General Medicine ConferenceGeneral Medicine Conference

“Hirsutism”“Hirsutism”

Selim Krim, MDSelim Krim, MDAssistant professorAssistant professor

Texas Tech University Health Sciences CenterTexas Tech University Health Sciences Center

OBJECTIVESOBJECTIVES

Define hirsutismDefine hirsutism

Get familiar with the Ferriman-Gallway scale to evaluate Get familiar with the Ferriman-Gallway scale to evaluate the extent of hair growththe extent of hair growth

Understand the pathogenesis of hirsutismUnderstand the pathogenesis of hirsutism

Be familiar with available therapiesBe familiar with available therapies

Use a stepwise approach when evaluating for hirsutismUse a stepwise approach when evaluating for hirsutism

CASECASE

A 19-year-old woman seeks care for slowly progressive hair growth. Since high school, she has shaved her upper lip weekly and waxed her abdomen and thighs monthly. Her menstrual periods are regular. Physical examination is unremarkable except for a body-mass index (the weight in kilograms divided by the square of the height in meters) of 31 and trace hair over the abdomen and thighs, with a moderate amount over her back. There is no clitorimegaly. How should this patient be evaluated and treated?

DEFINITIONDEFINITION

“ “Excessive terminal hair that appears in a male pattern (i.e., sexual Excessive terminal hair that appears in a male pattern (i.e., sexual hair) in women”hair) in women”

Deplewski et al. Endocr Rev 2000;21:363-92Deplewski et al. Endocr Rev 2000;21:363-92

CLASSIFICATIONCLASSIFICATION

PATHOGENESISPATHOGENESIS

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

HYPERTRICHOSISHYPERTRICHOSIS

Generalized excessive hair growth secondary to heredity Generalized excessive hair growth secondary to heredity or medications ( Steroids, phenytoin, Cyclosporine).or medications ( Steroids, phenytoin, Cyclosporine).

Hair is distributed in a Hair is distributed in a generalized, non sexual patterngeneralized, non sexual pattern..

Not causedNot caused by excess of androgens by excess of androgens

ETIOLOGIESETIOLOGIES

Normal androgen levels:Normal androgen levels:Idiopathic hirsutismIdiopathic hirsutism

Excess androgen levels:Excess androgen levels: Polycystic ovary syndromePolycystic ovary syndromeCongenital adrenal hyperplasiaCongenital adrenal hyperplasiaAndrogen secreting tumorsAndrogen secreting tumorsCushing’s syndromeCushing’s syndromeHyperprolactinemiaHyperprolactinemiaAcromegalyAcromegalyThyroid dysfunctionThyroid dysfunctionAndrogenic medicationsAndrogenic medications

DIAGNOSISDIAGNOSIS

History and physical exam helps ruling out other causes History and physical exam helps ruling out other causes of virilizing disorders, polycystic ovary syndrome, of virilizing disorders, polycystic ovary syndrome, medication use or other endocrinopathies.medication use or other endocrinopathies.

Look for evidence of Look for evidence of anovulation, obesity, metabolicanovulation, obesity, metabolic syndrome.syndrome.

A A rapid rapid pace of development or progression of hirsutism pace of development or progression of hirsutism or evidence of virilization (or evidence of virilization (Clitoromegaly or increasing Clitoromegaly or increasing muscularitymuscularity) should raise concern that an ) should raise concern that an androgen-androgen-secreting tumorsecreting tumor is present is present

STEPWISE APPROACH TO HIRSUTISMSTEPWISE APPROACH TO HIRSUTISM

MANAGEMENTMANAGEMENT

Cosmetic and physical measuresCosmetic and physical measures

Hormonal treatmentsHormonal treatments

Estrogen-progestin oral contraceptivesEstrogen-progestin oral contraceptives

AntiandrogensAntiandrogens

Other hormonal therapies: (Glucocorticoids, 5 alpha-Other hormonal therapies: (Glucocorticoids, 5 alpha-reductase inhibitors, metformin and thaizolidinediones)reductase inhibitors, metformin and thaizolidinediones)

AVAILABLE THERAPYAVAILABLE THERAPY

CASECASE A 19-year-old woman seeks care for slowly progressive hair

growth. Since high school, she has shaved her upper lip weekly and waxed her abdomen and thighs monthly. Her menstrual periods are regular. Physical examination is unremarkable except for a body-mass index (the weight in kilograms divided by the square of the height in meters) of 31 and trace hair over the abdomen and thighs, with a moderate amount over her back. There is no clitorimegaly. How should this patient be evaluated and treated?

Based on Ferriman-Gallway scale, this patient has mild hirsutismBased on Ferriman-Gallway scale, this patient has mild hirsutism

There are no signs of virilization and her menstrual cycles are regularThere are no signs of virilization and her menstrual cycles are regular

However the increase in her weight may warrant further testingHowever the increase in her weight may warrant further testing

Free testosterone levelsFree testosterone levels

CASECASE

A trial of eflornithine chloride cream may be tried for facial hirsutismA trial of eflornithine chloride cream may be tried for facial hirsutism

Encourage weight controlEncourage weight control

If hirsutism remains uncontrolled, oral contraceptives may be used If hirsutism remains uncontrolled, oral contraceptives may be used over a 9 to 12 months periodover a 9 to 12 months period

May also discuss the potential permanent benefit, risks, and cost of May also discuss the potential permanent benefit, risks, and cost of laser hair removallaser hair removal

Questions ?Questions ?

Thank youThank you