Hirsutism

Question 1

Define hirsutism.

Answer 1

Excessive terminal hairs in a male pattern (approx 25% of women with self-perceived excess hair qualify as hirsute)

Question 2

What are the Rotterdam criteria for diagnosis of PCOS?

Answer 2

Two of the following:
Oligo- or anovulation
Hyperandrogenism or hyperandrogenemia
Polycystic appearance of ovaries

Question 3

What is the mechanism of hirsutism secondary to obesity?

Answer 3

Decreased SHBG with increasing BMI = increased free testosterone
(Weight loss generally reverses this effect)

Question 4

List five relevant physical exam findings in cases of hirsutism.

Answer 4

Quantity & distribution of hair (ask about hair removal)
Male versus female-pattern alopecia (fronto-temporal vs fronto-parietal)
Acne
BMI/waist to hip ratio
Acanthosis nigricans
Increasing muscle mass
Abdominal or pelvic masses
Evidence of virilization (eg. clitoromegaly)
Decreased breast mass
Cushing’s stigmata

Question 5

What labs would you order when working up hirsutism?

Answer 5

Testosterone
DHEAS - correlates w/ hirsutism, marked elevations may suggest adrenal neoplasm
(Not recommended to measure androgen metabolites, eg. DHT)
SHBG - inverse relationship w/ hirsutism
17-OHP - suspected non-classic CAH
Glucose tolerance testing
Full metabolic work-up depending on results of GTT

Question 6

List three medical therapies for hirsutism.

Answer 6

OCP - decrease ovarian androgen production, increase SHBG
GnRH agonist
Anti-androgens (must co-treat w/ contraceptive)
Spironolactone - anti-androgenic effect at high doses
Flutamide (anti-androgen)
Cyproterone acetate (progestin, suppresses gonadotropin secretion)
Finasteride (5 alpha reductase inhibitor)

Question 7

How can you distinguish hypertrichosis from hirsutism?

Answer 7

Hypertrichosis: excess hair not stimulated by androgens, typically on extremities (whereas hirsutism is typically androgen-dependent, usually manifests with midline hair)

Question 8

What is the relationship between insulin resistance and hyperandrogenism?

Answer 8

Insulin acts synergistically with LH to increase ovarian androgen production
Insulin decreases hepatic synthesis & secretion of SHBG, leading to increased free testosterone