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Essay 313 - Hirsutism

Posted by L S.
LS:
(a) Discuss and justify the information you would obtain from the history [9 marks].
She should be approached sensitively as this can be distressing to her. Causes of hirsutism can be due to androgen excess, nonandrogen factors and idiopathic. Details on changes in body weight, breast size and facial contours asked. The presence of acne, hair loss or balding enquired. Disturbance in her menstrual history, infertility and family history of premature balding and diabetes enquired. All this if present can lead towards possibility of polycystic ovary syndrome (PCOS) which is the commonest cause and found in 70-80% of women with hirsutism. Based on Rotterdam criteria presence of two out of three of the following is diagnostic after other causes have been excluded: oligo or anovulation, hyperandrogenism and morphology of polycystic ovaries on ultrasound. The onset and rate of progression of facial hair is important as sudden rapid onset of excessive hair with virilisation can lead to possibly an androgen secreting tumour either from the adrenal or ovarian gland as cause of hirsutism. Abdominal distension or presence of a mass enquired. Other endocrine risk like family history of congenital adrenal hyperplasia, symptoms of hypothyroidism enquired. Drug history taken in detail as use of testosterone, danazol and anabolic steroids which has androgenic properties will induce hirsutism. Non androgeninc drug use like phenytoin, minoxidil, diazoxide or high dose corticosteroids has been found to induce increase hair growth independent of androgen should be enquired on. Details on desire for pregnancy and contraception use enquired. Impact of her problem to her quality of life enquired.

(b) Discuss the investigations that you will undertake [4 marks].
Blood sample for hormone profile which includes serum testosterone, FSH and LH, sex hormone binding globulin (SHBG), DHEAS and free androgen index to exclude or diagnose PCOS. A thyroid function test or serum prolactin taken if thyroid dysfunction or hyperprolactinaemia is suspected. A raised testosterone increases suspicion of adrenal tumour and an MRI or CT scan of abdomen should be undertaken to diagnose tumour. An ultrasound pelvis essential to rule out tumours within ovary and exclude or confirm features of PCOS. This scan is best done in early follicular phase.

(c) Discuss the treatment options given that no cause has been identified [6 marks].
Reassurance alone would help in mild idiopathic hirsutism if there is no significant social problem. Cosmetic approach would include plucking, waxing, bleaching and use of depilatory creams can be useful but chronic use can lead to skin irritation. More expensive methods are laser treatment which can be offered if earlier methods are unsuccessful. Final physical method is electrolysis which results in permanent hair destruction with best cosmetic results. However it is expensive and need to be performed by an experienced operator to minimize risk of scarring or infection. Medical treatment would be an option in this young woman with COCP containing anti androgen cyproterone acetate (CPA) for example Dianette offers added advantage of effective contraception, corrects menstrual irregularities. It is cheap and effective but compliance may be a problem as has to be taken regularly. Use of topical eflornithine (Vaniqa) which is licensed for use on face has been shown to be effective and is recommended as can be used underneath moisturizer or cosmetics as is rapidly absorbs. This can be offered if she does not require contraception. However development of rash (main adverse effect) and potential systemic toxicity if used over wide area can be particularly distressing. Use of finasteride was found to be as effective as CPA but feminisation of male fetus is a risk and effective contraception is advised if taking this drug. Emphasis on absence of pathology is the most important aspect to her care with reassurance and encourage positive outlook to self image.
Posted by Green K.
Green:

a) History of presence of hair at other areas of her body such as back, chest, lower abdomen and thighs which would indicate the severity of hyperandrogenism. The effect of the hirsutism on her perceived appearance and its impact on her quality of life. Menstrual history with regards to the age of menarche, last menstrual period , regularity and duration of bleeding as oligomenorrhoea may suggest polycystic ovarian syndrome. Obstetric history regarding parity and if subfertility was present as it may suggest polycystic ovarian syndrome. Change in facial appearance such as moon face to suggest Cushings syndrome. Change in facial features to suggest acromegaly. Change in mood or presence of fatigue or lethargy to suggest hypothyroidism. History of abdominal distention to suggest ovarian tumor (androgen secreting). History of visual disturbance such as homonymous hemianopia to suggest pituitary tumor. History of breast milk production if not currently breastfeeding to suggest hyperprolactinaemia. Family history of hirsutism to suggest late-onset congenital adrenal hyperplasia which is autosomal recessive. History of taking any medications that may have andrgenic effect such as Testosterone, Danazol or anabolic steroids.

b) Serum testosterone and sex hormone binding globulin to calculate free androgen index which is expected to be raised. A normal level may suggest idiopathic hirsutism especially if her other investigations are normal. Dehydroxyepiandrosterone sulphate level if raised will indicate an androgen secreting adrenal tumor. Early morning sample of 17alpha hydroxyprogesterone level, if raised would indicate nonclassic congenital adrenal hyperplasia. Pelvic ultrasound to detect presence of polycystic ovaries. If adrenal tumor is suspected, then a MRI may be arranged.

c)Reassurance if her hirsutism is mild and is not effecting her quality of life. Cosmetic methods such as plucking, waxing, bleaching and use of depilatory creams may be useful. However, plucking and waxing may result in folliculits and ingrown hairs especially andrognised areas. Depilatory creams and bleaching may result in skin irritation. Physical methods like electrolysis results in permanent hair reduction. However it is expansive, time-consuming, painful and practically limited area of treatment. It may also result in skin scarring, burns and depigmentation. Laser photothermolysis which covers a wider area and is less painful with less dermatological adverse effect compared to laser electrolysis. Hormonal therapy such as combined oral contraceptive pills which would halt the progression of hirsutism. It would not be appropriate if she is trying for a pregnancy. The use of progestational antiandrogen such as Cyproterone acetate which takes 6- 12 months to work. It is however associated with progestogenic side effects such as weight-gain and depression. Cell cycle inhibitors such as Eflornithine is effective in decreasing and arresting hair growth during the duration of use. It is however associated with rash , acne and potential for systemic toxicity if applied to a wide area. Patient\'s wishes will be respected and treatment adjusted according to her clinical condition.
Posted by SRABANI M.
SM
a.Detailed history is very important for investigation & treatment of this lady. Hirsutism may be familial or racial & it affects 5-15% of women. It may be social & cultural norm in some women .Age of onset & rate of progression of hirsutism may be suggestive of the etiology .For instance, slow progression is more consistent with PCOS or late onset CAH,whereas rapid progression is suggestive of adrenal and ovarian secreting tumours. History should also include excessive hair growth in other areas of body, hair loss,acne, musculinising features like deepening of voice, muscle bulk, reduced breast size or changes in weight may suggest androgen producing ovarian or adrenal tumours or late onset adrenal hyperplasia.Detailed menstrual history including LMP, menarche, cycle ( regular/irregular) is important as history of oligomenorrhea, obesity, hirsutism starting in late puberty points to PCOS .Information about drug history is important as various drugs may cause hirsutism like danazol,anabolic hormones, excessive doses of androgenic progestogens etc. Also some non androgenic drugs like phenytoin, corticosteroid or diazoxide may cause hirsutism as well.It is important to know whether she had any previous treatment for hirsutism or not.Social impact of hirsutism should be noted as well.History of increase in weight is important as it may indicate PCOS or Cushing syndrome. Other signs and symptoms like acanthosis nigricans ( in PCOS) , purple stiae, hypertension, easy bruising, proximal myopathy ( in cushing syndrome ) may be asked to find out the etiology.History of pregnancy & contraception are also important.

b.Investigation should include blood sample for hormone profile like serum testosterone, FSH,LH, Sex homon binding globulin, DHEA –S , DHEA & free androgen index.The aim of these tests is to confirm biochemical hyperandrogenaemia & identify the source of excess androgen production and also to exclude serious disorders of androgen secretion like Congenital adrenal hyperplasia,Cushing Syndrome , adrenal or ovarian tumours etc.
A thyroid function test which include free T4 & TSH should be undertaken to exclude thyroid dysfunction. If testosterone level is <5 nmol/l , PCOS is more likely cause, if testosterone > 5 nmol/L adrenal tumour will be more likely cause. For this case MRI/CT of abdomen should be done to exclude adrenal tumour.USS of abdomen & pelvis may be helpful to exclude PCOS, ovarian or adrenal tumour.USS is best done in follicular phase.Blood test for 21 OH progesterone is helpful to exclude late onset CAH.Blood tests for LH, FSH, prolactin & TFT are relevant in amenorrhoea. Dexamethasone suppression test is helpful if Cushing syndrome is suspected.Karyotyping may be helpful if virilisation is present.

