An Approach to the Patient with Hirsutism

Akbarian. A MD

This review provides a guide for diagnosis and management of hirsutism.

The majority of woman who was see an endocrinologist complaining of hirsutism are endocrinologically normal and derive no benefit from an endocrinologic evaluation .Idiopathic hirsutism refers to a woman who has normal serum androgen concentrations, no irregular menses, and no identifiable cause of her hirsutism . Most such patient can be treated using cosmetic measurer.

The cause of excess hair growth in most women who require an endocrinologic evaluation is hyperandrogenism due to polycystic ovary syndrome (PCOS) and other obesity –related disorders.

Other causes of androgen excess occur much less frequently: late onset or nonclassic congenital adrenal hyperplasia (CAH)in less than 3% of women and androgen-secreting tumors in 0.2%.polycystic ovary syndrome and other obesity-related causes of insulin resistance, as well as nonclassic CAH, typically begin in the pubertal years and tend to plateau during the reproductive years.

Testing for elevated androgen levels in women should be performed in women with moderate or serve hirsutism or hirsutism that is sudden in onset, rapidly progressive, or associated with menstrual irregularity, infertility, or obesity .in patient with plasma testosterone levels greater than 200ng/dh the cause is usually an adrenal tumor.

The selected treatment regimen depends on the cause of hirsutism .treatment of hirsute woman with idiopathic hirsutism should be cosmetic .

shaving is safe and effective as treatment for all forms of hirsutism but must be repeated often other cosmetic treatments include plucking and waxing; both are painful and are temporary solutions.

Another method, hair growth attenuation with topical administration of eflominithine, is effective for the removal of unwanted facial hair; it takes 8 to 12 weeks to reach maximum effect .Folliculitic therapies (direct hair removal methods)include electrolysis, thermolysis, nonlaser light (intense pulsed light), and lasers.

Obesity is a primary cause of insulin resistance and hyperinsulinism. Consequence of obesity includes PCOs and increased ovarian testosterone secretion .the most useful treatment for hirsutism with obesity and PCOs is weight loss. Hormonal therapies include the following

Hormonal therapies include the following

1-Ovarian suppression: ovarian suppression is a useful strategy

to decrease androgen levels (testosterone) to the time of

menopause. Ovarian androgen secretion can be suppressed in a majority of patient

using a combination of estrogen and progestin or a long-acting

gonadotropin-releasing hormone superagonist

2-Antandrogens:

antiadrogens are an effective treatment for androgen-mediated hirsutism.

The most useful antiandrogen for the treatment of hirsutism in the United States is spironolactone.

In fertile woman, it should be given only in combination with an oral contraceptive agent because of the teratogenicpotential of antiandrogen monotherapy.Flutamide is effective in women with hirsutism, but it can be hepatotoxic and has been associated with deaths. Finasterideappears to be less effective for hirsutism than spironolactone.

3-Glucocorticoid: These agents are useful only to treat

virilizing forms of CAH. There is no consensus for a standard program for evaluation of woman with hirsutism. Various combinations of the treatments discussed in this review are effective in many women. A trial of at least 6 months is needed with androgen suppression therapy because hair follicles have a half-life of up to 6 months.

Editorial comment

(I have known and admired Dr. Lynn Loriaux for many years .he is thoughtful, intelligent, a gifted investigator and clinician.

Although many of the issues described in this

study are not new this past year. They are presented in a lucid and logical manner, dealing with the common, and important, subject of hirsutism that affects males and females.

Although many individuals have hirsutism .it is often not a disease but an excessive amount of hair (although not in my case, in which the paucity is the problem!)

Lynn Loriaux also is a noted educator, scientist, and leader. But in addition to that , he is an excellent writer and artist each year ,

I have received, as do others, an excellent and thoughtful vignette about a meaningful incident, often related to a short story .as if that weren’t enough, he beautifully draws and makes sketches related to his stories .

He truly is a renaissance man.

As can be expected, he has a superb and extensive, Hirsutism, the subject of the present review. Dr Loriaux suggests an excessive amount of hair growth in normal locations, and with no abnormality of function.

It is important to remember that many, if not most, patient can be helped with mild cosmetics or occasional hair removal. That is not to say that there are not large numbers of patients who need careful diagnosis and therapy.

But it also says that a significant and therapy. But it not requires a very detailed workup, if there is no sign of significant disease. Having said that, it is very important not to miss or delay a suspicious lesion, as they can be fatal.

Let me turn my attention now to some of the various abnormalities encountered that do require medical attention. The important components include the age of puberty, the age of puberty, the age of menarche, and the subsequent menstrual history .

Dr Loriaux suggests that the age at onset of Hirsutism, its nature, its vellus or terminal, and the rate of progression should be determined. The benign from of hypersutism, hyperthecosis, insulin resistance, and nonclassic CAH, many of which are usually found after puberty are discussed

Dr Loriaux notes that Hirsutism that begins before puberty usually is caused by an ovarian or adrenal neoplasm, providing that it is not medication related.

In the article by Dr Loriaux the various disorders are described, the nature of the problems assessed, and , when indicated and feasible appropriate therapy instituted .

However the amount of the material presented in this excellent article is significantly beyond the scope of the commentary review .

Therefore , in this review , we will limit various discussions to lesions, abnormal development, and absence of menses.

Dr Loriaux points out that human skin contains hair follicles everywhere except on the lips, the palms of the hands, and the soles of the feet. He comments that all of the follicles produce and contain hairs, vellus or terminal, at sometime during one’s lifetime.

Many women who complain of hirsutism have normal endocrine functions. Dr Loriaux says that those patients do not need, nor will they benefit from, an endocrinogic evaluation.

He states that the purpose of his work was to help the physician identify which women complaining of Hirsutism need an endocrinoligic evaluation, what that evaluation should consist of, and how the patient should be treated.

The diagnosis of hirsutism and evaluation rely heavily on the history and physical examination, coupled with a few carefully chosen laboratory tests.

A pelvic examination is essential, which may detect acne, an assessment of clitoral size, and any evidence of fusion of the labioscrotal folds.

The physician should look for adnexal masses.

Dr Loriaux points out that woman with a normal menstrual history rarely have male pattern hirsutism. Woman with normal menstrual cycles who have a female pattern of terminal hair growth limited to arms, legs, cheek, and upper lip can be treated cosmetically.

Hirsutism that begins before of shortly after puberty often is caused bye an ovarian or adrenal neoplasm. Loriaux states that patients with an adrenal cause for hirsutism and those with ovarian hyperandigenism due to a neoplasm or insulin resistance should be treated with an antiandrogen

The most useful antiandrogen treatment is spironolactone. spironolactone was first used as a mineralocorticoid antagonist for use as a diuretic. Subsequent tests demonstrated that it had a potent antiandrogen use.

This led to its use in the treatment of androgen mediated hirsutism.

Thank you