Hirsutism resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Hirsutism is a common endocrinological and dermatological complaint that is defined as a condition that results in the presence of excessive amounts of dark coarse hair (terminal hair) in a male-like pattern distribution in females. It usually appears in chin, upper lip, chest, back and anterior thighs. Hirsutism presents in 5-10% of females in reproductive age. Hirsutism is different from hypertrichosis that defined as excessive hair growth all over the body with no sexual distribution and it is not an androgen-dependent condition. Underlying androgen disorders are the most common causes of hirsutism and polycystic ovary syndrome (PCOS) accounts for nearly 70-80% of these conditions. Pharmacological therapy or direct hair removal methods is considered as initial therapy for women with mild hirsutism without underlying endocrine disorders. Lifestyle modifications are also recommended in obese patients with PCOS.

Causes

Common Causes

Hyperandrogenic hirsutism

• Polycystic ovary syndrome
• Idiopathic hyperandrogenemia
• Non-classical Congenital Adrenal Hyperplasia
• Androgen-secreting tumors

Non-hyperandrogenic hirsutism

• Medications
• Endocrine disorders
• Idiopathic hirsutism

Diagnosis

Shown below is an algorithm summarizing the diagnosis of disease name according the Endocrine Society Clinical Practice guideline .

Initial evaluation & diagnosis of hirsutism

History & physical examination including pelvic examination

Medication use? *Ask for anabolic or androgenic steroids (in athletes, patients who are using dietary supplements, patients with sexual dysfunction, or in patients with a partner who uses testosterone gel) and valproic acid (in patient with neurologic disorders

Discontinue medication

Isolated local hair growth

Direct hair removal methods

Improvement or stable

Normal variant

Abnormal hirsutism score or local hair growth with symptoms suggesting hyperandrogenic endocrine disorder*? *menstrual irregularity, infertility, galactorrhea, signs or symptoms of hypothyroidism, Cushing syndrome, acromegaly, central obesity,acanthosis nigricans, clitoromegaly, or sudden-onset or rapid-progression hirsutism suggests the presence of a hyperandrogenic endocrine disorder

Early morning total testosterone blood level

Progression or unstable

Normal

Elevated

Mild isolated hirsutism

Moderate to severe hirsutism or presence of hyperandrogenic endocrine disorder

Direct hair removal methods or oral contraceptive

Improvement or stable

Progression or unstable

Free testosterone blood level

Normal

Elevated

Hyperandrogenemia

Full hormonal workup

Idiopathic hirsutism

Reevaluate if hirsutism progresses

Treatment

Shown below is an algorithm summarizing the treatment of hirsutism according the Endocrine Society Clinical Practice guideline

Initial therapy for patient with hirsutism

Mild hirsutism and no evidence of an endocrine disorder

Moderate or patient-important hirsutism

Severe hirsutism

Direct hair removal methods

Pharmacological therapy

Pharmacological therapy (add direct hair removal if needed)

Combined pharmacological therapy

• Photoepilation for women with auburn, brown, or black unwanted hair • Electrolysis for women with white or blonde hair

• Start oral contraceptives in women who are not seeking fertility ** Use oral contraceptives containing the lowest effective dose of ethinyl estradiol and a low-risk progestin for women at higher risk for venous thromboembolism (e.g., obese or >39 years old) • Start either oral contraceptives or anti-androgens in women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception

Oral contraceptives and antiandrogens

Add an antiandrogen if hirsutism remains despite 6 months of monotherapy with an oral contraceptive

Do's

• A trial of at least 6 months is required before making any changes in dose or type of the drug.

Don'ts

• Combination therapy of an oral contraceptive and antiandrogen is not recommended as an initial therapy unless the patient is suffering from severe hirsutism.
• Among the antiandrogen medications, flutamide is not recommended due to drug-induced hepatotoxicity.

References

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