c.Idiopathic hirsutism may be constitutioanal.If it is mild, reassurance is very helpful .Reassurance works better if there is a family history of hirsutism.The next option will be mechanical or cosmetic treatment like waxing, shaving, bleaching etc .They are cheap & easily available, patient feels normal, not medicalised. She can also have electrolysis, laser treatment etc which may be expensive but effective. Medical options include antiandrogen like Cyproterone acetate alone or in combination with oestrogen ( Dianette), Spironolactone, Flutemide .Dianette offers added advantage of contraception. It is important to emphasis that the effect may not be immediate & may take up to 4 months.This is effective in 70% cases. Flutemide is a nonsteroidal antiandrogen which has got side effect of hepatotoxicity.Potential side effects of cyproterone are breast tenderness, weight gain,loss of libido, fatigue & musculanisation of female fetus.Ovarian suppression with low dose contraceptive pills & GnRH analogues are effective is some women.Another option is Eflornithine hydrochloride ( Vaniqa) may be helpful especially in facial hair.It does not need contraception.Finesteride is another option but it is teratogenic & contraception should be offered.
Important aspect of management is the emphasis on no pathology detected.This will encourage & reassure her immensely & will have more positive image of herself.
Posted by Naheed M.
NM
I will ask the patient about the time since she noticed her abnormal hair growth, pattern, speed and body areas involvedother than face.
She should be asked about her menstrual history (menarche, regularity of cycle and last menstrual period).
Oligomenorhoea or amenorrhoea, weight gain acne in association with hirsutism show possibility of polycystic ovarian syndrome (PCOS). She should be asked if any contraception she uses.
The signs of hyperandrogenemia (obesity,acne, hirsutism) may al be caused by androgen secreting ovarian or adrenal tumors. Therefore history of any associated complains such as increase in muscle mass, breast atrophy, clitromegaly, abdominal or pelvic heaviness with discomfort and deepening of voice along with fast hair growth pattern indicate androgen secreting (adrenal or ovarian) tumors. In addition congenital adrenal hyperplasia (CAH) may present as late onset with secondary amenorrhoea and hirsutism so family history of amenorrhoea and abnormal hair growth should be asked( asCAH is an autosomal recessive disorder). It is very rare.
Woman should be asked about any other disorder such as hypertension , weight gain particularly on face and trunk sparing limbs (proximal myopathy with moon face and buffalo hump) excessive sweating and purple striae. These complains suggest cushings syndrome.
The woman should be asked if she has used any drugs or contraceptives: androgenic hormones e.g danazol and third generation progestogens are associated with abnormal hair growth. There are some drugs which change the hair texture (hypertrichosis) not growth such as phenytoin and minoxidil.
There is a high probability that history is negative for any condition and hirsutism is idiopathic.
The rate (speed) of abnormal hair growth must be asked as ovarian and adrenal
androgen secreting tumors are associated with faster hair growth compared to other causes.


B.
I will request the investigation according to the high probability order as directed by history.

Ultrasound abdomen and pelvis ( to exclude ovarian or adrenal tumors) and PCOS.
Serum testosterone level. If it is >5nmol/l then other androgens will be checked such as androstenedione,
Dihydroepiandroestenedione (DHEA,) Dihydroepiandroestenedions sulphate (DHEAS):
Raised DHEA-S show adrenal tumor. C.T scan or MRI scan
can be requested to confirm the tumors.
Other rare cause such as late onset CAH and cushings syndrome should be excluded by 17-hydroxyprogesterone and 24 hour urinary cortisol (2 occassions) respectively.

C.
Majority of hirsutism cases are idiopathic. Also there are some who just normally have more hair in families. It can also be just a patient’s (subjective) assessment without having true abnormal hair growth.
Therefore clinical assessment (ferriman-galway scoring) confirmed by objective testing reach any firm diagnosis.
In the absence of any cause,the aim of treatment is targeted towards improving patients self esteem about her body image and reducing hair growth.
She should be given detailed information about her condition and reassured for the absence of any hormonal or other disorder. She should be counseled verbally about the condition and treatment options for her along with leaflets.
Regarding her psychological support clinical counselors help should be considered if appropriate.

The options available for this patient are temporary and permanent.
Temporary options are quicker and cheaper such as shaving (it doesn’t cause more hair growth but can be associated with folliculitis)
Bleaching (makes hair lighter and show less) waxing, threading and plucking ( takes hair from the follicles and is painful).
The permanent method is electrolysis. It is slow, expensive, needs expertise and involve discomfort and pain.
Posted by Bindi J.

A: The woman should be approached sensitively to take in depth history. It is important to know the woman’s perception to her worsening facial hair. History regarding excess body hair and breast development should be asked. Menstrual history should be taken including menarche, last menstrual period and menstrual pattern and any changes in the pattern. Ask for increase in body weight, acne and diabetes in context with PCOS (Polycystic ovarian syndrome). History of weight gain, proximal muscle weakness and change in facial contours and easy bruising should be asked for Cushing’s disease. History of deepening of voice and male pattern baldness along with abdominal bloating should be asked for tumours of ovary or adrenal. Family history of hirsutism should be asked. Take history of medications like Danazol and anabolic steroids. Physical examination should be done to look for extent, type and pattern of hair growth. Ferriman and Gallwey scoring system should be used for assessing the severity of hirsutism. Presence of truncal obesity, abdominal striae and rounded facial contour support the diagnosis of Cushing’s syndrome. Presence of Clitoromegaly with other features of virilisation is suggestive of Congenital Adrenal hyperplasia. Look for Acanthosis nigricans for hyperandrogenic insulin resistant acanthosis nigricans syndrome. Per abdominal examination should be done for abdominal masses.
B:
Serum androgen levels to identify the source and confirm hyperandrogenimia. Decreased sex hormone binding globulin with raised free androgen index and free testosterone levels for PCOS. Raised DHEA and DHEAS indicate adrenal source of androgen. Raised levels of 17-hydroxy progesterone are seen in CAH. Raised serum cortisol levels are seen in Cushing’s disease. Pelvic ultrasound should be for polycystic ovaries and ovarian masses. CT/MRI of abdomen if markedly elevated androgen levels to look for adrenal and ovarian tumours. Karyotyping should be done if other features of virilisation are present.

C:
It is suggestive idiopathic hirsutism. The woman should be approached sympathetically as it is associated with body image. The aim of treatment is to stop or slow down the facial hair growth. Hormonal contraception like Yasmin may be offered which has the added advantage of contraception if the woman so desires. Cyproterone acetate, a progestogen and anti androgen may be used. Weight gain, depression and sexual dysfunction are some of the side effects of cyproterone acetate. Topical eflornithine can be used to arrest hair growth. It is effective as long as it is used. It acts by inhibiting hair protein synthesis. Acne is a common side effect. Success rate is 60%. Cosmetic methods that can be used are bleaching, waxing and plucking. Depilatory creams and bleaching minimize local hair growth but can lead to skin irritation on chronic use. Physical methods can be used which include electrolysis and laser photothermolysis for destruction of individual hair. It is expensive and time consuming. It can cause skin depigmentation, skin scarring and burns. There are second line drugs which can be used. They are Finasteride( 5 alpha reductase inhibitor), Flutamide( nonsteroidal anti androgen) and Spironolactone which is androgen inhibitor and aldosterone antagonist. The patient should be counselled that treatment can be lengthy.
Posted by H H.
hhh
I will ask in a sympathetic manner about the severity of her symptoms and effect on quality of her life,will ask of sites of hair growth and rate of progress(Rapid progress with virilsation in congenital adrenal hyperplasia CAH or androgen secreting tumour AST). Will ask of other symptoms of hyperandrogenism like acne, loss of scalp hair,breast wasting ,change of voice and virilisation . Would ask regarding her menstrual history,LMP and if there is possibility of pregnancy(Pregnancy luteoma) . Would ask regarding regularity of her period and if any periods of of amenorrhea (Polycystic ovary syndrome PCOS), and weight gain. would ask if using contraception as some types of hormonal contraceptives might be androgenic. would ask regarding her fertility wishes as some treatments for her case could be contraceptive. would ask if has intolerance to cold, fatigue and gain in weight pointing to hypothyroidism. Would ask of family history of hirsuitism (constitutional or CAH). Would ask of medications she is taking that cause hirsuitism as Danazol. Would ask if has abdominal distension or feeling of a mass (AST).



