VIMS Journal: July 2016

Pictorial CME

Hirsutism

Dr. Debdatta Kar, Dr. Jayanta Chakraborty


Hirsutism refers to excess growth of terminal hair in a woman in a male pattern. It is one of the most common endocrine disorders,and implies the presence of abnormal androgen action.

Causes of Androgen Excess in Women of Reproductive Age :
Ovarian :
Polycystic ovarian syndrome
Hyperthecosis
Ovarian tumour (eg sertoli leydig cell tumour)
Adrenal :
Nonclassic adrenal hyperplasia
Cushing syndrome
Adrenal tumour (hyperplasia, resistance)
Glucocorticoid resistance

Specific Conditions of Pregnancy :
Luteoma of pregnancy
Hyperreactio luteinalis
Aromatase deficiency in foetus
Others :
Hyperprolactinaemia
Medications (danazol, testosterone, anabolizing agents)
Idiopathic

Clinical Features :
Age of onset- idiopathic hirsutism usually begins at puberty. Hirsutism that occurs in middle age should point towards probable adrenal or ovarian tumour.
Positive family history points towards CAH, however, idiopathic hirsutism and PCOS can also be familial.
Early development of adrenarche points towards CAH. While ovarian hyperandrogenism is associated with normal adrenarche and delayed menarche.

Physical Examination :
Ferriman and gallwey scale may be used to quantitate androgen overactivity by judging hair growth in each of the 11 androgen sensitive areas. In women with moderate to severe hirsutism, additional signs of hyperandrogenism like temporal hair recession, oily skin etc may be present.
A thorough abdominal and pelvic examination to look for tumors.
Skin examination to look for acanthosis nigricans.

Laboratory Investigations :
- Initial testingl
- Total testosterone
- Prolactin
- TSH
Further testing based on clinical presentation
- 17 OH progesterone
- 17 OH progesterone 60 mins afterintravenous ACTH
- Overnight dexamethasone suppression test
- 8 AM serum cortisol
- DHEAS
- Imaging of ovary/adrenals

Treatment of Hirsutism :
1. lifestyle modification - in obese, PCOS women
2. patient counselling and reassurance
3. systemic therapies-
- Oral contraceptives-ethinyl estradiol,drospirenone and levomefolate
- Ethinyl estradiol and norethindrone
- Ethinyl estrdiol and norgestimate
- Ethinyl estrdiol and drospirenone
Glucocorticoids - prednisone/dexamethasone
Aldosterone antagonists-spironolactone
5 alpha reductase inhibitors- finasteride
Flutamide
Insulin sensitizers-metformin and thiazolidinediones
Cosmetic measures-plucking, waxing, hydrogen peroxide bleaching, shaving, chemical depilatories.
Laser therapy has been shown to be beneficial, not only in reducing unwanted hair, but also to improve depression and anxiety in women with hirsutism.

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