Hirsutism
Richard D. Blondell
The growth of terminal hair (long, coarse hair) in areas other than the scalp and eyebrows is dependent on androgens. Different hair follicles have varying degrees of sensitivity to androgens. Axillary and pubic hair follicles are relatively sensitive to androgens and respond to the androgens produced by the adrenal glands of girls during puberty. Women develop some terminal hair on their forearms and lower legs. Some will get hair on the chest and abdomen, but few will grow facial hair. Men grow more terminal hair than women because of testicular androgens.
Approach
The goal is to distinguish hirsutism from other patterns of hair growth and determine its cause.
A. Patterns of hair growth. Hirsutism in women is characterized by the development of a male pattern of terminal hair growth, which occurs on the upper lip, chin, chest, back, linea alba, upper portions of the limbs, and within the superior pubic triangle. Some hirsute women with excessive androgen levels will also develop male-pattern baldness. Hypertrichosis is the excessive growth of non–androgen-dependent villus hair (short, fine hair) over all areas of the body, which can be caused by neoplasms, hypothyroidism, or anorexia nervosa.
B. Causes of hirsutism. Many causes are found for hirsutism (Table 14.1). Some causes are functional and are thought to result from an increased sensitivity of the hair follicle to normal female levels of androgens, whereas others result from pathologic hyperandrogenism (1).
History
A. Onset. It is useful to determine the age of the onset of the hirsutism, its rate of progression, and the timing of any exacerbation of hair growth. The patient’s menstrual history, pregnancy history, or general medical history can yield important clues about an underlying endocrinopathy or another medical disorder.
B. Medications. A detailed medication history is important. Some medications cause hirsutism directly (e.g., androgenic oral contraceptives, anabolic steroids in body-builders) and can produce an increased libido. Others cause hirsutism indirectly by causing hyperprolactinemia (e.g., phenothiazines, tricyclic antidepressants), which can be associated with galactorrhea and menstrual abnormalities.
C. Family history. A familial pattern can be associated with idiopathic hirsutism, polycystic ovarian disease, and late-onset congenital adrenal hyperplasia.
Physical examination
A. Hair growth. The exact distribution of terminal hair growth should be noted. A male type escutcheon (hair filling the superior pubic triangle) is a presumptive sign of hyperandrogenism. Some patients will have had unwanted hair removed, altering the clinical presentation.
B. Secondary sexual characteristics. Pathologic androgen excess is suggested by acne, oily skin, and signs of virilization (frontal balding, deepening of the voice, increase in muscle mass, and clitoromegaly). This is especially true if defeminization (loss of breast tissue, vaginal atrophy) is also present.
C. Other findings. A bimanual pelvic examination may reveal ovarian enlargement. Obesity with acanthosis nigricans (dark, velvety hyperpigmentation of the axilla, groin, neck, umbilicus) is suggestive of the insulin-resistant form of polycystic ovarian disease. Corticosteroid excess can produce the signs of Cushing’s syndrome.
Testing
Diagnostic testing is directed at confirming the cause of hirsutism suggested by the medical history and the physical examination (2).
A. Clinical laboratory tests. It is useful to measure the serum concentrations of testosterone and dehydroepiandrosterone sulfate (DHEAS) if an androgen-secreting neoplasm is suspected. If pituitary abnormalities, polycystic ovarian disease, or premature menopause are possibilities, then determine the serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin, as indicated by the clinical impression.
B. Diagnostic imaging. Ultrasonography can be used to detect ovarian cysts, but other imaging studies may be indicated if a neoplasm of the adrenals or ovaries is suspected.
Diagnostic assessment
The vast majority of patients with hirsutism will have either an idiopathic cause or polycystic ovarian disease. Studying other hirsute women can become a major diagnostic exercise that is best left to a physician with experience in these unusual cases. A patient can be considered to have idiopathic hirsutism if she has mild hirsutism that began shortly after the onset of puberty and progressed slowly, has regular menses, has an otherwise normal physical examination, does not have galactorrhea or virilization, and is not taking any medication associated with hirsutism. No further diagnostic assessment is needed for these women. Polycystic ovarian disease is seen in women between the ages of 15 and 25 years and is associated with a mildly elevated serum level of testosterone and DHEAS, a LH:FSH ratio of 2 or more, and cystic ovaries on ultrasonography. Among women with hirsutism, an adrenal tumor is unlikely if the serum levels of testosterone and DHEAS are normal (3). A dexamethasone suppression test is indicated for women with elevated values of testosterone or DHEAS to exclude a sinister cause of hirsutism. Treatment is cosmetic in women with idiopathic hirsutism, otherwise the underlying cause is targeted (4).
References
1. Toscano V. Hirsutism: pilosebaceous unit dysregulation. Role of peripheral and glandular factors. J Endocrinol Invest 1991;14:153–170.
2. Kalve E, Klein JF. Evaluation of women with hirsutism. Am Fam Physician 1996;54:
117–124.
3. Derksen J, Nagessar SK, Meinders AE, Haak HR, van de Velde CJH. Identification of virilizing adrenal tumors in hirsute women. N Engl J Med 1994;331:968–973.
4. Knochenhauer ES, Azziz R. Advances in the diagnosis and treatment of the hirsute patients. Curr Opin Obstet Gynecol 1995;7:344–350.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Increased facial hair
» Next page: Alopecia/Hirsutism (Field Guide to Bedside Diagnosis)
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