Serum testosterone is increased in CAH and AST more than 4 nmol/l, steroid hormone binding globulin SHBG is reduced in hyperandrogenic states .Free androgen index FAI >5% will point to hyperandrogenic states with normal total serum testosterone(FAI= serum testosterone by 100/SHBG)
Measure serum 17 hydroxy progesterone ,high levels in CAH. Measure dehydro epiandrosterone acetate and the sulphate form (DHEA and DHEAS) will be increased in adrenal causes.
Dexamthasone suppression test and 24 hour urinary cortisol if suspect cushing disease.
Ask for FSH,LH and prolactin . LH may be elevated in PCOD and also prolactin is elevated..
Measure thyroid function (TSH,T3,T4) for hypothyroidism.Will do pelvic and abdominal ultrasound scans for PCO and AST. The later can be detected better with CT scan or MRI.
Karyo typing in presence of virilism.


Patients with idiopathic hirsuitism are told that there are medical treatments that are effective ,but it will take them up to 6months to one year to notice an effect.
For cosmotic reasons and to have a rapid effect ,removal of the hair can be done with puckering,electrolysis or laser.
Patients wishing to have contraception and regulation of their periods will benfit from Dianette, which contain cyproterone acetate which is an anti androgen and ethinyl estradiole which increase SHBG ,thus lower FAI.
Topical efflornithine ointement can be used which acts locally on hair follicles, but the condition will recure on stopping treatment and some patients notice skin manifestations.
Spironolactone and flut amid are both anti androgens and can be used. Finasteride act by inhibiting 5 alpha reductase enzyme .Also progestogens act by inhibiting this enzyme which change testosterone to dehydro testosterone which is the active form.
Psychological support is needed during treatment of this distressing complaint



Posted by SYAMALRANJAN S.
SRS
a. Sensitive and supportive enquiry of history from this young woman is essential because hirsutism is related to body image. Rapidly progressing hirsutism might be the cause malignancy and androgenic tumour.
Menstrual history ( LMP, cycle length, regularity) is important for thinking about polycystic ovarian syndrome. Family history of hirsutism( constitutional , late onset congenital adrenal hyperplasia) should be enquired. Obstetric history and reproductive intentions should be enquired for management plan. Drug history, contraceptive pill ( containing androgenic progestogens) may be associated with hirsutism / hypertricosis. Symptoms related to mood changes , libido , hyperandogenic symptoms ( like acne) would be enquired which are related to increased androgenic hormones. Virilising symptoms like voice changes, male type baldness, reduction of breast size may be related to androgenic tumour. Symptoms like abdominal mass, distension may be related to abdomino-pelvic tumour. Social impact and and quality of life should be assessed for management plan.


b. Serum androgenic hormones investigations like testosterone (total / free), sex hormone binding globulins(SHBG),dehyroepiandrosterone(DHEA),dehydroepiandrosterone-sulphate(DHEA-S) are to be undertaken to confirm hyperandrogenism and their source ( secretion of DHEA-S is almost exclusively from adrenal gland). 17-hydroxy-progesterone level is important for excluding late onset CAH.
Pelvic ultrasound scan is undertaken for detection of ovarian mass, polycystic ovaries. If high androgens levels and suspicion of adrenal and ovarian malignant tumour then CT scan and MRI scan may be requested.
Dexamethasone suppression test if suspicion of Cushing’ syndrome /disease would be done in consultation with endrocrinologist.
Karyotyping is advised if there is virilisation.


c. Explanation of the condition, discussion , reassurance is an important option which might be helpful for coping the problem if no serious pathology as in this case.
Medical option like combined oral contraceptive pills (COCP) is helpfull because it increases SHBG level and reduce androgens levels. Low estrogen and antiandrogens like cyproterone acetate (Dianette) combination is preferred. These will have added advantages for those wishing contraception and helpful for regular cycles. Progestogens like medroxyprogesterone acetate is an alternative option.
Spironolactone, flutamide, finasteride are other medicines but limited use because of their hepatic side effects and also need other contraception (masculising effects of female fetus).
Topical eflornithine cream is effective option and improvements may occur after 4-6 months but may relapse after discontinuation and possibility of skin allergy.
Physical treatments like bleaching,waxing, plucking,shaving,electrolysis,laser may be alternative or contemporary options.
Adequate support ,counseling like 6-9 months may be required for improvements to be noticed.
Posted by F N.

FN

History of onset,pattern and rapidity of growth of hair should be noted. Menstural history including age at menarche,regularity of periods should be obtained as oligomenoorhea and irregular periods might be suggestive of polycystic ovaies.History of acne and infertility is impotant in context of PCOs.History of weight gain ,easy bruising,weakness, tired ness and moon shape appearence of the face might be indicative of cushing disease.history of intake of anabolic steriods and danazol should be obtained as it can be a cause.drugs like phenytoin,cyclosprine and minoxidil may cause generalized increase of body hair.sudden onset and rapid groth of hair might be suggestive of ovarian or adrenal tomour.History of incresed body hair in other female relatives can saggest it to be familial in origin.History of development of seconday sexual characters should be obtained in the context of late onset congenital hyperplasia.
B:
History will guide the investigations that needs to be requested. pelvic Ultrasound scan can be done to exclude PCOS .CT or MRI of abdomen or pelvis is done if there is suspision of ovarian or adrenal tumours.Testosterone levels and adrogen binding globulin are requested which if normal then the diagnosis can be idiopathic.Raised Lh and Fsh levels may be requested to aid in the diagnosis of PCOS.Dihydroandrostanedione(DHEA) and Dihydroandrstanedione sulphate (DHEAS) levels can be requested to differentaite between ovarian and adrenal cause .
cortisol and dexamethsone suppression test can be requested if cushing disease is suspected.

C:The women should be reassured as no organic patholgy found and she should be fully involved in descision making regarding the treatment options.
No treatment is one of the option If she doesnot want any intervention and feels reassured that all the results are normal.
further options are cosmetics which include;Bleaching which makes the excessive hair less obvious however it can cause skin irritation.Depilatory creams can be used. Shaving is another option and contrary to popular opinion, shaving does not make the hair grow more thickly,however it can cause pseudofolliculitis.
Waxing pulls hairs out from the roots and needs to be repeated regularly. Epilady removes the hair by a combined cut and pull.
Electrolysis may result in permanent hair loss, but takes time as a small area is treated every few weeks. Electrolysis can be expensive and unskilled treatment may cause scarring.
Laser treatment is another option however it is expensive and can cause skin irritation.
Medical treatment can be given.oral contraceptive pills suppreses LH secretion and decreases ovarian androgen levels. avoid using OCPs with androgenic prgesterone like noretherterone and levonorgestestrel.OCPs with anti androgenic action like cyproterone acetate can be useful.The patient should be warned about the sideeffects of weight gain and tiredness and breast tenderness.She should use alternative contraception as it can emusculate a male fetus.
Medroxy pregesterone can be given it inhibits LH secretion and ovarian androgen production.
Fltamide an antiandrogen can be given.finesteride which is alpha reductase inhibiter can be given,it can emusculte male fetus therfore effective contraception should be used.
VaniqaÒ cream (eflornithine) applied twice daily slows the growth of facial hair by inhibiting a key enzyme involved in hair growth. It is said to slow hair growth in 70% of women.Spironolactone has anti-androgen activity. It can cause hypokalemia and low BP.
Posted by Sarika N.
23 year old woman is referred to the gynaecology clinic with a 12 months history of worsening facial hair. (a) Discuss and justify the information you would obtain from the history [9 marks]. (c) Discuss the investigations that you will undertake [4 marks]. (c) Discuss the treatment options given that no cause has been identified [6 marks].
a) Sensitive ans understanding approach should be taken as this situation could be very distressful for the patient. Excessive facial hair growth could be due to exogenous causes testosterone, anabolic steroids, danazol, also cortisol, phenitoin, so drug history should be taken. Weight gain, acne, oligo- or amenorrea could be due to polycystic ovary syndrome, increasing in abdominal girth due to pelvic mass can indicate oestrogen producing tumours (sertoli-leidig). Symptoms of Cushing syndrome and adrenal tumours - sudden onset, quick progression should be noted.
Careful family history and abnormal sexual development can be asked for. Signs and symptoms of thyroid dysfunction should be part of initial assessment.
Discuss the investigations that you will undertake [4 marks].
Blood test for FSH, LH, free androgen index to exclude PCOS, SHBG,if hyperandrogenism and total testosterone above 5 nmol/l identified - androgen secreting tumour should be excluded.
Testing for serum PRL, 17- hydroxyprogesterone are important. DExamethasone supression test for Cushing can be performed if suspected. USS to exclude ovarian mass and PCOS is important, CT and MRI could could help with the diagnosis of brain or ovarian tumours.
Discuss the treatment options given that no cause has been identified [6 marks].
Patient should be reasuured and the condition should be explained. Reducing the weight could help to reduse periferal conversion to testosterone.Physical methods include bleaching, which can lead to skin discoloration, shaving, electrolysis is more permanent, but the risk of irritation increased. Topical treatment include application of Vaniqa, may cause skin irritation as well.
Medical treatment involve COCP ciproterone actate containing (Dianette), or higher dose of Ciprone acetate but should be covered by effective contraception as can emasculate male fetus. Other treatment include spironolactone, finasteride with effective contraception and flutamide. Patient should be informed that treatment is usually prolonged and slow. Physicological support should be offered.
Posted by Seham S.
SS

