Hirsutism

Dr : Doaa mosaed Shohait

Hirsutism

Excessive growth of

aondrogen dependent

sexualhair (present on the

,upper lip, chin, inner thighs

limbs, chest, abdomen and

.)pubic triangle
Hypertrichosis; Excessive growth of aondrogen▪

independent hair (as in the forearm and legs)

Virilization; is hirsutism associated with other▪
signs of hyperandrogenism such as; increased
muscle mas cliteromegaly, temporal baldness, and
.voice deepening
CLASSIFICATION

Mild: fine pigmented hair affecting the face, chest, ▪

.abdomen and perineum

Moderate: coarse pigmented hair affecting same areas ▪

.as in mild cases

Severe: coarse pigmented hair affecting the face ▪

,(complete beard), tip of nose, ear lobes, chest

.abdomen, and perineum

AETIOLOGY
:ldiopathic ▪

increased hair follicles sensitivity to normal female

androgen levels

Increased receptor activity in the skin, or✓

Increased activity of the enzyme 5 alpha✓

reductase (responsible for conversion of T

)into DHT which has a more potent action than T

:Adrenal gland causes ▪

Congenital adrenal hyperplasia ✓

Adrenal tumours: secrete DHA,DHAS, and rarely ✓

.Testosterone
:Ovarian causes

,PCOS✓

Androgenic ovarian tumors as Sertoli lyedig cell✓

tumor, adrenal rest tumor, hilar cell tumor, and
.gonadoblastoma
:Pituitary gland

Cushing's syndrome due to increase production of ✓

.ACTH

.Acromegaly due to increased production of GH✓

Androgenic drugs: Rarely, long term use of drugs with ▪

androgenic side effects (as Danazol in endometriosis)
.may cause hirsutism and virilizing effects
Diagnosis

HX .

examination

for the site, density, and character ✓

of the hair investigations

INVESTIGATION
a. Hormonal assays ▪

Plasma T level (n= 0.2-0.8 ng/ml),levels > 2 ng/ml✓

.suggest androgen secreting tumor

Free T level (n= !-3% of total T) it is a✓

.good index for androgenicity

DHAS (n= 1500-2500 ng/ml), levels ✓

.ng/mls suggests adrenal tumour 9000 >

- :Radiological investigations

.CT or MRI on the pituitary gland✓

.IVP and abdominal US for adrenal tumor✓

Pelvic US, for PCOS, and virilizing ovarian✓

.tumors
;Treatment of hirsutism includes

,elimination of the cause✓

,suppression of androgen synthesis✓

use of androgen receptor blockers, and✓

.mechanical removal by depilation✓

Hair removal techniques .2 ▪

Shaving, tweezing, waxing, and✓

,use of depilatories✓

performed at repeated intervals Bleaching is✓

effective for mild hair growth

Permanent destruction of hair follicles by✓

.electrolysis or by laser is reasonably effective
Suppression of androgen synthesis .3 ▪

Oral contraceptive pills (OCPs), containing combined✓

low dose E and P, decrease ovarian androgen
production,increases SHBG, and decrease free T levels.
Progestins may also inhibit 5- alpha reductase activity

Corticosteroids (dexamethasone 1-5 mg/day ) induce✓

suppression of adrenal androgen production in severe

cases of CAH
Spironolactone is an aldosterone antagonist used✓

frequently as a diuretic that also inhibits 5alpha

reductase and variably suppresses ovarian and
adrenal synthesis of androgen

Cypretorone acetate is a potent progestin and✓

antiandrogen that inhibits LH and decreases

androgen levels
 HYPERPROLACTINAEM IA
AND GATACTORRHOEA

; :A. PITUITARY ADENOMAS ▪

Microodenomas (< 10 mm in size): these are the ✓

,commonest

and are usually associated with moderate elevations in

.serum PRL levels

Macroodenomos (>10mm in size): are relatively rare,✓

and are

associated with high serum PRL levels and possible signs

of increased intracranial tension (lCT). - Diagnosis and
Treatment: (see hyperprolactinaemia)
Prolactin is a polypeptide hormone secreted by the

.lactotrophic cells of the anterior pituitary gland

lts secretion is controlled by hypothalamic Prolactin ▪

.inhibiting factor (PlF) known as dopamine

:Hyperprolactinaemia; elevated serum Prolactin levels (N

).ng/ml 2.9-29

Galactorrhoea; refers to the continuous extrusion of ▪

milk from the nipples in the absence of recent pregnancy
or lactation. Lt is almost always secondary to
.hyperprolactinaemia
AETIOLOGY

.Physiologic causes✓

.Drug induced✓

Primary hypothyroidism: due to persistently elevated✓

.TRH levels

;Prolactin secreting pituitary adenomas (Prolactinomas)▷

Microadenomas (tumours < 10 mm) are a common cause

.for hyperprolactinaemia

Macroadenomas (tumours > 10 mm) are rare; may be▷

. associated with other symptoms and signs

Hypotholamic disorders: ) Severe stress and .5 ▪

.psychological conditions

Hypothalamic tumors (craniopharyngioma); cause ▪

damage to hypothalamus, or compression on the

pituitary stalk interfering with production of
.prolactin, or transport of dopamine
 CLINICAL PICTURE

Mastalgia (breast pain and tenderness), with or ✓

without galactorrhoea

Menstrual disorders (irregular cycles, 2ry✓

amenorrhoea);due to chronic anovulation

Infertility; due to anovulatory dysfunction (PRL ✓

interferes with GnRH pulses and with ovarian
.sensitivity to pituitary gonadotrophins)

.✓
DIAGNOSIS

History✓

Clinical Examination✓

:Diagnostic Investigations✓

:Laboratory

elevated serum PRL levels (N: 2.9-29 ng/ml)

N.B.: markedly elevated levels of PRL > 100 ng/ml
suggest PRL secreting adenomas. ) C.T scan and
MRI: in cases of persistently high serum PRL
levels, or in cases with signs of increased
intracranial tension suggestive of brain tumours
 TREATMENT

Stop medications ✓

) Treat primary hypothyroidism ✓

Drugs used for treatment of hyperprolactinaemia ✓

(dopamine Agonists

:Treatment of pituitary adenoma .

Medicol treatment: using dopamine agonists; is ✓

.the primary treatment for most cases

,Trons-sphenoidol surgery ✓