Hirsutism and Virilism

Question 1

What is normal androgen synthesis

Answer 1

Adrenals - DHEA and DHEAS

Ovaries - Androstenedione and testosterone –> estrone and estradiol

Question 2

What effect does ACTH have on androgen levels

Answer 2

Increased ACTH increases androgens

Question 3

What are the causes of increased androgens

Answer 3

Enzyme defects, increased ACTH

Question 4

What are the most common enzyme disorder in congenital adrenal hyperplasia

Answer 4

21 alpha-hydroxylase deficiency = accumulation of 17-alpha hydroxyprogesterone

11beta-hydroxylase
3beta-hydroxysteroid dehydrogenase (elevated DHEA)

Question 5

What are non-neoplastic causes of excess androgens?

Answer 5

PCOS
Theca lutein cysts which produce androstenedione and testosterone which get shunted into circulation because too much
Stromal hyperplasia and hyperthecosis

Question 6

What are neoplastic ovarian disorders causing hirsutism/virilization

Answer 6

Functional ovarian tumors = sex-cord tumors, leydig cell tumors,
luteoma

non-functional = stimulates proliferation of ovarian stroma

Question 7

How is hirsutism and virilization worked up?

Answer 7

Careful history, including medications and PMH, Fhx
Physical exam - escutcheon, face, chest, back, pelvic exam for clitoromegaly, cushingoid features
labs = 17-OHP, DHEAS, Testosterone
Pelvic and abdominal US
5alpha-reductase to look at peripheral conversion

Question 8

Treatment of hirsutism?

Answer 8

Glucocorticoid if androgen
Finasteride which blocks 5alpha-reductase
Spironolactone
OCPs to suppres LH and FSH, and increase sex hormone binding globulin