(a) history of onset,rate of progression and if there is excessive hair growth in other areas. I would ask her about other androgenic symptoms like acne, masculinizing features,voice changes,reduced breast size and weight changes.I would ask about menestrual history as time of menarch,last menestrual period,regularity of cycle and if she has menorrhagia or amenorrhea. Cases of polycystic ovaries can be associated with oligomenorrhea or amenorrhea.Drug history as some drugs has androgenic side effects like danazol , phenytoin,diazoxide,cyclosporin,cortisne and minoxidil. obstetric history and if she is suffering subfertility or if she is using contraceptive and not wishing to have pregnancy at present.Family history of hirsutism as some cases have racial and hereditary origin . I would ask her how much this complain is affecting her social life and if she received any treatment before.

(b) Aim to confirm biochemical hyperandrogenaemia and identify source of excess androgen production. serum testesterone total and free part is important in cases of ovarian origin . Dihydroepiandrstendion(DHEA) and DHEA -sulphate are almost exclsivly of adrenal origin. 17 -OH progesteron for late onset congenital adrenal hyperplasia. LH,FSH,prolactin and thyroid function tests if there is amenorrhea and polycyctic ovaries (PCO)is suspected.Pelvic u/s for PCO and abdominal u/s for abdominal mass or MRI for suspected tumours.Dexamethasone supression test if cushing syndrome is suspected and should be done by endocrinologist.

(c) I would explain condition to the patient and discuss expectations of successful treatment and leghth of time between commencment of treatment and clinical improvment which may take from 3m to 6m and usualy 9m . photographes can be used to assess progress in treatment. physical methods as bleaching could be used ,however it may cause skin dicouloration.shaving also could be used however it may cause irritation of skin and psaudofolliculitis. Electrolysis and laser ablation retard hair growth for long period however it is expensive.pharmacological treatment may include combined oral contraceptive (COC) which supress LH production and ovarian androgen synthesis. COC with androgenic activity should be avoided as that contain norethisterone and levonorgestrel .COC contain cyproterone acetate (Dianette) is effective . cyproterone acetate can be used alone however it is teratogenic and should be used with contraception.Medroxyprogesterone acetate could be used in those COC are contraindicated.It also inhibit ovarian steroidogenesis and inhibit LH production.Spironolacton is anti androgenic aldosteron antagonist , however BP should be monitored and elecrolyte in 1st few weeks of treatment.It may cause hypotention and hyperkalaemia. Flutamide is anti androgen but it is hepatotoxic and liver function tests should be done for monitoring. Finasteride is 5 alpha reductase inhibitor however effective contraception should be used as it may emasculate male fetus.Topical agents as (eflornthine hydrochloride) is effective during its period of use .It is only studed on face and below chin and is licened for this area only.Marked improvment occur within 8 weeks.it is highly teratogenic and contraception should be used during treatment and after stopping for one month.skin irritation is known side effect and dose should be reduced to once per day instead of twice daily and if irritation is not resolved discontinuation is recommended.
Posted by drvimaladkm@yah K.
The scenario suggests gradual onset of Hirsutism. I would like to know the details about her irregularity ,duration& last menstrual date which indicates anovulation. Polycystic ovarian syndrome(PCOS) is associated with anovulation, obesity, infertility, hirsutism, hyper androgenemia(acne vulgaris & acanthosis nigricans). Her marital or sexual activity status & parity details including the last child birth which gives an idea (Luteoma of pregnancy may be associated with hirsutism). or about her interest towards pregnancy for further management of induction of ovulation. Her contraception details regarding duration, type, mode & side effects to be known as progestogens (injectable medroxy progesterone) & hormonal intra uterine system can produce secondary amenorrhoea. Sibling sisters suffering with the same history suggests polycystic ovarian disorder. Race of the woman is important as Mediterranean & East Asian SubAfrican women are more affected with hirsutism & PCOS. Increase in weight in short period with anovulation,her food habits & lack of exercises may be associated with PCOS with hirsutism or with hypothyroidism. Drug history of using any androgens like Anabolic steroids, Danazol, Testosterone ,Dehydroepiandrosterone sulphate, Phenytoin, Cyclosporine, Phenothiazines, Minoxidil & high dose of corticosteroids can give rise to hirsutism. Other endocrinal disorders like hypothyroidism with H/O cold intolerance,obesity,excessive sleep & tiredness and cushing’syndrome with H/O obesity, moon face & striae &amenorrhoea can cause hirsutism. Late onset of congenital adrenal hyperplasia (CAH) may be associated with hirsutism. H/O galactorrhoea due to hyperprolactinemia may be associated with hirsutism.It could also be due to hyperinsulinemia or may be idiopathic where cause is not found.
B)Her BMI, blood pressure(high in cushings syndrome)& hairs distribution as per Ferriman –Galeway classificaton to be noted as15% reduction in weight improves anovulation & further hirsutism may not worsen.
1.Urine pregnancy test to rule out pregnancy.2.Ultrasongraphy(USG) of pelvis for presence of multiple small(1to 2cm) peripheral follicles arranged as necklace pattern in PCOS. Abdominal USG may show adrenal hyperplasia or adrenal tumour. 3.Blood tests for a)Serum Testosterone levels(better free Androgen index) more than 5nmol/L is found in PCOS,may be increased in adrenal causes like cushings syndrome or adrenal & ovarian tumours.b)Decreased sex hormone binding globulin levels in PCOS.c) Marginally raised serum prolactin levels in PCOS and more higher levels are found in hyperprolactnemia(lesser than in Prolactinomas). d)Increased Dehydroepiandrosterone (DHEA) levels are found in PCOS & increased DHEAsulphate in Adrenal causes. e) Increased serum levels of 17 hydroxy-progesterone levels indicate CAH. f) Low serum cortisol estimation indicates CAH & high serum cortisol levels cushings syndrome. g) Increased serum levels of DHEASo4 is found in PCOS & Cushings syndrome. h)Serum Androstenidione levels are increased in adrenal causes. i)Short Synacthen test with ACTH is positive with suppression of cortisone levels in cushings syndrome. j)Serum Thyroid assay with estimation of increasedTSH(Thyroid stimulating hormone)&low levels ofT4&T3 in Hypothyroidism.4.Urinary oxosteroids levels indicate Adrenal cause like Cushings syndrome.5.MRI/CTscan may be required to diagnose adrenal hyperplasia or tumours.
C)When the cause is idiopathic woman is empathetically dealt with reassurance. She is advised to adopt lifestyle management by reducing her weight with healthy diet & & exercise. Options to treat the current problem with topical cream application with Vaniqa (Eflorinithane hydrochloride) as growth inhibitor for 4to 6 months twice a day. Effect is seen after 4 to 6 weeks. Side effect is local irritation.Other permanent methods like electrolysis or laser destroys hairs & gives relief but sometimes with scarring as it is operator dependent. Epilation & shaving gives temporary relief with irritation & psuedofolliculitis. Bleaching only discolours hairs. If woman is not interested in pregnancy, pharmacological methods used like antiandrogens like cyproterone acetate with corticosteroids for about 6 months arrests further growth of hairs.It can emasculate the fetus so contraception is needed. Combined oral contraceptive pills without androgenic progestogens for 6 to 12 months reduces 5alphareductase activity & increases SHBG & controls hirsutism. Medroxy progesterone acetate (reduces LH& ovarian steroidogenesis) can also be used. Spiranolactone as an antiandrogen & aldosterone antagonist may be used.Hypotension & electrolytes imbalance to be monitored. Flutamide is nonsteroidal antiandrogen with hepatotoxicity arrests hirsutism. Finasteride is terratogenic & not advised.
Posted by Shamita S.
ANS
A history of onset and duration of hirsuitism has to be asked for, as a sudden onset and rapidly progressing hirsuitism would be suggestive of androgen secreting tumor.
Other places of hair growth has to be assessed as severe hirsuitism with features of virilism like deepening of voice with male type of baldness would suggest hyperthecosis of ovary. Irregular menstrual cycles along with weight gain would suggest PCOS.History of galactorrhoea is to be taken to rule out hyperprolactemia.History of swelling or pain in the abdomen is to be taken for any ovarian mass. Typical facies like moon facies and raised B.P would be suggestive of Cushing\'s syndrome .Family history of exessive hair growth and short stature would be sugggestive of delayed onset congenital adrenal hyperplasia which is an autosomal recessive disorder.History of drugs which alter the texture of hair growth like steroids ,cortisone ,minoxidil,phenytoin has to be taken.


