hirsutism
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Introduction
An androgen-dependent condition in women characterized by excessive growth of body hair following a male distribution pattern.
Etiology
- idiopathic
- polycystic ovary disease (50-70%)[3]
- hyperandrogenism, insulin resistance & acanthosis nigricans (HAIR AN)
- adrenal hyperplasia
- 21-hydroxylase deficiency
- 11-hydroxylase deficiency
- Cushing's syndrome
- adrenal neoplasm
- ovarian neoplasm
- prolactinoma[3]
- arrhenoblastoma (Sertoli-Leydig cell tumor)
- gynandroblastoma
- thecoma
- Brenner tumor
- lipid cell tumor
- gonadoblastoma
- pharmacologic
- testosterone containing topical agents
- anabolic steroids: DHEA
- danazol
- progesterone-dominant oral contraceptives
- high-dose glucocorticoids
- acetazolamide[3]
- corticotropin[3]
Clinical manifestations
- excessive growth of body hair following a male distribution pattern
- terminal hairs on the abdominal midline below the umbilicus
- deepening of voice
- acne
- clitoromegaly
- decreased breast size
- male balding pattern[3]
Laboratory
- serum DHEA-sulfate (DHEAS) [0.4-3.2 ug/mL]
- values > 8 ug/mL diagnostic for androgen-producing adrenal carcinoma[2]
- serum testosterone [0.2-0.7 ng/mL]
- if > 200 ng/mL, suspect ovarian tumor
- if < 200 ng/mL, suspect polycystic ovary disease or other cause
- normal serum DHEA (serum DHEAS) with high serum testoterone suggests ovarian source of androgen excess[3]
- screening tests for Cushing's syndrome
- serum androstenedione [0.5-2.5 ng/dL]
- serum luteinizing hormone (LH) [5-25 mIU/mL]
- serum follicle-stimulating hormone [5-20 mIU/mL]
- serum prolactin [2-15 ng/mL]
- 17-hydroxyprogesterone in serum*[3]
- CA-125 in serum[3]
* CT of adrenals & ovaries is 1st line[10]
Radiology
- transvaginal ultrasound to examine ovaries[3]
- 1st test when serum testosterone > 150 ng/dL
- computed tomography to visualize both adrenals & ovaries
- 1st test when serum DHEA-sulfate > 700 ug/dL[3]
- 1st test after onset of virilization in women[10]
Differential diagnosis
- in contrast to hypertrichosis, the excess hair in hirsutism is terminal hair; there is no increase in vellus hair
Management
- cosmetic depilation
- bleaching of hairs
- medical (based upon reducing/antagonizing androgens)
- oral contraceptives (first line)[3]
- idiopathic hirsutism
- polycystic ovary disease
- spironolactone (androgen antagonist) is added only when oral contraceptive is insufficient[3]
- teratogenic, do not use without contraception
- eflornithine
- finasteride[3]
- oral contraceptives (first line)[3]
- obesity control
- glucocorticoids for management of late onset congenital adrenal hyperplasia
More general terms
Additional terms
- Cushing's syndrome; hypercortisolism; hyperadrenocorticism; pluriglandular syndrome
- Stein-Leventhal (polycystic ovary) syndrome
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 619-21
- ↑ 2.0 2.1 Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 243-46
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18. American College of Physicians, Philadelphia 2012, 2015, 2018.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Martin KA, Chang RJ, Ehrmann DA, Ibanez L et al Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008 Apr;93(4):1105-20 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18252793
- ↑ Curran DR, Moore C, Huber T. Clinical inquiries. What is the best approach to the evaluation of hirsutism? J Fam Pract. 2005 May;54(5):465-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/15865908
- ↑ 6.0 6.1 Griffing GT, Rivlin ME (images) Medscape: Hirsutism http://emedicine.medscape.com/article/121038-overview
- ↑ 7.0 7.1 DermNet NZ. Hirsutism (images) http://dermnetnz.org/hair-nails-sweat/hirsutism.html
- ↑ Mimoto MS, Oyler JL, Davis AM Evaluation and Treatment of Hirsutism in Premenopausal Women. JAMA. Published online March 9, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29522641 https://jamanetwork.com/journals/jama/fullarticle/2674903
- ↑ Mihailidis J, Dermesropian R, Taxel P Endocrine evaluation of hirsutism. Int J Womens Dermatol. 2017 Feb 16;3(1 Suppl):S6-S10. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28492032 Free PMC Article
- ↑ 10.0 10.1 10.2 NEJM Knowledge+ Endocrinology