Hirsutism

Hirsutism and virilization

Hirsutism
is defined as the excessive growth of thick dark hair in an androgen-dependent pattern where hair growth in women is usually minimal or absent - eg, the face, the chest and the areolae. It occurs as a result of increased androgen production, increased skin sensitivity to androgens, or both. Hirsutism is different to hypertrichosis, which is increased hair growth in a generalised non-sexual distribution and is unrelated to androgens. Idiopathic hirsutism and polycystic ovary syndrome (PCOS) are the most common causes. When hirsutism in women is accompanied by other signs of virilism, it may be a manifestation of a more serious underlying disorder causing hyperandrogenism, such as an ovarian tumour or adrenal neoplasm.

Virilization

Refers to concurrent presentation of hirsutism with a broad range of signs suggestive of androgen excess,such as
*Acne,
*Front temporal balding, alopacia
*Deepening of the voice ,
* Decrease in breast tissue
*Clitormegaly
*Increase lipido
*Male pattern obesity
*Infertility

Aetiology

Idiopathic hirsutism:
• Common and often familial.
• Is a diagnosis of exclusion and thought to be related to disorders in peripheral androgen activity.
• Onset occurs shortly after puberty with slow progression.
• There are no other signs of virilism. Menstrual function and investigations are normal.
Drug-induced hirsutism - eg, glucocorticoids, danazol, sodium valproate and androgenic progestogens.
Ovarian causes:
• PCOS: virilisation is minimal and hirsutism is often prominent. This is the most common cause and is present in approximately 70% of cases.


• Menopause
• Androgen-producing ovarian tumours - eg, luteoma of pregnancy, arrhenoblastomas, Leydig cell tumours, hilar cell tumours, thecal cell tumours.
Adrenal causes:
• Androgen-producing adrenal tumour.
• Congenital adrenal hyperplasia (CAH).
• Cushing's syndrome.
Other causes include severe insulin resistance, anorexia nervosa, prolactinoma, acromegaly, hypothyroidism and porphyria

Presentation

Excess terminal hair in a masculine pattern: face (particularly the moustache, beard and temple areas), chest, areolae, linea alba, upper and lower back, buttocks, inner thighs and external genitalia.
Signs of associated virilism (hyperandrogenism) may be present. They include:
• Acne.
• Alopecia, temporal hair recession.
• Male-pattern (truncal) obesity.
• Clitoromegaly.
• Deepening of voice.
• Increased libido.
• Increased muscle mass (primarily shoulder girdle).
• Loss of breast tissue or normal female body contour.
• Infertility.
• Menstrual dysfunction.


*Other abnormalities associated with excessive levels of androgen are cardiovascular disease, dyslipidaemia, glucose intolerance/insulin resistance and hypertension. Acanthosis nigricans, a marker for insulin resistance, may also be present.
*Pelvic mass: ovarian (bimanual vaginal examination) or adrenal tumour.

Investigations

It is important to investigate to establish the cause of hirsutism, even when mild, as the degree of hirsutism does not correlate well with the magnitude of androgen excess required.
History
Age of onset, rate of progression.
Menstrual history, age of menarche.
Medication, including over-the-counter preparations and anabolic steroids.
Family history of hirsutism.
Level of distress caused by hirsutism.
Associated symptoms (eg, acne, weight gain, androgenic alopecia, galactorrhea

Examination

For signs of hyperandrogenism as above.
For signs of Cushing's syndrome (moon face, stretch marks, easy bruising, proximal muscle weakness).
For skin changes such as acanthosis nigricans or acne.
To exclude pelvic masses.
Blood pressure.
BMI.
The goal is then to establish whether the hirsutism is androgen-mediated and if so, the cause of excess androgen.
Further investigation is indicated if there are features of androgen excess, rapid progression, infertility or menstrual irregularity


Initial investigationsThese include:
Testosterone:
• Measure on day 4-10 of the menstrual cycle.
• A high total testosterone concentration (> 200 ng/dL) indicates that hyperandrogenism may be caused by an ovarian or adrenal tumour.
• If the total testosterone is normal or only slightly raised, an androgen-secreting tumour can be excluded.
• Free testosterone is more sensitive and may be raised in PCOS.
• Testosterone concentrations more than 1.5-2 times the upper limit of normal or a history of rapid virilisation are likely to be associated with tumour-associated hyperandrogenism.
• Dehydroepiandrosterone sulfate DHEASand androstenedione should then be measured to identify an adrenal or ovarian source of the hyperandrogenism.