A blood sample should be taken for a hormonal profile ,including serum testosterone ,LH/FSH, sex hormone binding globulin to exclude or diagnose PCOS. If the testosterone level is <5 nmol/L PCOS is the mostly likekly diagnosis whereas testosterone >5 is sugesstive of adrenal cause which would needCT/ MRI of the abdomen and further refferal to the endocrinologist .an ultrasound of the scan of the pelvis and abdomen would be required to look for ,and features consistent with PCOS and any other tumor in the ovary .Thyriod function test is to be done to rule out hypothyriodism.



If there is no specific cause identifyiable with the above-mentioned clinical and lab measures,it is most likely idiopathic and patient requires reassurance.
Diatary intervention and weight loss would help by preventing peripheral conversion of androstenedione to testosterone
Physical methods like waxing and shaving can be advised which is a temporary relief but only of cosmetic benefit. Patient should be told that these methods do not affect the rate of hair growth and permanent methods of hair removal like laser & electrolysis would be more effective with scarring and depigmentation as associated adverse events.
Medical treatment should be considered with COCPs especially with the less androgenic progesterones which would reduce the LH hypersecretion. The antiandrogen cyproterone acetate would effectively reduce hair growth but it shoud not be used alone as it would emasculate the male foetus .Drosiperone is also effective and additionally prevent fluid retention.The use of these hormonal preparations are effective and reduced hair growth is observed in 70%patients on 12 month use. These medicines have to be taken daily and for a long duration.
Spironolactone (an antiandrogen) can be used with polyuria as advese reaction. It is well tolerated and can be used as a part of combination therapy. Other drugs like flutemide are poorly tolerated .Finesteride a 5-alpha reductase inhibitor has also been used with positive results .
Topical treatment with eflorinithine hydrocholride has been shown to be effective especially on facial hair and may be therefore offered. However the drawback is that it has to be complemented with other hair removing methods and improvement reduces once treatment is stopped. It causes acne in some patients .It is advisale to stop treatment if no improvement is seen within 4 months period.


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Posted by Jan I.
JAN

A) The polycystic ovarian syndrome (PCOS) is associated with hyperandrogenism which can cause hirsutism. I would take a menstrual history looking for evidence of an irregular cycle with menorrhagia and/or oligomenorrheoa that may indicate PCOS. As a history of subfertility would also support this diagnosis a pregnancy history should be taken. PCOS is associated with other medical conditions including acne, obesity, hypertension and type 2 Diabetes Mellitus so I would take a past medical history for these which would increase the suspicion of PCOS. I would look for a history of recent excessive weight gain that may also be associated with the development of PCOS. I would take a social history to confirm the patient\'s ethnicity as idiopathic hirsutism is more common in those of Mediterranean origin. A family history of hypertension, type 2 Diabetes and PCOS may also be associated with PCOS. I would enquire whether other first degree female relatives of the patient had also experienced hirsutism as this may be more suggestive of an ethnic tendency to hirsutism. As rarely hirsutism can be associated with testosterone secreting tumours which can be ovarian in origin I would check for any evolving symptoms of ovarian tumours. These would include weight loss, cachexia, abdominal distention and discomfort or if the patient is aware of an abdominal mass. Adrenal tumours can also secrete testosterone and, as with ovarian testosterone secreting tumours, cause abdominal pain and other androgenic virilization symptoms including deepening of the voice and baldness which should be assessed. High prolactin levels can be associated with hirsutism. I would look for any symptoms suggestive of a prolactinoma which may include a bitemporal hemianopia or galactorrheoa. I would do a drug history as certain medicines, for example danazol, may cause hirsutism. Illicit use of anabolic steroids may do the same.

B) I would take the patient\'s weight and height to calulate a BMI. I would do blood tests which would include looking for biochemical changes associated with PCOS. These would include sex hormone binding globulin (SHBG) and testosterone levels. These can be combined to calculate a free androgen index which is characteristically raised in PCOS. Serum lutenising hormone (LH) and follicle stimulating hormone (FSH) levels are also altered in PCOS, though no longer part of the criteria for diagnosis. Characteristically the LH level is high and FSH level low resulting in a reduced or reversed FSH/LH ratio. A very high serum testosterone on its own may indicate excessive secretion compatible with an androgen secreting tumour. Serum prolactin is also mildly raised in PCOS so this should also be taken and is also very high in prolactin secreting tumours. I would arrange a pelvic (transvaginal) ultrasound scan. The TV scan would allow the assessment of ovarian morphology looking for the increased ovarian volume & multiple peripheral follicles associated with PCOS. It would also allow identification of any other ovarian masses consistent with ovarian tumours. If an adrenal tumour was suspected an abdominal CT scan should be arranged. If a prolactinoma were suspected a CT scan of the brain should be arranged.

C) Treatment would be based on symptom control and its necessity would be determined by the patient. In some patients reassurance that there is no sinister pathology associated with their hirsutism is sufficient and no further treatment is warranted. If the excessive hair is causing subjective distress (which can be significant and socially limiting) then there are multiple treatment options available. The most simple would be shaving of the affected area though this would require daily attention from the patient. Depilatory creams can be used to temporarily remove unwanted hair which would need to be repeated regularly to maintain the effect. An example of this would be Vaniqua cream. The offending hairs can also be dyed to a lighter colour in those with fair skin to reduce its visual impact. This can cause sensitivity reactions and will need to be repeated regularly. The hairs can also be removed using electrolysis or laser treatment. These treatments are longer lasting but more expensive and painful. Laser treatment can also darken the treated skin areas. If there are psychological sequelae to the patient\'s hirsutism then counselling or therapy through support groups can be arranged.
Posted by Ulduz A.
a)Menstrual history required to rule out oligo-and/or amenorrhea.It can be suggestive of PCOS.
Acne,oily skin,recent weight gain also associated with PCOS.
Deepening of voice,temporal baldness,clitoromegaly,reduction in breast size,weight loss asked in a sensitive manner to rule out androgen stimulating tumors of ovary and adrenals.
Contaceptive history asked because androgenic pregestogens can be a cause.
Drug history can indicate androgenic drug use as Danazol.anabolic steroids,testosterone.
Medical history as Cushing syndrome,CAH,acromegaly,thyroid disease ruled out.
Hystory of galactorrhea,visual disturbances may reveal hyperprolactinaemia which can be cause of hirsutism.
b)Testosterone levels should be checked to measure ovarian and adrenal activity.
DHEAS sereted by adrenals and measure adrenal activity.
17-OH progesterone levels should be checked if CAH suspected.
USS of ovaries and pelvis or CT/MRI requested if ovarian and adrenal tumours suspected.
OGTT will be done if insulin resistance suspected.
In case if thyroid disease,hyperprolactinaemia,Cushing disease,
acromegaly suspected the investigations done accordingly.
c)Mechanical measures including bleaching,shaving,tweezing,waxing aretemporary and needs to be repeated.They don\'t destruct hair follicles.
Laser and electrolysis are permanent measures which destruct hair follicles,but expensive.
Eflornitine cream(Vaniqa) is effective but can cause skin irritation.
It should be remembered that hirsutismis very distressing condition and woman needs psycological support.
Posted by Bgk H.
:x

