Review Management of Hirsutism
What is hirsutism?
Hirsutism is defined as excessive terminal hair that appears in a male pattern in women. It is indicated by a Ferriman-Gallwey hirsutism score. It has an incidence of 5-10%. It is the effect of androgen excess at the pilosebaceous unit and may be associated with acne and seborrhea. Hirsutism occurs due to an excess in circulating androgens or due to increased sensitivity of the pilosebaceous unit to the androgens.
Etiology of hirsutism
- Idiopathic: 5-15%
- Polycystic ovarian syndrome (PCOS): 70-80%
- Congenital adrenal hyperplasia (CAH): 2-8%
- Hyperthecosis
- Androgen secreting tumour: 0.2-0.5%
- Cushing’s syndrome
- Drug induced: anabolic steroids, danazol, valproate, etc.
- Others: hypothyroidism, hyperprolactinemia, anorexia nervosa, luteoma in pregnancy
Evaluation
Evaluation includes a thorough history, general and systemic examination, and Ferriman-Gallwey scoring. Investigations are not recommended for isolated mild hirsutism (FG score 8-15) but should be done in moderate to severe hirsutism, or where hirsutism is sudden in onset, rapidly progressive or associated with menstrual irregularities, features of virilism, central obesity or infertility. The initial investigation is serum testosterone level.
If testosterone is >200 ng/dl (>100 ng/dl in postmenopausal women), then a tumour is to be suspected and screened for. Testosterone >200 ng/dl with raised DHEAS levels is suggestive of an adrenal tumour.
If testosterone is <200 ng/dl, then other causes can be screened using glucose tolerance test with insulin levels, FSH, LH, prolactin, TSH, 17-hydroxyprogesterone (17-OHP), pelvic USG, etc. Patients with raised 17-OHP levels >200 ng/dl should undergo an ACTH stimulation test. An increased 17-OHP and an abnormal ACTH stimulation test is diagnostic of congenital adrenal hyperplasia.