APPROACH TOWARDS

PATIENTS WITH HIRSUTISM

By. Dr. Shaheen

Hirsutism
The excessive growth of terminal
hair in androgen dependent areas in
females .

Hypertrichosis

Excess hair (terminal or vellus) in areas that are

not predominantly androgen dependent in males or
females.

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Pathophysiology

• Production of androgens by the adrenals and

ovaries

• Androgen transport in the blood on carrier

proteins (principally sex-hormone–binding
globulin [SHBG])

• Intracellular modification and binding to the

androgen receptor

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Causes of Hirsutism
Ovarian causes
- Polycystic ovarian syndrome
- Neoplasms

Adrenal causes
- Congenital adrenal hyperplasia
- Cushing syndrome
- Neoplasms

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 Cont.
Exogenous causes (drugs)

- Cyclosporine
- Phenytoin
- Glucorticoids
- Minnoxidil
- Anabolic steroids
- Diazoxide
- Phenothiazine

Idiopathic

- Hair follicles are more

sensitive to normal levels of
androgens
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Other Causes

• Acromegaly

• Hypothyroidism

• Hyperprolactinemia

• Gonadal dysgenesis

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 POLYCYSTIC OVARIAN SYNDROME

National institute of health criterio

1- Clinical acne & hirsutism and /or biochemical
hyperandrogenemia

2- Menstrual irregularity

Rotterdam Criterio
1-Clinical acne & hirsutism and /or biochemical
hyperandrogenemia

2- Menstrual irregularity

3- Polycystic ovarian morphology on USG

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Congenital Adrenal Hyperplasia
• Enzyme deficiency of 21 hydroxylase

• 3B & 11 B hydroxylase deficiency

Types

1- Salt losing type

2- Simple virilizing type
3- Non classic ,adult onset type
4- Cryptic type

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 Congenital Adrenal Hyperplasia

Enzyme deficiency of 21 hydroxylase

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HISTORY
• Age at onset

• Rate of evolution

• Features of virilization
– Alopecia
– Frontal balding
– Hoarseness of voice
– Increased muscle bulk
– Decreased body fat
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 Cont.
• Family History

• Drug History
- Glucocorticoids
- Anabolic steroids
- OCP’s/ POP’s

• Medical History
- H/O Diabetes mellitus
- H/O HTN

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 Menstrual History
- Menstrual irregularities
(oligomenorrhoea,amenorrhoea,menorrhagia)

Reproductive history
- Infertility

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Other associated features

- Recent weight gain or weight loss

- H/O flank pain or mass

- Childhood Dehydration

- Precocious Puberty

- H/O breast discharge

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Ferriman & Gallway Score

• A quantitative method
of measuring hair
growth for the
determination of the
severity of hirsutism
by assessing the extent
of hair growth in 9 key
anatomic sites

• Upper lip
• Chin
• Chest

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Cont.

• Upper arm
• Upper abdomen
• Lower abdomen
• Thigh
• Upper back
• Lower back

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 PHYSICAL EXAMINATION
• Appearance / height /
weight / BP

• Pattern & severity of

hair growth

• Each area with point

score 0 for no hirsutism
& 4 for virile.

• Score of 8 or high is
consistent with
hirsutism.
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Cushingoid features

- Centripetal Obesity

- Moon facies

- Buffalo hump

- Skin atrophy

- Striae,acne

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 Systemic signs of virilization

- Deepening of voice

– Increased muscle bulk

– Breast atrophy

- Decreased body fat

- Receded temporal hair

– Clitromegaly

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Signs Of Insulin Resistance
- Acanthosis Nigrans.
- Obesity

Abdominal Palpation & Bimanual

pelvic examination
- Ovarian or pelvic Mass

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INVESTIGATION

Serum Testosterone

- Screening method …. Total testosterone

- Range …………………………. 70 – 90ng/dl

- Mild increase ………………. PCOS

- If > 200ng/dl or in post-menopausal >100ng/dl

,tumor workup is necessary
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 Serum DHEA-S

- Normal level …………Ovarian Origin

- Moderate elevation …… Adrenal Origin

- >700mg/dl (400mg/dl in postmenopausal) ….Suggest

tumor workup

Serum Androstenedione

- >100mg/dl suggest Ovarian Neoplasia

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LH & FSH level

• In Pco’s;

- LH increase
- FSH decreased
- LH:FSH >2

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17 Hydorxyprogesterone

• Screening test

• Levels >800ng/dl …. Diagnostic of 21

hydroxylase deficiency

• Intermediate level .. 200 – 800 ng/dl (ACTH

stimulation test)

Serum prolactin levels

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• Serum cortisol levels

• Urinary cortisol

• Urinary 17 ketosteroid

• Blood sugar fasting

• Thyroid profile

• Imaging studies( ultrasound,CT scan ,MRI, X-ray)

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Investigations

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Treatment
Physical & Topical Measures

- Pluck
- Shave
- Bleach
- Wax
- Depilatory creams
- Electrolysis
- Laser

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Pharmocological Measures
Oral contraceptive pills

- Hirsutism caused by ovarian hyperandroginism and

idiopathic hirsutism.

Cyproterone (Diane-35)
– Synthetic progestogen

– Androgen receptor blocker

– Dose 50-100 mg for 10 days

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Spironolactone (Aldactone)
• Anti adrogenic effect
• Dose 50-200 mg daily or cyclically for 3 weeks

Flutamide (Eulexin)
– Anti androgen by blocking androgen receptors

Finasteride
- 5 Alpha reductase inhibitor
- Blocks conversion of testosterone to it’s more
active form

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Glucocorticoids

– For classic CAH, systemic corticosteroids are used.

Metformin

– Hirsutism associated with insulin resistance and

hyperinsulinemias

GnRH Agonist

– Inhibit LH production
– Suppression of ovarian androgen production

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Summary

• History

• Examination

• Investigation

• Treatment

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