Chapter 17: Hirsutism

INTRODUCTION

Hirsutism represents a male pattern overgrowth of terminal and vellus hairs in women. Far from being solely a cosmetic concern, hirsutism can be an important manifestation of an underlying endocrine disorder arising from increased androgenic activity. Often, it results from an overproduction of adrenal and ovarian hormones and may accompany other signs of virilization. Its appearance produces social anxiety, distress, and ostracism in affected patients. It also merits an appropriate medical workup. By contrast, hypertrichosis features fine hairs in androgen-sensitive as well as androgen-insensitive areas. Normal racial and ethnic variations may cause confusion with these disorders.

EPIDEMIOLOGY

Incidence: common.

Age: usually postpubertal but age of onset can vary in the setting of medication, tumor, or endocrine abnormality.

Race: racial and cultural factors affect the perception of what constitutes abnormal hair growth. Skin type affects treatment options as well.

Sex: female.

Precipitating factors: hirsutism is caused by a host of endocrine abnormalities. Adrenal causes include Cushing’s disease, ectopic adrenocorticotropic hormone (ACTH) production, primary androgen-producing neoplasms, and congenital adrenal hyperplasia. Ovarian causes can be related to polycystic ovarian syndrome and primary tumors among other causes. Finally, medications such as oral contraceptive pills, anabolic steroids, and androgens may cause hirsutism.

PHYSICAL EXAMINATION

There is an overgrowth of hair in androgen-sensitive hair follicles. Common sites include the beard area of the face, chin, preauricular face, linea alba, periareolar area, and chest. Depending on the severity of the condition, other signs of virilization such as increased muscle mass, deep voice, male pattern hair loss, and clitoral enlargement may be present.

DIFFERENTIAL DIAGNOSIS

While both hirsutism and hypertrichosis feature hair overgrowth, these conditions can be differentiated by the location and quality of the hair growth. Hirsutism is characterized by terminal hair overgrowth in androgen-dependent areas, while hypertrichosis features fine hairs in androgen-sensitive as well as androgen-insensitive areas. Normal racial and ethnic variations may cause confusion with these disorders.

LABORATORY TESTS

The laboratory workup should be guided by the patient’s clinical findings as well as by a detailed patient history. Testing can help establish if there is an adrenal or ovarian source of the hair growth. Ovarian, adrenal, and pituitary tumors should be ruled out in cases of rapid onset by an endocrinologist and/or a gynecologist. Total testosterone levels, dehydroepiandrosterone sulfate levels, urinary free cortisol levels, dexamethasone suppression test, prolactin levels, ACTH stimulation, luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio, 17-hydroxy progesterone levels, and pelvic ultrasound may all present important components of a thorough endocrinologic workup.

COURSE

Course is dependent on the etiology of the hirsutism.

KEY CONSULTATIVE QUESTIONS

• Menstrual history—regular or irregular

• Medication history

• Onset and progression of symptoms

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