Hirsutism & Virilization

Question 1

Hirsuitism

Answer 1

More terminal hair; pubic hair changes to male diamond

Question 2

Virilization

Answer 2

Male features develop (voice deepens, balding, muscle mass increases, clitoromegaly, breast atrophy)

Question 3

Sources of androgens:

Answer 3

Can be adrenal (DHEAS elevated) or ovarian; both result in increased free T levels.

Question 4

Adrenal disorders

Answer 4

Cushing syndrome

Congenital adrenal hyperplasia

Question 5

Cushing syndrome

Answer 5

Cushing disease if from ACTH-secreting pituitary adenoma; also can be paraneoplastic or 2/2 adrenal tumor (which would suppress ACTH).

Question 6

Work up for Cushing syndrome

Answer 6

Get overnight dexamethasone suppression test (should decrease endogenous production if normal negative feedback); or 24h urine for cortisol

Question 7

Congenital adrenal hyperplasia

Answer 7

Usually 21-alpha-hydroxylase deficiency, causing 17-hydroxyprogesterone to build up (gets shunted down androgen pathway). Also don’t make cortisol or mineralocorticoids (adrenal insufficiency - hypotension, etc, and salt wasting)
If female, can present with ambiguous genitalia at birth or have late onset virilization

Question 8

Other variations of CAH

Answer 8

Can also be 11-beta hydroxylase (precursor builds up with mineralocorticoid activity, so hypertensive) or 3B-HSD deficiency too.

Question 9

Work up for congenital adrenal hyperplasia

Answer 9

Always check 17-OHP level
Can confirm with ACTH stim → check 17OHP 1h later (big rise =CAH)
Lower elevations can be c/w late-onset CAH or heterozygotes

Question 10

Treatment for congenital adrenal hyperplasia

Answer 10

Can suppress adrenal production with prednisone 5mg every night at bedtime

Question 11

Ovarian disorders: nonneoplastic

Answer 11

PCOS
Theca lutein cysts
Stromal hyperplasia/hyperthecosis

Question 12

Theca lutein cysts

Answer 12

LH → theca cells → androgens → granulosa cells → estrogens normally
These cysts make too many androgens!
A/w molar pregnancy.
Dx with Bx

Question 13

Stromal hyperplasia / hyperthecosis

Answer 13

Pts age 50-70, uniformly enlarged ovaries, large & fleshy
Areas of high utilization inside hyperplastic stroma

Question 14

Can generally treat nonneoplastic ovarian disorders with

Answer 14

OCPs, which suppress LH/FSH and increase SHBG

GnRH agonists + add-back estrogen are another option

Question 15

Ovarian disorders: neoplastic

Answer 15

Functional tumors - Sertoli-Leydig (arrhenoblastoma)
Granulosa-theca cell tumors
Luteomas

Question 16

Functional tumors - Sertoli-Leydig (arrhenoblastoma)

Answer 16

Make androgens, usually in young women
If rapid onset over months, be concerned for Sertoli-Leydig cell tumors (commonly diagnosed in women between the ages of 20-40, and are most often unilateral).
T elevated, LH/FSH suppressed

Question 17

Granulosa-theca cell tumors

Answer 17

Generally make estrogens but may make androgens too

Question 18

Luteomas

Answer 18

Benign tumor growing in response to b-HCG → virilization of pt, fetus!
Seen in pregnancy

Question 19

Drugs that can cause virilization

Answer 19

Drugs: steroids, minoxidil, phenytoin, diazoxinde, cyclosporin

Question 20

Idiopathic hirsutism

Answer 20

Can try finasteride (inhibits 5-alpha reductase) or sprionolactone (antiandrogen)
These in addition to OCPs
Lupron / Depo-provera are also reasonable 2nd line if not on OCPs

Question 21

Hair loss postpartum

Answer 21

High estrogen levels in pregnancy cause increased synchronicity of hair growth, so that there can be significant alopecia afterwards (all hair in same phase, falls out at same time) - nothing to worry about.