A. I will obtain the history of onset and progression of the facial hair development as rapid onset may suggest hormone secreting tumour and may need urgent attention to rule out malignancy. Distribution and pattern of hair development apart from the facial area need to be determined as it may suggest normal hair growth. Patient need to be asked about any symptoms like nausea vomiting, persistent headache and blurring of vision as this may suggest brain tumour. Detail of her menstrual cycle including age of menarche need to be asked as irregular and oligomenorrhoiec patient may suggest of polycystic ovarian syndrome. Recent weight gain may also lead to this condition. Her medication history need to be asked as there are medication such as anabolic steroid, androgenic progesterone may cause this condition. A few other drugs like phenytoin may also has side effect like this condition. Her family history congenital or adult onset of adrenal hyperplasia may be present as it runs in family. Past history of meningitis or encephelaitis may lead to this condition. She should be asked about abdominal distension and bloatedness as this may be the symptoms of abdominal mass or tumour that arise from ovary and adrenal glands.

B. I will do blood investigation to look for free androgen index. If it is raised will further do her DHEA level as the rise may suggest androgen secreted by ovary. And DHEAS level also should be taken to rule out androgen from adrenal. I will also arrange an ultrasound of abdomen to rule out any evidence of adrenal or ovarian tumour. Both her ovarian volume and features should be evaluated to rule out PCOS. If she has symptoms of space occupying lesion of the brain, I will arrange an MRI brain for her to rule out possibilities of brain tumour.

C. She should be managed in sensitive approach as she may be socially withdrawal due to her condition and referral to psychologist needed if indicated. I will inform the patient regarding the diagnosis. She should also be informed that no identifiable cause is found. I will inform her regarding the management plan and tell her a realistic expectation of the treatment. I will suggest physical method like shaving stripping and plucking but she should be aware that these methods may cause pain and only temporary measures. Medical managemet such as combine oral contraceptive pill can be given. Other medication will be finasteride, flutamide and spirinolactone can also be given. All these medication need to be take n in long ter as stopping the tretment may cause recurrence symptoms. The new recommended treatment like topical application of eflornithine (Vaniqa) should be prescribed. Objective assessment of the response need to be done by using ferrimen gallaway staging or taking photograph of her.
Posted by shmaila S.
SS
(a) a detailed history should include development of other secondary sexual characteristics i.e breast development,axillary ans pubic hair pattern.Any discharge from breast as galactorrhea is associated with polycystic ovarian syndrome(PCOS).menstrual history including Last menstrual period,regularity of cycles,flow and any dysmenorrhea as oligomenorhea is one of the sings of PCOS. any other endocrine problems like hyper or hypothyroidism,cushing disease etc can cause hirsutism as well.drug history is important some drugs like spirinilactone can cause hirsutism.personal history is improtant like weight gain as its is associated with PCOS. she is young girl so it is improtant to know how much this facial hair problem has effected her personality and confidence and also if she became aware of this problem herself or her peer group made her realise it as an issue.
(b) blood test for prolactin, FSH,LH,serum progesterone,estradiol,sex hormone binding glubulin, and serum testosterone should be arranged to rule out PCOS.ultrasound scan should be arranged to check if polycystic ovaries.
(c) patients is most l;ikely having idiopathis hirsutism and needs detailed explanation and reassurance that pathological causes of hirsutism has been ruled out.treatment options are mostly cosmetic (hair removing cream,waxing etc),electrolysis is a more permanent and long lasting option.vaniqa can be prescribed ,it may help in slowing the growth of hair.if patient is finding it too distressing and effecting her personality and confidence, pschycological councelling should be advised.
Posted by Nadira N.
A) This is an extreamly distressing condition for a young women ,she need to be approached sensitively.PCOS is the most common cause accounting for 70 to 80% of women with hirsutism.History of oligomenorrhoea or amenorrhoea is suggestive of PCOS.Adrenal or ovarian tumour account for only 1% of women presenting with hirsutism but they can be life threatening .History of rapid onset and progression of hirsutism with sign of virilization such as muscle hypertrophy breast atrophy ,deepening of voice and clitromegali suggest androgen secreating tumour. development of cushinoid features such as trunckal obesity weakening of peripheral muscle and moon face should be asked to assess risk of cushing syndrome.Non classic congenital adrenal hyperplasia is an autosomal ressesive condition found in 1.5 to 2.5% women with hirsutism therefore family history of the condition should be asked.Family history of diabetes is also important to assess insulin resistance,features of acanthosis nigrecans ,pigmentation of skin in the axilla and back of neck are suggestive of extream insulin resistance.personal and family history of thyroid dysfunction, acromegali and multiple sclerosis should be asked.Androgenic drugs ,like phenytoin diazoxide glucocorticoids, anabolic steroids,danzole and progestogen should be asked.Her reproductive history and desire for future fertility also need to be assessed.
B) Women with oligo or amenorrhoea should have lab tests suggesting hypothalamo pitutary ovarian axis disturbance : serum FSH and LH ,TSH and prolactin levels.TSH and prolactin are raised in cases of anovulation due to hypothyroidism or hyperprolactineamia.FSH ,LH ratio is elevated in 50 to 60% women with PCOS.Persistantly raised FSH level in amenorrhoeic women would help to make diagnosis of premature ovarian failure.An androgen profile is asked which include free and total testosterone ,dehydroepiendrosterone sulphate ,androstenidione and SHBG .Testosterone level more than 200ng/dl indicate underlying neoplasia.DHEAS more than 7000 ng/dl suggest adrenal neoplasia.17 hydroxyprogesterone should be measured in early morning sample ,level more than 200 ng/dl suggest non classic CAH therefore she should undergo a short ACTH stimulation test .If history and examiation are suggestive of cushing syndrome 24 hour urine cortisol should be measured ,if more than 100mg/ml then she should undergo short dexamethasone suppression test.Transvaginal ultrasound is important in diagnosing polycystic ovarian morphology and any suspected neoplasia and to determine endometrial thickness in women with long term amenorrhoea.In women with suspected neoplasia MRI of overies and adrenals should be asked.
C) Weight reduction and lifestyle changes in obese women can reduce hirutism to 40 to 50%.Mild hirsutism( ferrriman gallway score 8 to 15 )may need only reassurance and cosmetic therapy.Cosmetic methods are waxing ,bleaching ,plucking and depilatory creams.Physical methods are electrolysis and laser photothermolysis.Electrolysis is a permanant method of hair removal but it is expensive and may cause skin damage.Laser damage hair follicle without damaging the surrounding skin and it can cover a wide area and it is less pain full than electrolysis.Topical medication ,eflornithine 13.9% is another efficacious method of permanent hair removal.COCPs reduce SHBG and LH production from overies and reduce hirsutism to 50%.Drosperinone containing COCP (yasmin ) has antiandrogenic property.Cyperone acetate is a strong progestogen which decrease LH and peripheral androgen antagonist .side effects are fatigue oedema loss of libido and weight gain.Spironolactone is an effective antiandrogenic ,in 100mg per day dose it is superior to cyperterone acetate in one systemic review.Flutamide is as efficacious as spironolactone but it is hepatotoxic and need carefull monitoring.Finasteride is 5 alpha reductase inhibitor and a potent drug but teratogenicity is main concern.
Posted by ASB -.
ASB
(a) I would ask about timing of onset as onset at time of puberty may indicate late onset congenital adrenal hyperplasia (CAH). Course of the problem should be asked about as rapidly progressive disease suggest androgen secreting tumors . Drug history of androgenic drugs like danazol or androgenic progestogen should be asked about as this may be the cause .Virilizing mainifestations like deepening of voice, decreased breast size and hair loss may indicate androgen secreting tumors . Family history of hirsutism may indicate late onser CAH . Menestrual and fertility history should be obtained as menstrual irregularity and infertility may indicate polycystic ovary syndrome (PCOS) .

