Download DRAFT `HIRSUTISM PATHWAY` v1 7

PRIMARY CARE MANAGEMENT PATHWAY: HIRSUTISM
JAN 2013. Dr J Webster & Endocrine Team, Dr Jenny Stephenson
Definition:
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Hirsutism is the growth in a woman of androgen-dependent thick dark hair where
it is usually absent, such as on the face, round the nipples and on the chest.
Causes:
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Many cases are “idiopathic”. This is often familial or racial
Commonest underlying pathology is polycystic ovary syndrome (PCOS)
Less frequent causes include congenital adrenal hyperplasia, Cushing’s
syndrome and ovarian or adrenal androgen-secreting tumours
Drug therapy
Diagnosis:
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PCOS: 2 out of 3 of: a) infrequent or absent periods; b) hirsutism and/or raised
testosterone; c) polycycstic ovaries on ultrasound scan. Raised BMI often (but
not always) present.
Androgen-secreting tumours of ovary or adrenal: signs a) rapid onset of hirsutes,
which can be severe; b) virilisation eg male pattern baldness, deepening voice,
clitoromegaly. c) possible pelvic or abdominal mass; d) loss of breast tissue
Idiopathic: Exclude other causes. Often familial; normal testosterone levels;
onset soon after puberty; slow progression; normal periods and no signs of
virilisation.
Drugs: Anabolic steroids, phenytoin, progestogens, ciclosporin, methyldopa,
minoxidil.
Differential Diagnosis:
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Hypertrichosis is the differential. This is the uniform growth of vellus (soft downy)
hair all over the body, especially in non-sexual areas. It can be familial, drugrelated or be associated with other conditions such as anorexia nervosa.
Investigation:
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If PCOS is suspected, check LH/FSH (ratio typically increased), testosterone
(typically mildly raised). USS not required if clinical and biochemical picture
typical.
Women with confirmed PCOS and high BMI should be offered blood glucose and
lipid profile
In other cases, check Testosterone, Free Androgen Index, LH/FSH, TFT,
prolactin and 17-hydroxyprogesterone.
If Cushing’s syndrome is suspected, refer to Endocrinology
Management:
 PCOS – manage the BMI and cardiovascular risk along the usual lines, as the
condition may improve with weight loss. Metformin may be helpful in improving
insulin sensitivity, menstrual irregularity and hirsutism.
 A combined pill containing a non-androgenic or anti-androgenic progestogen
(Yasmin or Dianette, respectively) may help, but effects are slow, taking at least
6 months.
Local treatment with eflornithine cream (Vaniqa): shared care protocol available;
http://www.sheffield.nhs.uk/professionals/resources/scps/scp_eflornithine.pdf.
Laser therapy or electrolysis can be effective but are not available on the NHS.
Referral Pointers:
 Refer if any suspicion of adrenal or ovarian tumours following clinical and
biochemical assessment
 Refer if Cushing’s syndrome is possible
 Refer if the problem is worsening despite treatment as above