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  • Hirsutism Aboubakr Elnashar Benha University Hospital, Egypt Aboubakr Elnashar
  • Outline Introduction Definition Causes Clinical evaluation Investigations Treatment Guidelines Aboubakr Elnashar
  • Introduction Aboubakr Elnashar
  • Gynecological, Endocrinological, Cosmetic & Psychogenic: {great anxiety, nature of the disease, social acceptance} Aboubakr Elnashar
  • Incidence Not known Mediterranean> Asian American females: 10% European: 5% Aboubakr Elnashar
  • Cycle growth of hair Several months 2 weeks 3 months Aboubakr Elnashar
  • Types of hair Lanugo Fetal hair Vellus Short, fine, Unpigmented Before puberty Terminal Long, coarse, pigmented arises from vellus hair Clinically, terminal hairs can be distinguished from vellus hairs primarily by their length (i.e.`0.5 cm) and the fact that they are usually pigmented.Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • Androgen production Androstenedione Testosterone Adrenal DHEA Ovary DHEAS 50% 50% 50% 25% 25% 90% 10% 100% Aboubakr Elnashar
  • Androgen in the blood Male Normal female Hirsute female Free 3% 1% 2% Albumin 19% 19% 19% SHBG 78% 80% 79% Aboubakr Elnashar
  • Androgen at target cell (hair follicle) Testosterone (T) 5-reductase. Dihydrtestosterone (DHT) Androstanediol Glucuronide 3 alpha androstanediol glucuronide(3 alpha AG) Aboubakr Elnashar
  • Definitions Aboubakr Elnashar
  • Virilization: Defiminization: Atrophy of the breast & vagina Musculinization: Hirsutism, deepening of voice temporal balding. Increase: size of the clitoris, muscular mass & libido Aboubakr Elnashar
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  • Main Causes of Virilization 1-CAH 2- Iatrogenic 3- Ovarian tumour 4- Cushing's syndrome. Aboubakr Elnashar
  • Hirsutism: Latin hirsutus = shaggy, hairy Excessive growth of terminal hair in male sexual sites. Excessive: Socially unacceptable to the patient F& G score >8 Aboubakr Elnashar
  • Hypertrichosis Excessive growth of (Lanugo, vellus or terminal) hair in non-sexual sites (James et al, 2005) Cong Acquired Localized Generalized Congenital hypertrichosis lanuginosa Drug-induced hypertrichosis Aboubakr Elnashar
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  • Hirsutism: Not an increase in the number of hair follicles but an alteration in their character. An increase in the transformation of the vellus to terminal hair. {Androgens will convert lanugo & vellus hair to terminal hair}.Aboubakr Elnashar
  • 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 5-reductase. Aboubakr Elnashar
  • Causes Aboubakr Elnashar
  • A. Ovarian: 1. PCOS: 90% 2. Tumors: 0.5% Virilizing ovarian tumors Luteoma of pregnancy 3. Dysgenesis B. Adrenal:5% 1. Cong adrenal hyperplasia 2. Tumors 3. Cushing syndrome C. Peripheral 1. Idiopathic: Regular ovulation & normal androgen levels 2. Insulin resistance HAIRAN syndrome: HyperAndrogenic Insulin-Resistant Acanthosis Nigricans 5H syndromeAboubakr Elnashar
  • A. Ovarian: 1. PCOS: 90% Aboubakr Elnashar
  • Rotterdam Criteria Of PCOS, 2003 2 out of 3 features are present: 1. Oligomenorrhoea and or Anovulation 2. Clinical Hyperandrogenism and/or hyperandrogenemia. 3. Polycystic ovaries (U/S). After exclusion of other etiologies. Aboubakr Elnashar
  • Clinical Hyperandrogenism 1. Hirsutism: The primary clinical indicator of androgen excess . 2. Acne : Potential marker 3. Androgenic alopecia: Poor marker unless with Oligomenorrhoea. Hyperandrogenemia FT) or FTI) are the more sensitive methods Routine measurement of Androstenedione: are not recommended. DHEAS is raised in small fraction of patient with PCOS .Aboubakr Elnashar
  • Hirsutism Hirsutism Aboubakr Elnashar
  • Hirsutism Aboubakr Elnashar
  • AcneHirsutism Aboubakr Elnashar
  • PCOS with hirsutism Aboubakr Elnashar
  • Ovarian orgin. Lateral mammary hirsutism, score 1 Aboubakr Elnashar
  • Grading scale for female pattern hair loss mild but obvious female pattern hair loss Female androgenic alopecia Frontal and temporal hair loss Aboubakr Elnashar
  • Rotterdam U/S Criteria of PCOS At least one of the following: 12 or more follicles measuring 29 mm in diameter increased ovarian volume (>10 cm3). The distribution of follicles and a description of the stroma are not required for diagnosis. The presence of a single PCO is sufficient to provide the diagnosis. Aboubakr Elnashar
  • Hirsutism in a young woman with PCOS. Note the acne lesions and excessive hair on her face and neck. Aboubakr Elnashar
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  • PCOS with hirsutism (Ferriman and Gallwey score 4) on the abdomen Aboubakr Elnashar
  • Examples of hirsutism affecting the back, chest, and abdomen Aboubakr Elnashar
  • 2. Ovarian Tumors:0.5% 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} 3. Ovarian dysgenesis Aboubakr Elnashar
  • Uterus and adnexa during caesarian sectionboth ovaries were enlarged (mean diameter 8 cm). Luteoma Aboubakr Elnashar
  • B. Adrenal:5% 1. Cong adrenal hyperplasia 2. Tumors 3. Cushing syndrome Congenital adrenal hyperplasia Androgen secreting tumor Centipetal obesity in Cushing's syndrome Aboubakr Elnashar
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  • Adrenal SAHA. Central hirsutism, score 2 Adrenal SAHA. Severe papulo-pustular acne and central hirsutism Aboubakr Elnashar
  • Cushing's Syndrome Aboubakr Elnashar
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  • Centripetal obesity 79-97 Facial plethora 50-94 Glucose intolerance 39-90 Weakness, proximal myopathy 29-90 Hypertension 74-87 Psychological changes 31-86 Easy bruisability 23-84 Hirsutism 64-81 Oligomenorrhea or amenorrhea 55-80 Acne, oily skin 26-80 Abdominal striae 51-71 Ankle edema 28-60 Backache, vertebral collapse, fracture rare Clinical manifestations % Aboubakr Elnashar
  • Cushings Syndrome One should be aware of the possibility of Cushings syndrome in women with stigmata of the : PCOS & Obesity as it is a disease of insidious onset and dire consequences Aboubakr Elnashar
  • Forearm of a women man with Cushing's disease showing multiple ecchymoses due to minimal trauma. 30-year-old woman with Cushing's disease showing round, plethoric "moon" face, facial hirsutism, and increased supraclavicular fat