(b)Measurment of serum androgens ( testosterone, androstendione and dehydroepiandrostendione sulphate ( DHEA-S) ) , sex hormone binding globulin and free androgen index(FAI).
High level of DHEA-S indicate adrenal cause as it is entirely excreted by adrenal gland . Markedly elevated testosterone may indicate androgen secreting tumor . Therefore , CT or MRI are required for assessment of adrenal gland for tumors . pelvic ultrasound is helpful in diagnosis of PCOS and ovarian tumors .Measurment of 17 OH progesterone for diagnosis of late onset CAH . Overnight dexamethazone suppresion test for diagnosis of cushing syndrome if clinically suspected .Karyotyping is required if there are virilizing manifestations .

(c)weight loss is helpful as it decreases conversion af androstendione to testosterone . Physical methods include bleaching but this may be associated with skin discolouration .sheaving is another method . it does not affect the rate of hair growth but may be associated with skin irritation .laser electrolysis is another method.
Combined oral contraceptive (COC) are effective . It may require up to 6-9 months for improvment to be seen . COC containing anti androgenic progestogen like drosperinone (yasmin) are preferred . side effects include weight gain , breast pain and GIT upset.
spironolactone has anti-androgenic activity . side effects include hypotension and hyperkalemia . so, monitoring of blood pressure and serum potassium reqiured. Flutamide is another anti-androgenic drug. rarely , it may be associated with hepatotoxicity so assessment of liver function is needed. finesteride is 5 alpha reductase inhibitor . adequte contraception is required during therap as it may emasculate male fetus .
eflornithine hydrochloride is a topical treatment that retard hair growth . main side effect is skin irritation . the problem may return to pretreatment level 8 weeks after stopping treatment and adequate contraception is required during treatment
Posted by S S.
(a) It is important to know about the history of oligomenorrhoea or amenorrhoea, weight gain, acne, acanthosis nigricans and infertility as these may be suggestive of PCOS. Sudden onset and rapid progression of symptoms along with virilizing features point towards androgen producing ovarian and adrenal tumour. It is associated with hyper prolactenemia hence enquire about galactorrhoea and headaches. Drug history should be asked as it is a side effect of certain drugs like danazole and anabolic steroids. Ask about liver disease and hypothyroidism which are associated with hirsuitism.
(b) Blood investigations like FSH, LH, E2, SHBG and testosterone should be done for PCOS. Prolactin levels and thyroid functions should be checked. If testosterone levels are high then DHEAS, 17 alfa hydroxy progesterone and cortisol should be checked for adrenal cause. CT abdomen may be required at a later stage for adrenal tumors. Pelvic ultrasound should be done to give information about polycystic ovaries and ovarian masses.
(c) Cosmetic methods like bleaching, waxing , laser and electrolysis can be tried. First two are cheap but needs to be done regularly. Electrolysis is permanent but takes longer time and is painful. Combined oral contraceptives can be used especially those with anti androgenic progesterone like cyproterone acetate and gestrinone. They have added advantage of better cycle control, if irregular.
Posted by Sahithi T.
((A)) I will ask her about the onset of facial hair growth as rapid onset suggests androgen secreting tumours. History of menstrual cycles is important. In absence of menstrual irregularity facial hair growth suggests idiopathic origin. If menstrual cycles are irregular, it suggests polycystic ovaries or other endocrinological cause and androgenic excess. I will obtain information about any medical conditions she may have. Cushing syndrome, congenital adrenal hyperplasia, androgen secreting ovarian tumours can cause hirsuitism. History of certain medication is important in this case. Medications like anabolic steroids, testosterone, androgenic progestone and danazole causes hirsuitism. I will take history of virilisation including reduction of breast size, clitoromegaly, libido or deepening of voice. These symptoms suggest androgenic hormonal cause. I will enquire about weight gain. Rapid weight gain indicates Cushing syndrome. History of fertility is significant. It hints towards ovulation. At the same time present and future fertility needs should be enquired which will help in management plan. History of previous medical or any laser treatment of hirsuitsm is significant as it helps for better patient counselling and plan treatment. History of similar condition in other female member of family points towards genetic origin of the condition.

((b)) I will do the hormonal profile including serum follicle stimulating hormone, lutenising hormone, total testosterone and serum estriodol on third day of menstrual cycle. If she is not menstruating regularly then I will do random sample. I will do sex hormone binding globulin level. If the total testosterone is high then I will do 17-OH progestone level, and androgen levels. Serum progestrone on day 21 (in 28 day cycle) is done to check for ovulation.
Depending on her history and clinical suspicion of Cushing syndrome I will do dexamethazone suppression test, on clinical suspicion of late onset congenital adrenal hyperplasia I will do ACTH stimulation test. Glucose tolerance test to access insulin resistance. Pelvic scan for ovarian tumours or polycystic ovaries and abdominal scan or CT scan may be required to diagnose adrenal tumour. Karyotyping is required when genetic abnormality suspected.

((C)) Treatment of idiopathic hirsuitsm should address woman’s need and expectations from treatment. Patient counselling is vital. Treatment options offered are physical methods of removing hairs. Bleaching, shaving or waxing is cosmetic measures. It does not prevent hair growth. There is need of continuing these treatment options. There is risk of hair follicle infection with shaving. Laser or electrolysis of hair follicles can be offered. There may be re growth of hairs after this. Pharmacological treatment includes cyproterone citrate containing pills or medroxy progestone acetate pills can be offered. Side effects are weight gain, breast tenderness and headache. Spironolactone, anti androgen can be used but it causes electolye imbalance, hyperkalemia, and hypotension. Fenasteride can be used. It is 5 alfa reducatase inhibitor. Topical treatment, Vaniqa cream local application on face can be advised. Marked improvement seen with it in 8 weeks but hirsutism reappears after stopping treatment. This cream can cause skin irritation. Thus physical, laser,
Posted by Dr Dyslexia V.
X

a) Hirsutism is a distressing symptom to a young girl and care should be taken to obtain information delicately. The etiology are usually due to endrogen excess, none endrogen cause and idiopathic. A history which include acne, increase in weight, menstrual irregularities (anovulation) could point to polycystic ovarian syndrome. Progressive onset of hirsutism with presence of virilisation such as male type distribution of hair such as on abdomen, chest, back and lower thighs with clitoromegaly could suggest an androgen secretion tumour. Facies such as presence of moon shaped face with hump, and purple striae could suggest Cushing’s disease and changes in facial contour and spade like hand, widening of jaw suggests acromegaly. History of lost of weight, tremors or low mood and irritability could suggest thyroid disease. Presence of visual disturbances such as bitemporal hemianaopia, lactation could be due to pituitary tumour causing hyperprolactinemia. Family history of congenital adrenal hyperplasia which is autosomal recessive and PCOS and diabetes could contribute to etiology.

History of drug consumption such as anabolic steroids in competitive sports, or usage of phenytoin in epilepsy, or taking drugs like danazol could be contributing to the hirsutism. Rarer cause such as acanthosis nigricans could also be attributing to this.

b) The investigation should include follicle stimulating hormone and leutenizing hormone which if raised could suggest PCOS. Serum testosterone and serum androgen binding glokulin with a level of more than 5 nmol of testosterone could suggest androgen secreting tumour. High level of serum 17 hydroxyprogesterone could suggest late onset congenital adrenal hyperplasia. Serum prolactin of more than 1000 could be due to pituitary tumour. Thyroid function test could be used also to detect hypothyroidism. Level of DHEAS could be raised in adrenal tumours. An ultrasound of abdomen to look for ovarian mass in ovarian tumour secreting androgen could be seen or CT scan for an adrenal tumour could be done.

c) Treatment should include reassurance and psychological counseling to cope with her problem. Then maybe attempting to lose weight and change in lifestyle such as exercise has been shown to reduce hirsutism. Other physical methods such as shaving, waxing, plucking, bleaching and use of depilatory cream could also be used for temporary measures. Other more extensive methods could include hair follicle hydrolysis and photothermolysis.

