8 - Hirsutism

Question 1

What causes hirsutism?

Answer 1

Androgens act on:

• sex-hormone responsive hair follicles
• Sebaceous glands

Question 2

Hirsutism definition

Answer 2

Latin - shaggy or hairy

Excessive terminal hair growth that appears in women in a male pattern

Question 3

What causes the causes the hair growth?

Answer 3

Increased sensitivity of the follicles to normal levels of androgens
Or
Elevated levels of circulating androgens

Question 4

How is hirsutism quantified?

Answer 4

Ferriman-gallwey score

Score of 0-4 in 9 areas

Max = 36
Moderate = 8-15
Severe = > 15

Question 5

What are the major female androgens?

Answer 5

Testosterone
Androstenedione
DHEA S Dehydroepiandrosterone sulfate

Question 6

What forms of testosterone are found in women?

Answer 6

65% is bound to Sex hormone binding globulin (SHBG)
33% is bound to albumin
1% circulates free
-fixed

Question 7

What is “fixed” testosterone?

Answer 7

After free test circulates for 30-60 min it gets “fixed” to tissues
It is then converted to DHT by 5a-reductase in the skin

DHT is the active form-> hirsutism

Question 8

What are the 5 etiologies of hirsutism?

Answer 8

1. Idiopathic or familial hirsutism
2. Polycystic ovarian syndrome
3. Steroidogenic enzyme defects
4. Neoplastic disorders
5. Rare/pharmacologic

Question 9

What is idiopatic or familial hirsutism?

Answer 9

Normal androgen levels 
Peri-pubertal onset
Slow progression
Regular menses
Otherwise normal exam 

This amount of hair is normal for this person

Question 10

What is the MC cause of hirsutism?

Answer 10

PCOS - found in 4-6% of premenopausal women

Question 11

What causes PCOS?

Answer 11

Its a familial autosomal dominant trait

Excess LH:FS (>2 ratio) -> adrenal and ovarian hypersecretion

Question 12

SS of PCOS?

Answer 12

Hirsutism
Acne
Androgenic alopecia (male balding in women)
Oligomenorrhea/amenorrhea w anovulation
Infertility
Obesity (70%)
Elevated insulin (dm in 13%)
Obstructive sleep apnea
HTN 
Hyperlipidemia

Question 13

Only 70% of PCOS women have ?

Answer 13

Cystic ovaries,

30% have PCOS but not cystic ovaries

Question 14

What types of congenital adrenal hyperplasia (21-hydroxylase deficiency) are there?

Answer 14

Classic: ambiguous genitalia

Non-classic: (partial deficiency): adult onset hirsutism and PCOS common

Question 15

What are some etiologies of neoplastic disorders?

Answer 15

Ovarian tumors
Adrenal carcinoma -> cushing and hyperandrogenism
Pure androgen-secreting tumors (very rare)

Question 16

What are some ovarian tumors associated with hirsutism?

Answer 16

Arrheanoblastomas
Sertoli-leydig cell tumors
Dysgerminomas
Hilar cell tumors

Question 17

What are the feature sof neoplastic disorders?

Answer 17

Onset outside peri-menarche period
Rapid and sever progression of hair
Recent menstrural irregularity
Virilization

Question 18

What are some rare or pharmacologic hirsutism etiologies?

Answer 18

Minoxidil - tx of alopecia
Cyclosporine - immunosuppressant
Phenytoin - anti-seizure med
Anabolic steroids
Contraceptives (progestins)

Question 19

Besides hair and oily skin what else is common s/s of hirsutism?

Answer 19

Menstrual irregularities, anovulation and amenorrhea are also common

Question 20

What will be seen in hirsutism where androgen excess is pronounced (score >15)

Answer 20

Defiminization

Virilization

Question 21

If you see defminization and virilization what must be considered?

Answer 21

Androgen secreting neoplasm

Question 22

What labs need to be ordered for hirsutism?

Answer 22

Free and total testosterone
Androstenedione
DHEA-S
HCG

Question 23

What will testosterone levels usually look like with hirsutism?

Answer 23

Normal to mildly elevated

Question 24

If total test > 200 and free test >40 what must also be done?

Answer 24

Pelvic exam and US

If neg:
Bilateral adrenal CT scan

Question 25

High aldosterone (>100ng/dL) suggests?

Answer 25

Ovarian or adrenal neoplasm

Question 26

What does high (>700 mcg/dL) DHEA S suggest?

Answer 26

Adrenal source of androgen

Get a bilat adrenal CT

Question 27

Other labs that may be helpful with hirsutism?

Answer 27

LH/FSH
17-hydroxyprogesterone
Fasting insulin
Fasting glucose
Estradiol
TSH/FT4/PRL
Urinary free cortisol (cushings)
Lipids

Question 28

What may not be detectable on MRI?

Answer 28

Small virilizing ovarian tumors may not be detectable

Question 29

Management of neoplastic origin hirsutism?

Answer 29

Cut the tumor out

Question 30

Management of classic congenital adrenal hyperplasia (CAH)

Answer 30

Bilat adrenalectomy

Glucocorticoid and mineralcorticoid replacement

Question 31

Management of Non-classic Congenital adrenal hyperplasia (CAH)

Answer 31

No hormone replacement required

Dexamethasone increases risk of cushing syndrome

Question 32

MC Drug therapy for hirsutism?

Answer 32

Sprionolactone - diuretic/androgen antagonist

Question 33

Flutamide

Answer 33

Nonsteroidal nonselective anti-androgen

Question 34

Finasteride?

Answer 34

5a-reductase inhibitor

Postmenopausal women only

Question 35

Who is a good candidate for oral contraceptives?

Answer 35

Mild elevations of testosterone and androgens

It also improves menses regularity and acne

Question 36

Metformin?

Answer 36

Reduced insulin resistance

- PCOS

Question 37

Simvastatin?

Answer 37

Reduces hirsutism and testosterone levels in PCOS

Question 38

Clomiphene?

Answer 38

Fertility aid in PCOS + infertility

Question 39

Vaniqa cream?

Answer 39

Cosmetic therapy to reduce hair growth topically

4-8 weeks to start working

Question 40

Why do owls always get inited to parties?

Answer 40

They’re such a hoot