4. INTRODUCTION
Hirsutism is a common clinical condition affecting 5-10% of the women across
the globe
Hirsutism has a huge psychosocial impact, especially in the young females
Excess body hair outside of cultural norms can be very distressing
Distinguishing normal variations of hair growth from hypertrichosis and true
hirsutism is important
The cause is mainly hyperandrogenism , which may be ovarian or adrenal. It may
be part of a rare metabolic syndrome, drug induced, or just idiopathic
6. SITES OF HAIR
Non sexual Ambi-sexual Male sexual
Sites Lower parts of the
scalp, eye brow,
lashes, fore-arms,
lower legs.
Temporal & vertical
parts of the scalp,
axilla, lower pubic
hair.
Ears, nasal tip, chin,
sternum, upper pubic
triangle, back.
Depend on Growth hormone
from pituitary.
Androgen in low
concentration from
the adrenals &
ovaries in females &
adrenals in males.
Androgen in high
concentration.
7.
8. HIRSUTISM and SINISTERS
Hirsutism
presence of excessive terminal hair in androgen-dependent areas (male pattern)
in a woman’s body
a sign of increased androgen action on hair follicle (endogenous or exogenous)
increased sensitivity of hair follicles to normal levels of circulating androgens
Hypertrichosis
Androgen independent excess hair growth
May be generalised or localised
May consist of lanugo, vellus or terminal hair
Frequently associated with the use of medication such as antiepileptics
9. Masculinization : the process of becoming more manlike and developing a male hair
pattern, increased pectoral musculature, and huskiness of the voice
Virilization : masculinization associated with a more complete voice change,
changes in libido, and clitoromegaly
SIGNS SUGGESTIVE OF ANDROGEN EXCESS
Acne
Frontotemporal balding
Deepening of the voice
Decrease in breast size
Clitoral hypertrophy
Increased muscle mass
Amenorrea / oligomenorrhea
10. NEED FOR AN APPROACH
Although treatment for hirsutism is sought for cosmetic reasons , hirsutism
may signal more serious internal pathology
Unattended, this can lead to serious psychosocial morbidity,especially in young
females
Therefore , a proper diagnostic approach entails a thorough history , clinical
and biochemical evaluation
11. Evaluation of History
Age of onset :congenital/early onset and late onset
Menstrual history : regular or irregular
Drug intake : drugs causing hirsutism and drugs causing hypertrichosis
12. AGE of ONSET
Congenital /Early onset H. Late onset H.
CAH (Congenital Adrenal Hyperplasia) Idiopathic hirsutism
Pituitary adenoma PCOS (Polycystic ovarian syndrome)
Acromegaly Late onset CAH
13. MENSTRUAL HISTORY
Normal Abnormal
Hair pattern Hair pattern
Vellus Terminal Vellus Terminal
Ethnic variation Misunderstanding of normal hair pattern Medications Medications
Medication Hirsutism by proxy
Delusional fixation
Plasma Testosterone
>2ng < 2ng
Nonclassic CAH Insulin Resistance
17. VELLUS VS TERMINAL HAIR
Vellus Terminal
Medication History Menstrual History
Positive Negative Normal Abnormal
18.
19. Modified Ferriman-Gallwey score : Nine body regions are evaluated for their degree of hair growth from 0–4.
A total score >8 is a sign for hirsutism.
20. AMBIGUOUS GENITALIA FLOW CHART
External Genitalia
Ambiguous Not Ambiguous
Measure Plasma Hair Type
17-hydroxyprogesterone
11-deoxycortisol
17-hydroxy pregnenolone Vellus Terminal
Medication History Menstrual History
Normal Abnormal
Medical genetics consultation Congenital Adrenal Hyperplasia Positive Negative Positive Negative
Treat with glucocorticoids
21. BMI FLOW CHART
BMI
Increased Normal
Insulin Resistance- likely Gonadotrophin suppression with GnRH Superagonist
Treat with weight loss if possible
Cosmetic treatments also very helpful
Positive Negative
Gonadotrophin dependent Gonadotrophin independent
Ovarian Hyperandrogenism Ovarian Hyperandrogenism
22. ENDOCRINE OVARIAN VS OTHERS
Endocrine
Ovarian Others
Neoplasms Acromegaly
Insulin resistance Cushing’s syndrome
Familial ovarian hyperandrogenism Hypo or hyperthyroidism
Hyperthecosis Adrenal tumors
Persistent corpus luteum of pregnancy
27. BIOCHEMICAL EVALUATION
• Testosterone : normal /increased and definitely raised (>200ng/dl)
• Dehydroepiandrosterone sulfate (DHEAS) : Raised DHEAS (>700 μg/dl)
always indicates an adrenal cause, benign or malignant.
• 17 Hydroxy progesterone : Levels < 200 ng/dl excludes the disease
Post-stimulation values (>1,000 ng/dl) constitute a positive test
• Twenty four hour urine free cortisol in women with signs and symptoms of
Cushing's syndrome.
28. Prolactin : raised in hyperprolactinemia due to hypothalamic disease or a pituitary tumor.
Serum TSH: Hypophyseal hypothyroidism can act as a cofactor in hirsutism causing raised TSH
LH/FSH greater than 3 is indicative of PCOS.
29. TESTOSTERONE FLOW CHART
Plasma Testosterone
>200 ng/dl <200 ng/dl
Probably neoplastic ACTH Stimulation Test
MRI Adrenal Glands 17-OH progesterone
Abnormal Normal >1000 ng/dl <1000 ng/dl
Must rule out adrenal Ovarian Source
adenoma or carcinoma Non classical CAH BMI
MRI and/or ultrasound
of pelvic organs
Insulin Normal
Resistance
33. Key Message
Hirsutism is very common; the causes are usually benign
but the psychological impact can be severe
Few investigations are needed in most cases of hirsutism
Effective treatment usually requires a combination of physical hair
removal and endocrine treatment
