Hirsutism Disease

BASICS

DESCRIPTION

Excessive male-pattern hair growth due to increased androgenic hormones

Often accompanied by menstrual irregularities
Extreme androgenic effects (deep voice, clitorimegaly, balding) is known as virilization
System(s) affected: Endocrine/Metabolic, Reproductive
Genetics: Multifactorial
Incidence/Prevalence in USA: 8% of adult women
Predominant age: Postpubertal females
Predominant sex: Postpubertal females

SIGNS AND SYMPTOMS

Hair thickens and darkens in "male" pattern - beard, moustache, chest hair
Usually accompanied by irregular menses and anovulation
Usually accompanied by acne
May be accompanied by infertility
Onset is usually gradual

CAUSES

Excessive androgenic effects:
- Excess hormone production from the ovary or adrenal gland
- Increased peripheral sensitivity to androgens
- Decreased sex hormone binding globulin
Causes with persistent anovulation:
- Polycystic ovary disease
- Hypothyroidism
- Hyperprolactinemia
Ovarian causes:
- Polycystic ovaries
- Ovarian tumors
- Premature ovarian failure
Adrenal causes:
- Tumor (rare)
- Cushing's (rare)
- Late onset congenital adrenal hyperplasia

RISK FACTORS

Family history
Anovulation

DIAGNOSIS

LABORATORY

Basic workup - total testosterone, DHEAS, 17-OHP, TSH, prolactin
If testosterone > 200, need ovarian tumor workup
If DHEAS > 700, need adrenal tumor workup
LH/FSH ratio is elevated in 75% of polycystic ovarian disease
If testosterone, DHEAS or 17 OHP are elevated, but not in tumor range, treat

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

Fasting glucose to insulin ratio to rule out insulin resistance in polycystic ovary syndrome
Some do endometrial biopsy if > 35 years old
If strong suspicion of Cushing's disease, can do dexamethasone suppression test. Give 1 mg dexamethasone po at PM and draw plasma cortisol at 8:00 am. If cortisol > 5, borderline; if > 10, abnormal.
If 17-OHP is 300-800, do ACTH (Cortrosyn) test (ACTH 0.25 mg IV and check 17-OHP at 0 and 1 hour)
Some do 3 alpha-androstanediol glucuronide to check for peripheral conversion - but not a good test and doesn't change therapy
If DHEAS is high, but not in tumor range, can do low dose dexamethasone test (0.5 mg dexamethasone qid x 5 days, then recheck DHEAS and testosterone - they will decrease if androgens are adrenal and won't if they are ovarian)

IMAGING

If testosterone > 200 or DHEAS > 700, need CT of ovaries or adrenals
Ultrasound can image polycystic ovaries as a supplement to clinical diagnosis

DIAGNOSTIC PROCEDURES

N/A

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Treatment is slow and often lifelong
If patient desires pregnancy, ovulation induction may be necessary
Provide contraception as needed
Encourage patient to maintain ideal weight
Treat accompanying acne

SURGICAL MEASURES

N/A

ACTIVITY

No special activity

DIET

No special diet

PATIENT EDUCATION

Hormonal treatment stops further hair growth but will not usually reverse present hair
Treatment takes 6-24 months and may be life long
Cosmetic measures include - plucking, bleaching, shaving, electrolysis, laser hair removal and cover up cosmetics
Electrolysis should be by a licensed professional

FOLLOW UP

PREVENTION/AVOIDANCE

Tumor must be ruled out before beginning therapy
As hormone balance improves, fertility may increase - provide contraception as needed
Patients desiring pregnancy may need fertility intervention such as ovulation induction
Women with late onset congenital adrenal hyperplasia may be carriers for the severe early onset childhood disease - counsel
Avoid quackery and unlicensed electrolysis
Prolonged amenorrhea may, over time, put the patient at risk for endometrial hyperplasia or carcinoma
There is an increased incidence of diabetes and insulin resistance in polycystic ovarian disease which can increase risk of heart disease

POSSIBLE COMPLICATIONS

Dysfunctional uterine bleeding and anemia
Androgenic excess may adversely affect lipid status, cardiac risk and bone density
Poor self image/shame

EXPECTED COURSE AND PROGNOSIS

Good (with long term therapy) for halting further hair growth
Moderate to poor for reversing current hair growth

MISCELLANEOUS

ASSOCIATED CONDITIONS

Acne
Infertility
Obesity
Hyperinsulinemia

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: Can occur after menopause if peripheral conversion of estrogen is poor
Others: N/A

PREGNANCY

May have related infertility
If pregnancy occurs, must discontinue known contraindicated drugs
Pregnancy outcome is related to underlying cause of hirsutism

OTHER NOTES

N/A

ABBREVIATIONS

LFTs = liver function tests

Clinical Investigations

ROLE OF HOMOEOPATHY

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