Hirsuitism

Question 1

D?

Answer 1

Hirsutism is a condition seen in women that is associated with development of androgen-dependent terminal hair (coarse, pigmented) following a male-pattern distribution (face, chest, abdomen, back).

Question 2

Epidemiology?

Answer 2

Age:
Sex: Women
Ethnicity: Southern European

Question 3

Aetiology?

Answer 3

• PCOS
• Idiopathic
• Hyperprolactinoma
• Non-classic congenital adrenal hyperplasia
• Cushing’s syndrome
• Androgenic meds
• Androgen-secreting ovarian tumour
• Ovarian hyperthecosis
• Adrenocortical carcinoma

Question 4

CP?

Answer 4

• Excessive hair in male distribution pattern
• Male-pattern alopecia
• Deepening of voice
• Clitoromegaly
• Increased muscle bulk
• Virilisation

Question 5

Pathophysiology?

Answer 5

• Normally
• Hair -has a follicle underneath skin and a shaft that is fully keratinised and above the skin surface.
• Vellus hair:short, soft, thin, nonpigmented, fine hair. It is usually present on the limbs, and these areas show minimal sensitivity to normal levels of androgens in girls and women.
• Terminal hair: coarse, thick, pigmented, long, stiff hair present in the axilla or pubis of both sexes and on the chest, face, lower abdomen, back, etc. of males.
• The pilosebaceous units of the axilla and pubis are sensitive to even low levels ofandrogens(from the adrenal glands) because of the local activity of the 5α-reductase enzyme, which converts testosterone to its active metabolite, dihydrotestosterone; therefore, vellus hair is transformed to terminal hair during puberty.
• Adrenal glands produce androgens in response to ACTH and LH-whcih converts cholesterol to pregenelone, whcih is then converted into DHEA and progesterone converted into androstenedione, which is converted into either DHT or estradiol
• Most testosterone made by ovaries and adrenal glands is bound to Sex Hormone Binding Globulin (SHBG), so less free cirulating testosterone in the blood.
• But in hirsuitism, due to a lack of oestrogen or production of oestrogen, the pathways are more shnted to making testosterone, which there is less SHBG to bind to-more circulating testosterone means more terminal hair growth.

Question 6

I-first line?

Answer 6

• Exam
• Ferriman-Gallwey scoring system
• Signs of underlying cause
• Serum total testosterone level-confirms diagnosis
• Free androgen index-
• To calculate the free androgen index, the total testosterone concentration is divided by the sex hormone binding globulin concentration and multiplied by 100
•

Question 7

I-second line?

Answer 7

Second line:

• Screen for Congenital Adrenal Hyperplasia

Question 8

M?

Answer 8

• Refer to endocrinology if underlying suspected neoplasm (sudden, virilisation or mass) or underlying endocrine condition suspected
  
  • Weight loss
  • Hair reduction and removal
  • Topical eflornithine if facial
  • COCP-Dianette
  • Refer for specialist treatment after 6 months

Question 9

P and C?

Answer 9

• Adverse effects on quality of life
	• Complications
	• Depression
	• Folliculitis
SE of meds