse with spironolactone where we're trying to lower those levels, is there gonna be any sort of impact or outcome changes?
Rena: Yeah. And and is spironolactone primarily used? I mean, before the podcast you were talking about it treating acne or hirsutism, which you know, I've always heard related to PCOS. So is it primarily used for people of PCOS or who would be prescribed spironolactone?
Dr. Thornton: So it is a lot of PCOS patients. So I would say that the most common group of women that I have that are thinking of freezing their eggs that are on this medication are women with PCOS. But PCOS is a spectrum, so hirsutism and acne is not enough to lead to the diagnosis. Some people have regular menstrual cycles, they don't have PCOS ovaries and you know, genetic or what, what, maybe they're just more prone to this. So it doesn't, you know, it's not exclusive for PCOS, but it is a common medication prescribed to women with that disorder.
Dara: Yeah, it was interesting. I was doing some research and I was like, Ooh, it's actually a blood pressure medication. I just love med medications that sometimes are used for one thing and we find out that it could also be helpful for other aspects. So it, it appears that this is one, because I was thinking, I'm like how many pe, how many of our patients come in with high blood pressure? You know, long-term high blood pressure. But the fact that it can be used for, and I, I see a bunch of patients who are on it who have PCOS and my thought was always, okay, when someone wants to get pregnant, they should be off of it. But it never occurred to me - okay, what about those patients who just wanna freeze their eggs? That's, you know, something a little bit more nuanced and would the same recommendation hold true for that?
Dr. Thornton: Yeah, and I would say clinically it's always a question I have. Like I'm always telling patients, well we don't know. We know it has some hormone effects. We know it makes your cycles irregular, but I don't have good evidence to say you need to discontinue it. I don't have good evidence saying that it's, you know, you know, helpful if you stop it. Like, it's sort of a conversation. And so most of the time if I have a patient that's like, oh my gosh, my symptoms are so horrible. If I come off of it, I, we usually often opt to stay on it. And a lot of people, if they're like, well, I can easily just go off of it for a short period of time, then we often say, well, okay, just to be really overly cautious, maybe we should just stop it because we, we don't know. And so I was always, you know, asking other physicians like, what are you doing? Everyone had a different consensus because none of us really knew data-driven-wise what we should be doing in these scenarios.
Rena: So what did your study find?
Dr. Ghofranian: So I will talk about a little bit of the methods first and then we can get into what we found. But basically what we did was we looked back at all of our patients who had a history of spironolactone use, who underwent egg freezing cycles between 2011 and 2022. We didn't include patients who had prior ovarian surgery, chemotherapy, any ovarian pathology or patients who had a history of gender affirming testosterone therapy since that could skew our results. And then we compared the patients who continued spironolactone during their cycle with patients who discontinued it before starting as well as to a control group of patients who had no history of spironolactone use. And we matched those patients by age and their BMI and their AMH levels. And what we ended up with was 105 patients who continued spironolactone during their cycle, 56 who discontinued it, and then our matched control group of 315 patients without any spironolactone use in the past. And what we found was that there was no difference in the number of eggs retrieved or the number of mature eggs that were frozen between patients who continued spironolactone and our control group or between patients who continued or discontinued spironolactone. And we also looked to see if there was any difference in the dose of spironolactone between the subgroups or if there was any association with the dose of spironolactone, the number of eggs that were frozen or any difference in stimulation parameters like peak estrodiol or progesterone. And basically none of the findings showed any significant difference or association.
Dara: That's reassuring. Really! I mean, and I was impressed to see that 105 you were able to get 105 patients who were still on it?
Dr. Ghofranian: Yeah, yeah, it was, it was a really interesting finding and I think it, you know, obviously having more patients, you know, the more patients in the study the better and there are some limitations, but so far the the findings are very reassuring that people that are significantly affected by their symptoms that we were talking about earlier may not, you know, need to come off of the medication.
Rena: So that sounds like it's pretty groundbreaking and you know, reassuring for people that they can stay on this medication that's really helping them while they go through the process.
Dr. Thornton: Yeah, I mean I think it definitely is going to like, changing how I'm starting to counsel patients because now I actually have some data and information rather than being like, well we don't know one way or the other. There are unfortunately always limitations with every study. And so I think the next big step for this study is we, we wanna take a look at people with spironolactone use who continue versus discontinue in controls when they come back to thaw their eggs and just make sure that we're not seeing any difference in thaw survival or fertilization or a number of healthy embryos and, and pregnancy outcomes. At this point in time, I, I don't think we have enough patient numbers of people who use the eggs. So that will definitely be the, I would say the next step to make sure that the full circle, everything is looking reassuring, but at, at this point in time, you know, things are looking more positive in the sense that people likely can continue this medication.
