Hirsutism

Definition: Excessive male-pattern hair growth

· affects between 5-10% of reproductive-age women

· note that VIRILIZATION is when androgen levels cause not only hirsutism but also additional signs/symptoms such as voice changes, increased musculature, clitoromegaly, etc.

Differential Diagnosis

1) Hypertrichosis: hair would be distributed in a generalized, non-sexual pattern

2) Idiopathic (familial trait, more common in some ethnic groups)

3) Various causes of hyperandrogenism

a. PCOS (most common cause of hirsutism)

i. Insulin resistance leads to increased insulin levels; insulin stimulates ovarian theca cells to produce more androgens

b. Congenital adrenal hyperplasia (Non-Classical)

c. Androgen-secreting tumors

i. Would see a rapid rate of hair growth a, evidence of virilzation (clitoromegaly, increased muscularity)

d. Cushing’s syndrome

e. Hyperthecosis

i. Increased production of testosterone from theca cells of the ovaries

f. Hyperprolactinemia

g. Acromegaly

h. Thyroid Dysfunction

i. Obesity or insulin resistance

j. Idiopathic Hyperandrogenism

i. Idiopathic production of androgen precursors leads to increased androgen levels

k. Androgenic medications

i. Examples: valproate, steroids, cyclosporine, minoxidil (also known as Rogaine – can be used for high blood pressure), penicillamine, metaclopramide, and more

Criteria for Assessing Hirsutism

Ferriman-Gallwey Scoring System

· looks at NINE body areas that are sensitive to androgens: lip, chin, back, abdomen, arms, and thighs

· each location scored between 0 and 4; higher than 8 is considered androgen excess in Caucasian women (varies between different ethnic groups)

o Mediterranean women have more hair while Asian and Native-American women have less hair but, notably, all have similar androgen levels

Diagnosis

· NOTE: androgen levels are NOT well-correlated to the level of hirsutism

When To Test:

* Hirsutism is moderate or severe OR a secondary cause is possible

When NOT to Test:

· Hirsutism is mild, patient is having a regular period, and secondary cause (such as ovarian tumor) is unlikely à most likely idiopathic

TESTS TO RUN

Random Testosterone Level

· If normal, supports idiopathic hirsutism

· If elevated, need to order a plasma free testosterone level

Plasma free testosterone level

· If elevated, refer to an endocrinologist

o If due to free testosterone, related to LOW levels of SHBG (sex-hormone binding globulin) – total testosterone could be normal but low binding levels mean free testosterone is elevated

· Test 50% more sensitive than total testosterone

· Testosterone excess usually due to ovarian origin, DHEA from adrenal origin, and androstenedione from adrenal or ovarian origin

Pelvic Ultrasound

· indicated if concerned for PCOS

Ovarian Ultrasound and/or Adrenal Ultrasound

· for concern about androgen-producing tumor

Management/Treatment

· management guided by the degree to which the patient is bothered by the hair growth

Cosmetic Management

· Bleaching

· Shaving

· Eflornithine hydrochloride cream (Vaniqa) for facial hirsutism

· Electrolysis

o Works by destroying individual hair follicles

· Laser treatment

o Has less pain and side effects than electrolysis, decreases cosmetic measures for months, can permanently decrease hair density after 3-4 treatments

Hormonal Management

· Anti-androgens (high dose spirinolactone)

o Off-label use à there is a risk of pseudohermaphroditism in male fetuses if woman becomes pregnant

· Estrogen-Progestin (Oral Contraceptives) à need to use nonandrogenic progestins

References

1.) Rosenfield RL. Hirsutism. NEJM. 2005; 353: 2578-2588.

2.) Ferriman, Gallwey. Clinical assessment of body hair growth in women. J Clinic Endocrinol Metab 1961; 21:1440.