HIRSUTISM-CASE PRESENTATION

Department of Streeroga & Prasutitantra

HODDr.Mrs.S.S.Chaudhari

Name: xyzSex: femaleAge: 35 YearsOPD No.:27380

Chief Complaints: On Dt.14 May 2009 Irregular menses Scanty menses Since 4 years Hirsutism Weight gain

Menarche: At 14th years of agePast Menstrual History (Before 4 Yrs.):3 day/28-30 day -Reg./Med./PainlessPresent Menstrual History (Since 4 Yrs.):3 day/2-2½Month -Irreg./Scanty/PainlessMarital Status: Married since 16 Yrs.Obstetric History: G₅ P₂ A₃ L₂ D₀

1)Mch-15 yr-FTND2)Mch-12 yr-FTNDThree MTP done.

H/O Tubectomy done 10 yrs back.Personal History: NADFamily History: NAD

Examination:

Pulse- 90/minBlood Pressure- 120/80 mmHgTemperature- 98.6 F⁰Build- ObeseHeight- 145cmWeight- 65kgBMI- 31F & G Score - 10

STROTAS PARIKSHAN:Rasawaha- Twak-SnigdhaRaktawaha- Yakrit

Pleeha Not Palpable

Mansawaha- Snaya- PrabhutTwak- SnigdhaRoma- Atiloma

Medowaha- Vrikka- No tendernessKati- KatishulaSweda- Prabhut

Asthiwaha- Dant- Prakrut Nakh- Prakrut

Kesh-Krishna

Majjawaha- Akshisneha- AlpaTwakasneha- PrabhutVitsneha- Alpa

Stanyawaha- Stana- PrakrutPranawaha- Nasa- Prakrut

Kantha- PrakrutAnnawaha- Ostha- Prakrut

Jivha- SamaDanta- Prakut

Udakawaha- Talu- PrakrutJivha- SamaTrishna- Prabhut

Purishawaha- Pakwashaya- Prakrut Sthulaguda- Prakrut

Mutrawaha- Vankshana- PrakrutBasti- Prakrut

Swedowaha- Sweda- PrabhutMeda- Prabhut

ABDOMINAL EXAMINATION:INSPECTION- Fat distribution over abdominal region(Android Obesity)PALPATION-L S K⁰ ⁰ ⁰Soft Abdomen

SYSTEMIC EXAMINATION: RS- ClearCVS- S₁S₂ NormalCNS- Well conscious & oriented

GNAECOLOGICAL EXAMINATION:Per Speculum- Cx & Os-Normal

Vagina- HealthyPer Vaginal- Uterus - AV & NS

Rt. Fx- TendernessLt. Fx- Clear

INVESTIGATIONS:Hb%- 8.9 Gm%Urine- NADHIV- NRVDRL- NRUSG- Uterus-Normal size

Ovary-Normal size e/o Right Hydrosalpinx of size 7x4cm

BSL®- 85.5mg/dl

Total Testosterone- 93.51ng/dl (↑ ) (Dt.09/09/09)Total Testosterone- 68.39ng/dl (N) (Dt.09/01/10)TFT- T3 -87.7ng/dl

T4 -5.2ug/dlTSH -27.94uIU/mL(↑) ?subclinical hypothyroidism

Ayurvedic ConceptHair- Mala of Asthidhatu

Upadhatu of Majjadhatu

Pitruja Avayava

Good quality of loma mentioned in Twaksar

A person with Aloma & Atiloma mentioned in Astha Nindit

Cycle growth of hair

Several months 2 weeks 3 months

Types of hairLanugo

Fetal hair

VellusShort,fine, UnpigmentedBefore puberty

TerminalLong, coarse, pigmented arises from vellus hair

Non sexual Ambi-sexual Male sexual

Sites Lower parts of the scalp, eye brow, lashes, fore-arms, lower legs

Temporal & vertical parts of the scalp, axilla, lower pubic hair.

Ears, nasal tip, chin, sternum, upper pubic triangle, back.

Depend on Growth hormone from pituitary

Androgen in low concentration from the adrenals & ovaries in females & adrenals in male

Androgen in high concentration

Sites of hair

Androgen production Androstenedione

Testosterone

Adrenal DHEA Ovary

DHEAS

50% 50%50%

25% 25%

90% 10%

100%

Hypertrichosis Excessive growth ofLanugo, vellus or terminal hair in non-sexual sites (James et al, 2005)•CongAcquired•LocalizedGeneralized

Congenital hypertrichosis lanuginosa Drug-induced hypertrichosis

Hirsutism: Latin hirsutus = shaggy, hairy

Excessive growth of terminal hair in male sexual sites. Excessive: Socially unacceptable to the patient F& G score >8

Hirsutism is a consequence of several

factors. An increase in: 1. Androgen production

2. The sensitivity of the androgen receptors at the level of the hair follicle.

3. The activity of 5œ-reductase.

CAUSES

A. Ovarian:.PCOS: 90% {hyperandrogenism, oligo-ovulation, PCO}

.Virilizing ovarian tumors {arrhenoblastoma, hilus cell tumor, lipod cell tumor, granulosa cell tumor}

.Luteoma of pregnancy { Not true tumor but an exaggerated reaction of ovarian stroma to chorionic gonadotropins. It is solid, usually unilateral & regress after labour}

.Ovarian dysgenesis

Turner’s syndrome

B. Adrenal:•Cong adrenal hyperplasia•Tumors•Cushing syndrome

Congenital adrenal hyperplasia

C. PERIPHERAL•Idiopathic: Regular ovulation & normal androgen levels

•Insulin resistance– HAIRAN syndrome: HyperAndrogenicInsulin-Resistant Acanthosis Nigricans– 5H syndrome

acanthosis nigricans.

•Aromatase deficiency•Glucocorticoid resistance•Hyperprolactinema can cause an increase in DHEAS. TT with bromocriptin: dec PRL & DHEAS

HirsutismAnabolic steroidsDanazolMetoclopramideMethyldopaPhenothiazinesProgestinsReserpineTestosterone

HypertrichosisCyclosporineDiazoxideHydrocortisoneMinoxidilPenicillaminePhenytoinPsoralensStreptomycin

Hunter, 2003

D. Drugs

Degree of hirsutism Photography or scoring systemsa. Ferriman & Gallwey(1961): 9 areas upper lip, chin, chestupper abdomen, lower abdomen, upper arm, thighs, upper back,lower back/buttocks

minimal=1, mild=2, moderate=3, severe=4

>8 = hirsutism

Degree of hair growth (Ferriman & Gallwey,1961)

TREATMENT

Principle of Treatment-

A. To Remove the Source of Androgen

B. To Supress the Action of Androgen

C. Removal of Excess Hair

A. To Remove the Source of Androgen

Vamana Karma

Weight Reduction

B. To Supress the Action of Androgen

Hyponidd Tablets-Yashad BhasmaKarvellakaExtracts-Haridra, Tarwar, Amalaki, Jambu, Mamajavo, Meshashringi, Vijaysaar, Guduchi, Neem, Kirattikta.

To Decrease Insulin Resistance

C. Removal of Excess Hair

Lomashatan Yoga-(Sharangdhar)

Shudha Shankha Churna- 2 partShudha Hartal -1 partShudha Manahashila - ½ partShudha Swarjika kshar - 1 part

Mixed together, pasted in water & applied after waxing for 7 times.

"Once the Black Terminal Hair is produced, the changes persist even in the absence of a continuing androgen excess"