Dara: That's great. I was gonna ask whether you plan to follow these patients to see, you know, long-term the potentials, but that's, I think it's a great starting point in terms of, of reassuring patients. I think there's a lot of, a lot of a muddle area, like a, an in-between area of like, we're not quite sure, the research is not, isn't there. So we always wanna err on the side of caution, but it can be really tough I think for patients who have found success in a medication and are afraid that if they get off of it, like, how it can change things. And this is a great step towards that reassurance for them. And in terms of like, future research in this area, in this field, is there anything else that you kind of wanna do testing on?
Dr. Thornton: I mean for me the main one is wanting to see the thaw, that thaw outcomes in pregnancy rates. And of course, you know, I I think the other area too is I think a lot of patients when they stop it, we have also a lot of people the different methods. Some people are off of it a couple months, some people a couple weeks. And so it would be good to get more definitive timelines and just saying, you know, is if people are just stopping it when they start meds right away is is that, you know, have any difference versus somebody who went off a couple months. I mean overwhelmingly we're probably not gonna see much differences based on the fact that we haven’t at this point. But those are the other questions that as a clinician I have, but the main one really being the, the pregnancy outcomes, but the fact that the number of eggs, the number of mature eggsis the same is is really reassuring at this point in time.
Rena: Yeah and it's wonderful because I think, you know, so many of my patients struggle with wanting to know specifically, you know, in in my role about mental health meds and you know, for a physician to say, well we don't know, right? Like, hmm, you could stay on or you couldn't, we don't really know. There's no evidence and I think that's so hard for a patient to then make the choice. And so the fact that you have concrete information, you can back this up with a study and say something concrete is amazing for people.
Dr. Thornton: Yeah and I would say I feel like I was always one of the more conservative ones who was like, I don't know, I was like, you know, if you can out abundance of caution because what if we find something out? And so it's definitely, you know, it's great having this information. It definitely I think will change the way we all counsel patients and, and I see so many PCOS patients, so I have a lot of patients on spironolactone. It's something I encounter, you know, at least once a week if not more. And I, I know we've all been on this podcast before and I know Dara and I have talked about our personal history with PCOS, but I think it's something of a personal interest to me as well. I'm excited for it to be presented at ASRM.
Dara: It’s brilliant how this came about. Not like by default, but basically 'cause you wanted to see what it would be like to test the opposite side. So it, it's interesting how something that kind of, you know, came by happenstance, like just the topic ended up really having some interesting results that I know not only will the, the, you know, people at ASRM appreciate, but our listeners I think will really, really appreciate hearing as well. So it's, good luck and, and congratulations really on such interesting findings and for all the hard work that you've put into this abstract. Really appreciate it.
Dr. Ghofranian: Thank you. Thanks for having us.
Rena: Well thank you so much for coming on and sharing this. We like to call our little ASRM podcast. They're kind of just little snacks or snapshots of the studies, but it's so nice that we can share another avenue, the amazing research that's being done out of RMA so we so appreciate you coming on and the way that we like to end our podcast is by sharing a gratitude. So something that you're grateful for today.
Dr. Ghofranian: I guess I can start. I just started my genetics rotation, so I am grateful for the opportunity to see what all the screening and things we. in counseling. we do, how that stuff comes to fruition and giving it more context for our counseling.
Dr. Thornton: I'm just grateful it's October. It's one of my favorite months. I love seeing the, the fall and apple picking and leaves changing. So I'm just grateful for the time of year and the moment
Dara: You took the words right out of my mind, Dr. Thornton. I was gonna say apple picking. I went apple picking for the first time in like, I wanna say 10 years and we had a very warm start to October, so I'm very grateful for going apple, picking in sunshine. Rena?
Rena: I will say I'm just kind of grateful for human kindness. My little pup has been quite sick and people have just been so kind. I don't usually ask for help or show emotion. Usually I'm the one helping other people, but people have just been really kind, so it's just been really nice to, to get that from other people.
Dara: Sending love to your dog and sending love to you.
Rena: Oh, well, lots of love to all of you. And this was so nice. Thank you both for coming on and sharing this research. Thank you for the work that you do and we're so excited for you to present at ASRM.
Dr. Ghofranian: Thank you.
Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember – you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.