Free androgen index:

• Total testosterone is often normal in PCOS but the free androgen index is raised because sex hormone-binding globulin is suppressed.
• The free androgen index is calculated by also measuring sex hormone-binding globulin (free androgen index is total testosterone concentration divided by sex hormone-binding globulin concentration multiplied by 100).
Follicle stimulating hormone (FSH), luteinising hormone (LH): women with PCOS may have an increased LH/FSH ratio (>2 is common).

17-hydroxyprogesterone:

• Blood should be taken at about 9 am in the first half of the menstrual cycle.
• A 17-hydroxyprogesterone value of 5 nmol/L has a sensitivity of 100% and specificity of 88.6% for diagnosing non-classical CAH.
24-hour urine cortisol (to rule out Cushing's syndrome if suspected):
• Cushing's syndrome is a rare cause of hirsutism and exclusion is not necessary unless the patient has Cushnoid features
Pregnancy should be ruled out in women with irregular or absent menstrual cycles.


Prolactin:
• If prolactin concentrations are more than 1.5-2 times the upper limit of normal, other causes of hyperprolactinaemia should be considered.
TFTs: thyroid dysfunction can affect menstruation and hypothyroidism is associated with changes in hair.
Ultrasound: patients with either menstrual disturbances or clinical or biochemical evidence of hyperandrogenism alone should have transvaginal ultrasound imaging of the ovaries.
Further investigations as indicated:
• Glucose tolerance test Lipid profile.
• HbA1c.
• Ultrasound, CT, MRI: if an adrenal or ovarian tumour is suspected. MRI brain scan: if a pituitary tumour is suspected.

Management

Lifestyle modification
Encourage weight loss if overweight:
• Weight loss increases steroid hormone-binding globulin levels and decreases insulin resistance and the levels of serum androgens and luteinising hormones.
• Obesity has an adverse effect on the outcome of all systemic treatments.
Smoking cessation advice.

Topical cosmetic therapies

Shaving, threading, waxing, using depilatory creams, electrolysis and laser epilation or photo-epilation do not exacerbate hair growth and are effective, at least in the short-term.
Chemical depilation may be suited to treatment of large hairy areas in patients unable to afford more expensive treatments such as electrolysis and laser epilation.
Temporary epilation:
• Plucking
• Waxing.
• Home epilating devices
Permanent epilation:
• Electrolysis and thermolysis.
• Laser epilation :Can treat larger areas faster than electrolysis and thermolysis


Pharmacotherapy
Eflornithine, a topical hair growth retardant, inhibits the enzyme ornithine decarboxylase.
Combined oral contraceptives:
• Recommended as first-line treatment. There is evidence of limited quality that they are effective for mild hirsutism.
• Pills containing progestogens with anti-androgenic properties (eg, Co-cyprindiol (Dianette®) or Yasmin®) are effective but those containing levonorgestrel and norethisterone are more androgenic and could potentially exacerbate hirsutism. Dianette® is licensed for this purpose and should be used first-line.

Anti-androgens:

• Flutamide, finasteride and spironolactone have all been used in the management of hirsutism.
• May be combined with oral contraceptives for the treatment of hirsutism.
• Cannot be used in pregnancy and should be prescribed with secure contraception.
• May be associated with side-effects.
Gonadotrophin-releasing hormone (GnRH) agonists:
• For severe cases, these are occasionally used in secondary care.
• GnRH agonists such as leuprorelin or goserelin should be reserved for use in women who do not respond to combination hormonal therapy or those who cannot tolerate oral contraceptives.

• Metformin and other insulin-sensitizers have been shown to improve insulin sensitivity and decrease testosterone levels in patients with PCOS. They may have a limited role in management of subfertility in this context but the evidence is currently against them being used for hirsutism alone.
Complications
Hirsutism may have a detrimental impact on a woman's body image.
Facial hirsutism may cause considerable emotional distress and social embarrassment to women; hirsutism exceeding culturally normal levels can be very distressing.
Hirsutism is commonly associated with lower quality of life and symptoms of anxiety and depression.