Hirsutism

The causes of hirsutism can be divided into endocrine imbalances and non-endocrine etiologies. It is important to begin by first determining the distribution of body hair growth. If hair growth follows a male distribution, it could indicate the presence of increased androgens or hyperandrogenism. However, there are other hormones not related to androgens that can lead to hirsutism. A detailed history is taken by a provider in search of possible causes for hyperandrogenism or other non-endocrine-related causes. If the distribution of hair growth occurs throughout the body, this is referred to as hypertrichosis, not hirsutism. Endocrine causes Endocrine causes of hirsutism include: • Ovarian cysts such as in polycystic ovary syndrome (PCOS), the most common cause in women. • Adrenal gland tumors, adrenocortical adenomas, and adrenocortical carcinoma, as well as adrenal hyperplasia due to pituitary adenomas (as in Cushing's disease). • Acromegaly and gigantism (growth hormone and IGF-1 excess), usually due to pituitary tumors. • Drug-induced: medications were used before the onset of hirsutism. The recommendation is to stop the medication and replace it with another. • Androgens like testosterone, anabolic steroids, and androgenic progestins Around 10 to 15% of women with hirsutism have idiopathic hirsutism. Idiopathic hirsutism may be due to increased production of dihydrotestosterone (DHT) in hair follicles and hence may actually still be due to hyperandrogenism. ==Diagnosis==

Hirsutism is a clinical diagnosis of excessive androgenic, terminal hair growth. A complete physical evaluation should be done prior to initiating more extensive studies, the examiner should differentiate between widespread body hair increase and male pattern virilization. One method of evaluating hirsutism is the Ferriman-Gallwey Score which gives a score based on the amount and location of hair growth. The Ferriman-Gallwey Score has various cutoffs due to variable expressivity of hair growth based on ethnic background. Diagnosis of patients with even mild hirsutism should include assessment of ovulation and ovarian ultrasound, due to the high prevalence of polycystic ovary syndrome (PCOS), as well as 17α-hydroxyprogesterone (because of the possibility of finding non-classic 21-hydroxylase deficiency). People with hirsutism may present with an elevated serum dehydroepiandrosterone sulfate (DHEA-S) level, however, additional imaging is required to discriminate between malignant and benign etiologies of adrenal hyperandrogenism. Levels greater than 700 μg/dL are indicative of adrenal gland dysfunction, particularly congenital adrenal hyperplasia due to 21-hydroxylase deficiency. However, PCOS and idiopathic hirsutism make up 90% of cases. == Treatment ==

Treatment of hirsutism is indicated when hair growth causes patient distress. The two main approaches to treatment are pharmacologic therapies targeting androgen production/action, and direct hair removal methods including electrolysis and photo-epilation. These may be used independently or in combination. Pharmacologic therapies Common medications consist of antiandrogens, insulin sensitizers, and oral contraceptive pills. All three types of therapy have demonstrated efficacy on their own, however insulin sensitizers are shown to be less effective than antiandrogens and oral contraceptive pills. The therapies may be combined, as directed by a physician, in line with the patient's medical goals. Antiandrogens are drugs that block the effects of androgens like testosterone and dihydrotestosterone (DHT) in the body.'' It is effective similarly to flutamide but is much safer as well as better-tolerated. Examples include birth control pills containing cyproterone acetate, chlormadinone acetate, drospirenone, and dienogest. • Finasteride and dutasteride: 5α-Reductase inhibitors. Flutamide is safe and effective. • GnRH analogues: Suppress androgen production by the gonads and reduce androgen concentrations to castrate levels. • Metformin: Insulin sensitizer. Antihyperglycemic drug used for diabetes mellitus and treatment of hirsutism associated with insulin resistance (e.g. polycystic ovary syndrome). Metformin appears ineffective in the treatment of hirsutism, although the evidence was of low quality. Other methods • Electrology • Epilation • Laser hair removal • Lifestyle change, including reducing excessive weight and addressing insulin resistance, may be beneficial. Insulin resistance can cause excessive testosterone levels in women, resulting in hirsutism. • Shaving • Waxing ==See also==