hirsutism

Question 1

virilization

Answer 1

Male pattern baldness
Deepening of voice
Hirsutism
Breast atrophy
Inc muscle mass

Question 2

hirsutism

Answer 2

inc growth of coarse terminal hair in a male-pattern distribution

Question 3

MOA virilization

Answer 3

Either excess T or decrease in SHBG
* Testosterone stimulates PSU, hair growth and pigmentation EXCEPT sa head huhu
* Even if normal T, SHBG can be decreased (by insulin, glucocorticoids, androgens), so inc free T (80% of T bound to SHBG)

Question 4

differentials

Answer 4

PCOS
HAIR-AN
CAH
Idiopathic hirsutism
Cushing
Ovarian/adrenal tumor
Thyroid disease

Question 5

diagnostics

Answer 5

Serum Testosterone (>150ng/ml, tumor likely) - done early morning in the follicular phase if regular menses

DHEAS (just so u know if ovarian or adrenal yung source of androgen)

ACTH

TV-UTZ (for tumors)

Overnight dexa test/PM cortisolx2 / 24 hour urine cortisol x 2 (for Cushing)

17-OHP (CAH)

Adrenal CT

If with irregular menses: LH, FSH, estradiol and progesterone, TSH, PRL

Question 6

clitoromegaly definition

Answer 6

Clitoromegaly (defined as >10mm or clitoral index >35mm)

Question 7

MOA idiopathic hirsutism

Answer 7

inc sensitivity to androgens (5a reductase activity)

normal androgen levels
normal menses
not necessarily ovulatory
baka pcos variant lang

Question 8

MFG parts

Answer 8

1) Upper lip
2) Chin
3) Upper back
4) Lower back
5) Breast
6) Lower abdomen
7) Upper thigh
8) Pubes
9) Upper arm

Question 9

tx

Answer 9

1st line: OCPS
2nd line: anti-androgens

Q6 months evaluation to check if dose ok

Question 10

goal

Answer 10

1) decrease production of androgen
2) increase protein-bound androgen
3) block androgen action

Question 11

COCs MOA

Answer 11

• Progestin - negative feedback to LH to dec ovarian androgen production
• Estrogen - inc SHBG to dec free androgen
• E2+P4 - dec adrenal production of DHEAS
• 19-nortestosterone derivatives - still have androgen binding powers, can inhibit 5a reductase activity in SKIN but can be androgenic (so no if may acne)
• Better si DRP or CPA (inhibit androgen signaling at the level of AR) - Yaz (20mcg EE + 3mg DRP or 30mcg + 3 mg DRP Yasmin), (35mcg EE + CPA 2mg Diane-35)
• If Estrogen CI, use POP kasi it can still inhibit androgen prod by suppression of LH (MPA also inc T clearance)

Question 12

anti-androgens MOA

Answer 12

1) Spironolactione 50-100mg BID - aldosterone antagonist, androgen receptor antagonist which competes with DHT (diuretic, hyperK)
2) Finasteride 2.5mg BID or 5mg OD- 5a reductase inhibitor (bawal sa preggo or else ambigu genitalia bb boy)
3) Flutamide 250-750mg OD - non-steroidal androgen receptor antagonist (hepatotoxic)
4) Flornithine hydrochloride 13.9% cream - inhibitor of elfornithine carboxylase needed for hair growth in skin (hair regrow after 8 wks of d/c)

Question 13

mechanical

Answer 13

Plucking (6-8 weeks regrowth)
Shaving (1-3 days regrowth)
Electrolysis - 6 months
Laser/Pulse light - photoepilation (4-6 times)

Question 14

how to overnight dexa suppression test

Answer 14

1mg dexa PO at 11-12mn then measure cortisol at 8am
OR
0.5mg dexa PO q6 x 8 doses starting 9am d1 then measure cortisol 6 hours after last dose

Question 15

MOA hyperpigmentation

Answer 15

excess a-MSH, a by-product of ACTH synthesis from POMC

activation of keratinoyctes by IGF1

Question 16

Ovarian tumors causing hirsutism

Answer 16

sertoli-leydig > lipid cell > hilar cell> rare-androgen producing theca> brenner

Question 17

selective venous catheterization results to indicate tumor

Answer 17

R:L venous effluent testosterone >1.44