HIRSUTISM

Hirsutism- cosmetically unacceptable terminal hair growth in women, in a male pattern. (Or excessive terminal hair growth in women).

Virilization- male physical characteristics development in women, like pronounced muscle development, deepening voice, clitoromegaly, male pattern baldness, & severe hirsutism.

Causes:

polycystic ovary syndrome, ovarian hyperthecosis, neoplastic disorders, steroidogenic enzyme defects, rarely medications, acromegaly, or ACTH induced Cushing disease.

Idiopathic or Familial:

no detectable hyperandrogenism. Patients may have increased androstenediol glucuronide, a metabolite of dihydrotestosterone.

Polycystic Ovary Syndrome (PCOS, Hyperthecosis, SteinLeventhal Syndrome):

A diagnosis of PCOS must have three criteria-

(1) androgen excess & clinical hyperandrogenism or increased total or free testosterone;

(2) ovarian dysfunction & oligoanovulation or polycystic ovarian morphology;

(3) absence of other causes of testosterone excess or anovulation like pregnancy, thyroid dysfunction, neoplastic testosterone secretion, 21-hydroxylase deficiency, Cushing syndrome, or hyperprolactinemia.

affected women have signs of hyperandrogenism, like hirsutism, acne, male-pattern thinning of scalp hairs; this persists even after natural menopause.

70% of women have polycystic ovary on pelvic USG & 50% have oligomenorrhea or amenorrhea & anovulation.

30% of women with polycystic ovary syndrome may not have cystic ovaries;

25–30% of normal menstruating women may have cystic ovaries.

Obesity & high serum insulin, due to insulin resistance contribute to PCOS in 70% of women. LH:FSH ratio greater than 2.0.

Both adrenal & ovarian androgen hypersecretion commonly present.

Steroidogenic Enzyme Defects:

Congenital adrenal steroidogenic enzyme defects- reduced cortisol secretion & compensatory increase in ACTH, causes adrenal hyperplasia.

Partial deficiency of adrenal 21-hydroxylase may present as hirsutism.

Neoplastic Disorders:

Ovarian tumors (0.8%) causes hirsutism- like arrhenoblastomas, Sertoli-Leydig cell tumors, dysgerminomas, and hilar cell tumors.

Adrenal carcinoma, is rare cause of hyperandrogenism & Cushing syndrome.

Pure androgen-secreting adrenal tumors seen very rarely (about 50% malignant).

Rare Causes of Hirsutism & Virilization:

Acromegaly & ACTH-induced Cushing syndrome.

Pharmacologic:

minoxidil, anabolic steroids, cyclosporine, phenytoin, interferon, diazoxide, cetuximab, and certain progestins.

Symptoms and Signs:

Modest androgen excess by any source increases sexual hair (chin, upper lip, chest & abdomen) & increases sebaceous gland activity, leads to acne.

Menstrual irregularities, amenorrhea & anovulation.

Androgen excess is pronounced- defeminization (decrease in breast size, loss of feminine adipose tissue) and virilization (severe hirsutism, frontal balding, clitoromegaly, muscularity, and deepening of the voice) occurs.

Virilization points towards the presence of androgen producing neoplasm.

Investigations:

total testosterone and free testosterone.

A serum testosterone > 200 ng/dL (6.9 nmol/L) or free testosterone > 40 ng/dL (140 pmol/L) indicates need to manual pelvic exam and USG.

Androstenedione > 1000 ng/dL (34.9 nmol/L) points towards ovarian or adrenal neoplasm

DHEAS > 700 mcg/dL (35 nmol/L) indicates adrenal source of androgen- adrenal hyperplasia & rarely adrenal carcinoma.

Screening for patients with nonclassical late-onset (CAH) congenital adrenal hyperplasia due to 21-hydroxylase deficiency for women with (1) high total or free testosterone and (2) hirsutism with normal testosterone who are at high risk to CAH due to family history of hirsutism or member of a high-risk ethnic group.

Early morning blood- for serum 17-hydroxyprogesterone.

Congenital adrenal hyperplasia- baseline 17-hydroxyprogesterone > 300 ng/dL (9.1 nmol/L).

FSH and LH are elevated if amenorrhea due to ovarian failure.

LH:FSH ratio > 2.0 is common in PCOS.

Pelvic USG or MRI- usually detects virilizing tumors of ovary.

women of child-bearing age with amenorrhea- do test for pregnancy.

