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HIRSUTISM
Definition
Hirsutism
• Excessive growth of hair in abnormal
position on the body
Virilism
• Masculinization of female i.e. deepening of
voice, male type baldness, clitoral
hypertrophy, breast atrophy, increased
musculature and oligo or amenorrhoea
Pathogenesis
• Increased circulating androgens ovarian or
adrenal in origin
• Increased free testosterone due to
decreased SHBG
• Increased peripheral conversion of
testosterone to DHT due to increased 5
alpha reductase activity
• Genetic ir racial predisposition
Causes
1. Ovarian
PCOS
Tumours
2. Adrenal
CAH
Tumours
3. Pituitary Tumours
ACTH secreting (Cushing’s disease)
Prolactin secreting
Growth hormone secreting (acromegaly)
Causes
4. Ectopic ACTH producing tumours
(bronchus, pancreas, thyroid, thymus)
5. Iatrogenic
Androgenic drugs(testosterone,
danazol ,glucocorticoids,progestogens,
phenytoin)
6. Idiopathic
Polycystic Ovarian Syndrome
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LH:FSH ratio of 3:1
Baseline estrogen level increased
Hyperprolactinaemia (15%)
Testosterone slightly raised (< 5 nmol/L)
Ultrasound criteria
Peripheral distribution of 10 or more follicles 2 to
8 mm in diameter
• increased ovarian stroma
• Increased ovarian volume
Idiopathic Hirsutism
• Absence of an identifiable pathology
• Increased end organ sensitivity to normal
androgens level due to increased 5 alpha
reductase activity
• Regular menstrual cycle
• Normal ovaries on ultrasound
• Serum testosterone <5 nmol/l
(After excluding all possible organic causes )
• Normal LH,FSH, prolactin and estrogen
Congenital Adrenal Hyperplasia
• Excessive production of androgens due to
deficiency of enzymes required for
biosynthesis of glucocorticoids
• Raised testosterrone level > 5 nmol/l
• Raised serum 17 alpha hydroxy
progesterone
• Raised urinary ketosteroids
Cushing Syndrome
• Over production of cortisol by adrenals
due to excessive production of ACTH
• 24 hrs urinary free cortisol
• plasma cortisol
• ACTH levels
Androgen Producing Ovarian
tumours
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Mostly benign in young females < 30 yrs
Androblastoma, luteoma
Hirsutism is rapid in onset
Signs of virilism
Serum testosterone grossly elevated
Diagnosed by USG, CT or MRI
Adrenal Tumours
• Marked hirsutism associated with virilism
• Common in premenopausal women
• Serum testosterone & DHEAS are
markedly raised
• Final diagnoses is made by CT scan or
MRI
Acromegaly
• Excessive production of growth hormones
by pituitary adenoma
• Raised growth hormone levels during GTT.
In normal subjects growth hormone levels
are suppressed during GTT
• X – ray skull, CT scan and MRI may be
useful
Iatrogenic Hirsutism
• Androgenic drugs
• Hair growth returns to normal once the
drug intake is stopped
Management
History
• Duration of complaint
• Hair distribution on body & rate of growth
• Weight gain, oligomenorrhoea, infertility
with hirsutism suggestive of PCOS
• Deepening of voice, reduction in breast
size, secondary amenorrhoea, changes in
external genitalia to rule out adrenal or
ovarian tumours
• H/o primary amenorrhoea with hirsutism
suggests CAH
• Changes in facial appearance , striae on
skin , polyuria & polydypsia indicates
Cushing syndrome
• Drug history
• H/o galactorrhoea & enlargement of
extremities suggests acromegaly
• Family history
Examination
• Weight & BP
• Whole body inspection
• Examination of breasts, extremities, facial
changes
• Ophthalmic exam
• Abdominal exam for any mass
• Pelvic exam for clitoromegaly, labial
thickening, uterus and adnexa
Investigations
a. Hormonal levels
 First line in every patient
• FSH, LH, testosterone, prolactin, and
DHEAS
 Second line
• 17 alpha hydroxyprogesterone, cortisol &
growth hormone
Investigations
• Ultrasonography
• Ct & MRI of pituitary & adrenals
Treatment
Aims of treatment
• Counselling
• Weight control
• Cosmetic treatment
• Suppression of excessive androgen
production
• Prevent new hair growth by antiandrogens
Cosmetic treatment
• Useful in mild hirsuitism
• Must be used alongwith medical therapy
• Methods are: shaving, bleaching, waxing,
plucking,electrolysis & laser.
• Laser & electrolysis are most satisfactory
Antiandrogens
• Cyproterone acetate
– Can be used alone or with COC
– Preferred is Diane-35
• Spironolactone
• Flutamide
• Ketoconazole
Suppression of excessive
androgen production
Ovarian suppression
• COC
• GnRH analogues
• Surgical
– Ovarian wedge resection
– Laproscopic drilling
– Bilateral oophorectomy
Adrenal suppression
• Small nocturnal dose of
dexamethasone(0.25-0.5 mg) to lower
elevated levels of DHEAS
• Combination of COC & dexa can be used
5 alpha reductase inhibitors
• Finasteride to suppress active form of
testosterone
Efficacy of treatment
• Take 03 to 06 months to show its effects
• 60 – 70 % improvement by the end of 12
months
• Maintenance therapy is needed to prevent
recurrence
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