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Hirsutism

N.Sneige MD
Prof. of Endocrinology ,Diabetology
Medicine Faculty

Hirsutism
Hirsutism is the development of androgen- dependent terminal body hair in a women in places in which terminal hair is normally not found

Hirsutism may affect between 5 and 10 percent of women of reproductive age

Modified scale of Ferriman and gallway

95% of women have Ferriman and gallway < 8

Hirsutism is due to

Increased production rate of androgens usually testosterone
Increased conversion of testosterone to dihydrotestosterone in peripheral tissue including hair follicles

The definition of normal must also consider race

The most important consideration
the women’s background
The pattern of hair growth has changed
The rate of growth has increased

Clinical findings that suggest The serious
causes of hirsutism

Abrupt onset
Short duration
Progressive worsening of hirsutism
Onset in the third decade of life or later, rather than near puberty
Symptoms or signs of virilization

Hirsutism with virilization

Hirsutism without virilization

Hirsutism + Virilization

androgen excess
adrenal and ovarian tumors

Stimulation of hair growth from the follicle depends
Circulating androgen concentration
Local factors
Variability in end –organ sensitivity to circulating androgens

The cutaneous manifestation of androgen disorder

Hirsutism
Acne
Male–pattern balding

Androgens

Testosterone
DHEA-s
Androstendione

Causes of Hirsutism

Idiopathic
Adrenal
Ovarian
Drugs

Ovarian Hirsutism

PCOs
Neoplasm
Imulin resistence syndroms

Adrenal Hirsutism

21 – OH – deficiency
Neoplasm
Chushing syndrom
Hyperprolactinemia

Causes of Hirsutism

Idiopathic
Drugs

Ovarian Hirsutism

PCOs
Neoplasm
Insulin resistence syndroms

Adrenal Hirsutism

21 – OH – defiiencyc
Neoplasm
Chushing syndrom
Hyperprolactinemia

Hirsutism

Less common causes
hyperprolactinemia
Drugs
Congenital adrenal hyperplasia
Ovarian tumors
Adrenal tumors

PCOs
Menstrual irregularity
Evidence of hyperandrogenism whether clinical (Hirsutism ,acne ,or male pattern balding)or biochemical (elevation serum androgen concentration )

PCOS is achronic condition but several treatments can alleviate the hirsutism
PCOS is also associated with other medical problems such as infertility, obesity, DM , high cholesterol levels,and possibly heart disease

Idiopathic Hirsutism
Normal serum androgen concentrations
No menstrual irregularity
No identifiable cause of the Hirsutism

Congenital adrenal hyperplasia

Hirsutism
AGS

17 – hyperoxyprogesterone
androstenedione

Hirsutism

Late – onset congenital adrenal hyperplasia

peripubertally Hirsutism
Menstrual irregularity or
Primary amenorrhea

Hirsutism
Severe insulin resistance syndromes
marked hyperinsulinemia
Ovarian hyperandrogenism
Decreases serum sex hormone binding globulin concentrations
free testosterone

In obese women,weight loss can reduce androgen production Therefore slow hair growth and improve menstrual function

Hyperprolactinemia and Hirsutism

Evaluation of women with hirsutism:

History-

Menstrual history
Time course of symptoms
Weight history
Medication history
Family history

Physical examination-
Hirsutism
Labor in hirsutism
Testosterone
DHEA - S
Prolactine
LH

Adrenal tumors adenomas–Carcinomas

testosterone
DHEA - DHEAs
Cortisol

Hirsutism
Testosterone values
Idiopathic---- normal
PCOs ---- normal -slightly elevated
AGS --- normal -slightly elevated
Tumors --ovarian ,adrenal-- very elevated

The relationship
between ultrasonography and PCOS
is limited

Why

Ultrasound appearance in pcos
-peripheral follicles ---at least 8 to 10 in each
Ovary – small 2 to 8mm---
-increased amount of stroma
-increased of Ovarian volume

Treatment of Hirsutism

Treatment of hirsutism
Nonpharmacologic
Pharmacologic

Hirsutism
Cosmatic therapy
Shaving
Wax depilation
Chemical Depilation & bleaching
Electrolysis
Laser treatment
Vaniqa

Hirsutism
The goals of therapy are
to slow or stop hair growth
To ameliorate any related problems such as
Menstrual irregularity
Infertility

These goals can be achieved by
Reducing androgen secretion
Reducing androgen action
Specific therapy directed at the cause of the Hirsutism

Women should be warned not to expect improvement for at

least three to six months after therapy has begun

The treatment response
improvement in hirsutism scores
Follow up hormonal testing is not required

Therapy is usually continued indefinitely because increased androgen production or sensitivity is life -long

All currently available medications for hirsutism need to be stopped when a pregnancy is desired

The hirsutism drugs
ORAL contraceptives
Antiandrogen therapy
Gn- RH – agonist
Glucocorticoid therapy
Combined therapy

Oral contraceptives ? slow hair growth in approximately 60 to 100 % of
hyperandrogenic women

And are considered first – line therapy

Hirsutism
The mechanism
inhibition of luteinsing Hormone
Stimulation of sex hormone –binding globulin production
Inhibition of adrenal androgen secretion

Norgestrel and levonorgestrel

Hirsutism
Antiandrogen therapy
are an effective treatment for hirsutism
Potential teratogenic risks

Combined therapy
Oral contraceptive + antiandrogen
(severe Hirsutism)

Antiandrogen drugs
spironolactone
Flutamid
Finasteride
Cyproterone acetate

spironolactone
inhibition testosterone binding to its receptors
it also decreases the ovarain production

Hirsutism
The usual dose is 50 to 200 mg
give once daily

he side effects of spironolatone include hyperkalemia
Gastrointestinal discomfort
Irregular menstrual bleeding

Cyproterone acetate is a progestin with antiandrogenic
activity

Gn-RH – agonist

ostrogen

+ Oral Contaceptive

hirsutism
Women with pcos have an increased risk of
Endometrial hyperplasia
Infertility
Cardiovascular disease

To prevent endometrial hyperplasia
The endometrium must be stimulated with progesterone to undergo secretory differentiation

Ovulation induction therapy for infertility
Clomiphene
Gonadotropines
Gonadotropines + Gn RH- agonist

Control of cardiovascular risk factors
weight reduction

Treatment of other causes of hirsutism
Hyperprolactinemia
21- hydroxylase deficiency

Glucocorticoid therapy

adrenal androgens

weight
Osteosperosis
Impaired Glucose tolerance
Adrenal suppretion

Conclusion
Hirsutism accerus to many factors
We must recognize between hirsutism and virilization
Medical therapy is life long
Medical therapy is contraindicated in the pregnancy
The most common causes of hirsutism are PCOs and idiopathic hirsutism

Thank you