HIRSUTISM

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HIRSUTISM
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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

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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

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Causes

1. Ovarian
   PCOS
   Tumours
2. Adrenal
   CAH
   Tumours
3. Pituitary Tumours
   ACTH secreting (Cushings disease)
   
   Prolactin secreting
   Growth hormone secreting
   (acromegaly)

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Causes

• 4. Ectopic ACTH producing tumours (bronchus,
  pancreas, thyroid, thymus)
• 5. Iatrogenic
  Androgenic
  drugs(testosterone, danazol ,glucocorticoids,proge
  stogens, phenytoin)
• 6. Idiopathic

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Polycystic Ovarian Syndrome

• LHFSH ratio of 31
• Baseline estrogen level increased
• Hyperprolactinaemia (15)
• Testosterone slightly raised (lt 5 nmol/L)
• Ultrasound criteria
• Peripheral distribution of 10 or more follicles 2
  to 8 mm in diameter
• increased ovarian stroma
• Increased ovarian volume

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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 lt5 nmol/l
• (After excluding all possible organic causes )
• Normal LH,FSH, prolactin and estrogen

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Congenital Adrenal Hyperplasia

• Excessive production of androgens due to
  deficiency of enzymes required for biosynthesis
  of glucocorticoids
• Raised testosterrone level gt 5 nmol/l
• Raised serum 17 alpha hydroxy progesterone
• Raised urinary ketosteroids

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Cushing Syndrome

• Over production of cortisol by adrenals due to
  excessive production of ACTH
• 24 hrs urinary free cortisol
• plasma cortisol
• ACTH levels

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Androgen Producing Ovarian tumours

• Mostly benign in young females lt 30 yrs
• Androblastoma, luteoma
• Hirsutism is rapid in onset
• Signs of virilism
• Serum testosterone grossly elevated
• Diagnosed by USG, CT or MRI

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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

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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

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Iatrogenic Hirsutism

• Androgenic drugs
• Hair growth returns to normal once the drug
  intake is stopped

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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

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• 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

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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

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Investigations

• Hormonal levels
• First line in every patient
• FSH, LH, testosterone, prolactin, and DHEAS
• Second line
• 17 alpha hydroxyprogesterone, cortisol growth
  hormone

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Investigations

• Ultrasonography
• Ct MRI of pituitary adrenals

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Treatment

• Aims of treatment
• Counselling
• Weight control
• Cosmetic treatment
• Suppression of excessive androgen production
• Prevent new hair growth by antiandrogens

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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

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Antiandrogens

• Cyproterone acetate
• Can be used alone or with COC
• Preferred is Diane-35
• Spironolactone
• Flutamide
• Ketoconazole

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Suppression of excessive androgen production

• Ovarian suppression
• COC
• GnRH analogues
• Surgical
• Ovarian wedge resection
• Laproscopic drilling
• Bilateral oophorectomy

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• 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

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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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