Other tests if clinically indicated to exclude these diseases-

dexamethasone suppression test- for Cushing syndrome,

serum insulin-like growth factor- for acromegaly,

thyroid function tests (TFT)- for hyperthyroidism & hypothyroidism,

serum prolactin- for hyperprolactinemia,

Treatment:

Topical Treatment

Local treatment of facial hirsutism- shaving, depilatories, plucking of hairs, electrolysis, or bleaching, waxing.

Eflornithine 13.9% topical cream retards hair growth, twice daily to unwanted facial hair; improvement within 4–8 weeks.

Eflornithine used during laser therapy for more dramatic response.

Topical minoxidil- for androgenic alopecia and applied to scalp twice daily.

Laser Treatment

Laser therapy (photoepilation)- very effective treatment for facial hirsutism, for women with dark hair and light skin.

For women of color- longer-wavelength laser such as Nd:YAG or diode laser with skin cooling.

Medications

Oral contraceptives- initial therapy for women with hirsutism if she is not actively pursuing pregnancy.

Low-dose of estradiol (20 mcg) & a progestin having relative low risk for venous thrombosis (norethindrone, levonorgestrel, norgestimate).

A favorable combination for daily use- norethindrone 1 mg with ethinyl estradiol 20 mcg.

Cyproterone acetate- a unique progestin- that blocks androgen receptors & 5-alpha-reductase activity, also suppressing testosterone.

Given as oral contraceptive in a dose of 2 mg plus ethinyl estradiol 35 mcg.

Spironolactone- effective in reducing hirsutism, acne, and androgenic alopecia in women, in those patients is first-line medical strategy 50–200 mg orally daily devided dose, on days 5–25 of menstrual cycle or daily if used with oral contraceptive.

Flutamide (250 mg twice daily for first year & then 125–250 mg/day maintenance) & bicalutamide (50 mg once daily) – inhibit testosterone binding to androgen receptors & suppress serum testosterone. Rarely causes severe hepatotoxicity.

Finasteride (2.5-7.5 mg/day) – inhibits 5-alpha-reductase, enzyme that converts testosterone to active dihydrotestosterone in the skin.

Metformin- alone ineffective for hirsutism, but can enhance spironolactone anti-hirsutism effect.

GLP-1 agonist & simvastatin are under study.

Glucocorticoid (prednisone, methylprednisolone) replacement- in classical congenital adrenal hyperplasia (21-hydroxylase deficiency) in women with hirsutism & adrenal insufficiency, requires glucocorticoid & mineralocorticoid replacement.

GnRH agonist- successful in treatment of postmenopausal women with severe ovarian hyperandrogenism, if laparoscopic oophorectomy is contraindicated or denied by patient.

Surgery

Androgenizing tumors of adrenal or ovary- resected laparoscopically.

Postmenopausal women with severe hyperandrogenism should undergo laparoscopic bilateral oophorectomy (if CT scan of the adrenals and ovaries is normal), since small hilar cell tumors of the ovary may not be visible on scans Women with classic salt-wasting congenital adrenal hyperplasia and infertility or treatment-resistant hyperandrogenism may be treated with laparoscopic bilateral adrenalectomy

Advice From- DR RAKESH UKEY MBBS, MD MEDICINE.:-

Please consult in clinic, then start medicine according to diagnosis.

Clinic No. +917744491139.

We Want You To Be Healthy Today. RMC Walk-In-Clinic, We Update Daily Our Clinic Cases For General Information Only.

Owner Of Highly Reputable Rakesh Multispeciality Clinic.

International Associate Member Of American College Of Cardiology (ACC), Member Of Indian Medical Association (IMA).

Certified from Royal College of physician of the United Kingdom (UK), Journal Of American College Of Cardiology (ACC), ETC.

Is One Of The Leading Physician, Best Doctor In RAJNANDGAON CHHATTISGARH For Difficult Diagnosis And Treatment In Neurology, Cardiology, Gastro+ Hepatology, Respiratory Medicine, Rheumatology, Hematology, Nephrology, Endocrinology, Infectious, Geriatric, Diseases, Women’s & Men’s Health Issue, Etc.

Online Advice-

For Appointment. Pay Fee In Payment Link Given Below.

https://www.instamojo.com/@drrakeshukey/l55370e300fae49969f3b8739eac81429/

Inform Or Call For Any Help On Manager Mobile No. +919145035204 Or Clinic +917744491139. We Will Call You Within 2 Hour.

For More Details Visit In-

https://www.facebook.com/DrRakeshUkeyMD

https://www.instagram.com/dr_rakesh_ukey_md/

https://twitter.com/ukey_rakesh https://www.linkedin.com/in/dr-rakesh-ukey-82051635/