Hirsutism in women

Question 1

Hirsuties is

Answer 1

This is growth in the female

• of excess, coarse terminal pigmented hair
• in androgen dependent sites,
• namely in a male sexual pattern
• e.g. upper lip, beard area and back

Question 2

Probability diagnosis

Answer 2

Constitutional (physiological or familial)

Polycystic ovary syndrome (PCOS)

Question 3

Serious disorders not to be missed

Answer 3

Cancer/tumour:

• virilising ovarian tumour
• adrenal tumours (cancer and adenoma)
• ectopic (paraneoplastic) hormone production (e.g. lung cancer, carcinoid)

Question 4

Pitfalls (often missed)

Answer 4

Postmenopausal

Rarities:

• porphyria cutanea tarda
• congenital adrenal hyperplasia

Question 5

Masquerades checklist

Answer 5

Drugs, many incl.

• phenytoin
• danazol
• minoxidil
• anabolic steroids
• cyclosporin
• corticosteroids
• OCP
• phenothiazines
• interferon
• penicillamine

Thyroid/other endocrine;

• prolactinaemia
• Cushing
• acromegaly
• hypothyroidism

Question 6

Is the patient trying to tell me something?

Answer 6

Consider anorexia nervosa

Question 7

Key history

Answer 7

History of;

• age of onset
• extent
• activity of the hair.

FHx aand PMHx including endocrine disorders and drugs

Question 8

Key examination

Answer 8

General inspection including;

• distribution and character of the hair growth
• endocrine abnormalities (e.g. Cushing syndrome)
• skin
• abdomen a
• breasts

Question 9

Key investigations

Answer 9

1. Consider pituitary hormones (e.g.

• FSH
• LH
• ACTH
• TSH
• prolactin

1. Serum thyroxine
2. testosterone
3. DHEAS
4. Pelvic ultrasound (?PCOS)
5. Urinary porphyrins
6. Imaging of pituitary and adrenal regions

Question 10

Diagnostic tips

Answer 10

Mild longstanding hirsutism does not require investigation.

Keep in mind possibility of self-medication, especially in athletes (anabolic steroids).

Red flags include;

• sudden appearance of hirsutism/virilisation
• pelvic or abdominal mass.

Question 11

Management

Answer 11

Most cases are due to idiopathic hirsutism along racial or familial lines.

Exclude adrenal or ovarian pathology (e.g. PCOS)

Use bleaching, waxing or depilatory creams, or shave

Do not pluck hairs, esp. around the lips and chin; plucking stimulates hair growth but shaving appears to have no effect

Women of reproductive age may use the combined oral contraceptive pill (COCP):

• ethinyloestradiol + cyproterone
• or drosperinone

Drug treatment: spironolactone 100–200 mg daily; takes 6–12 mths to respond; preferred to cyproterone acetate