Hormonal therapy such as use of combined oral contraceptive pill such as Dianne and Yazmin could be used to relief symptoms and as a form of contraception. Other drugs such as spiranolactone, finasteride an 5 alpha reductase inhibitor, flutamide a non steroidal anti androgen could be used. Other newer modalities, such as cell cycle inhibitors such as eflornithine which has a significant reduction in facial hair for use over 6 months.
Posted by fluffy F.
from fluffy
a) history of rapid hair growth with signs of virilization , suggestive of androgen secreting ovarian tumour. History of drug intake , danazole , anti epileptic such as phenytoin, anabolic steroids can cause increase hair growth. History of dysmenorhoea , oligomenorhoea sugestive of polycystic ovarian syndrome. Increase in weight can cause increase testosterone levels and increase in hair growth.History of diabetes , increase in body weight , purplish striae on the abdomen , hypertension and easy bruising suggestive of cushing syndrome which can cause increase hair growth.

B) Hormonal assay , serum testosterone levels will be elevated in androgen secreting ovarian tumours and polycystic ovary syndrome.A 24 hour serum cortisol level done to rule out cushings syndrome . Serum luteinizing hormone levels and follicle stimulating hormone levels show a reversal in ratio for polycystic ovarian syndrome. Reduced levels of 17 alpha hydroxylase levels in adult onset congenital adrenal hyperplasia.Ultrasound pelvis , for any ovarian mass and features of polycystic ovarian syndrome.

c) It is important to explain to the patient regarding successful treatment and duration of treatment will take at least 3-6 months. Physical methods , using bleaching for discoloration of the excessive hair. Shaving and waxing can be used for hair removal.Explain that speed for hair growth is not increased with these physical methods.
non pharmacological methods - reducing weight is a effective was as it reduces peripheral conversion of testosterone .
Pharmacological methods - combined oral contraceptive pills , with anti androgen - such as cyproterone acetate is effective. Diannete is usually combined with ethinyl estradiol to be effective as a contraception as the effect of cyproterone acetate can emasculate a male fetus.Medroxy progesterone acetate - inhibits luteinizing hormone levels thus can reduce ovarian androgen production.Finasteride 5 alpha reductase inhibitor, can be used to reduce hirsutism , but should be used with a contraception as can emasculate a male fetus. Flutamide, anti androgen , is hepatotoxic thus used with caution can be used effectively as well. Spiranolactone , anti aldosterone , a potasium sparing diuretic is effective in hirsutism , but should monitor blood pressure and potasium levels for the first few weeks of use .
Posted by R S.
R S

a. Menstrual history is obtained like amenorrhea and oligomenorrheo which reflect hyperandrogenisim. Parity and history of sub fertility is taken as the lady might have polycystic ovary syndrome (PCOS). Weight gain during the previous 12 months can worsen PCOS symptoms.
Past medical history is explored like thyroid disease, cushion disease or syndrome or other endocrine abnormalities that might be associated with elevated serum androgen level. Drug history like anabolic steroid or other androgenic drug like Danazol is also important as they can cause hirsutism.
Family history of similar conditions is paramount because PCOS and congenital adrenal hyperplasia (CAH) run in families.
We enquire about other symptoms like voice changes, acne, creasy skin and hair all can occur as a result of hyperandrogenisim.
In addition, we ask about social history and quality of her life to assess size of problem to this lady and we ask whether she had any investigations before and what were the results.
We try to explore whether she is only distressed by her hirsutism or she has another complaint like fertility issues or cycle irregularities so as to help doing appropriate management plan. We also explore her expectation of results of treatment.

b. Free serum androgen is tested to diagnose hyperandrogenisim; alternatively we can measure fre androgen index and SHBG. Elevated level of 17 Hydroxy progesterone occurs with ate onset CAH. Thyroid function test and serum cortisol can detect underlying thyroid or adrenal causes. Dexamethasone suppression and stimulation tests can be misleading.
Abdominal US can detect PCOS or adrenal tumors. CT- scan and MRI can be requested if the US is inconclusive.

c. Cosmetic treatment is implied like plucking, bleaching and waxing; they are easy and effective but ned to be repeated. Shaving can also attempted, it does not lead to overgrowth of hair.
Electrolysis is another option, it involves destruction of hair follicles, it’s a permanent method with little complication if done by experienced hands but it will need multiple sessions as each session is done to limited area only. Laser electrolysis is a newer technique; it can cover a wider area in each session so by 3-4 sessions it can complete treatment. Its associated with less damage to adjacent skin than electrical electrolysis. Eflornithin cream can also be use, its safe and effective and can be used with laser treatment and under cosmetics, however , it migh cause skin allergy in few cases.
Although she has normal serum androgen level, we can prescribe medication that act locally by blocking androgen receptors or prevent conversion of dihydrotestosteron to tetrahydrotestosteron which is more active , subsequently they will improve hirsutism like finasteride and flutamide, they are both effective but the result will take 4-6 months till it become apparent. The lady offered support and reassurance with adequate information about her condition.
Posted by Bee N.
(bee)

A 23 year old woman is referred to the gynaecology clinic with a 12 months history of worsening facial hair. (a) Discuss and justify the information you would obtain from the history [9 marks]. (c) Discuss the investigations that you will undertake [4 marks]. (c) Discuss the treatment options given that no cause has been identified [6 marks)

A)History will include the onset and distribution of hair. This will help to differentiate hypertrichosis and hirsutism, though facial hair in a female suggests hirsutism.Male pattern hair distribution suggests hirsutism. Sudden Onset and rapidly progressing symptom may indicate the presence of adrogen secreting tumour.
I will inquire about presence of symptoms which suggest hyper androgenism such as deepening of voice and acne.I will also ask about any recent weight gain. These in the presence of oligomenorrheoa suggests polycystic ovary syndrome. I will ask about experience of abdominal enlargement or pain which may suggest the presence of a tumour in the ovary or adrenals. I will ask about her medical history as well as drug intake. Some drugs which are used as antihypertensives such as diaxoxide or minoxidil can cause increase in hair growth. I will ask about family history of similar symptom. Congenital adrenal hyperplasia which can be inherited as autosomal recessive gene can cause hyper-androgenism and hence hirsutism. Besides, polycystic ovary syndrome and idiopathic hirsutism can have a constitutional element associated with it. I will ask if she is an athlete and if on and performance enhancing drug. Androgenic steriods can cause hirsutism.

B)The investigations I will undertake will include Blood tests to investigate for PCOS. They include LH, FSH, LH/FSH ratio,estradiol, Testosterone, free androgen index, Dihydroepiandrosterone, adrostenedione, dihydroepiandrosterone sulphate level may indicate source of androgen.DHEA sulphate is elevated in adrenal tumours while DHEA is elevated in ovarian tumours. It must be noted that testosterone could be increased in ovarian and adrenal secreting tumours so I will do a pelvic USS looking for ovarian tumour. this may also show evidence of PCOS. I will do an abdominal USS looking for adrenal tumour. If congenital adrenal hyperplasia is suspected, I will check for levels of 17-hydroxyprogesterone levels which is raised in 21-hydroxy deficiency.

C)Treatment option will include weight loss especially if PCOS is suspected. this will cause the reduction in peripheral conversion of estrogen to testosterone and the dihydro testosterone. I will offer physical methods of treatment which include shaving . this may however cause folliculitis. Other options include bleaching which may cause skin lightening. Electrolysis and laser treatment are more long lasting but more expensive..
patient can use combine contraceptive pills containing anti androgen such as Dianette (contain cyproterone acetate). Other option will include use of medroxxprogesterone acetate. Hormonal pills listed above reduce the amount of luteinising hormone. Finasteride reduces the peripheral conversion of testosterone to dihydrotestosterone but can cause feminisation of male fetus and hence must be used with adequte contraception.Topical application like eflornithine (Vaniqua) has also been proven to be effective. Patient needs to be informed that which ever option that is chosen will take months to have a reasonable effect.
Posted by tahira jabeen J.
Tj
A)
thorough history is important to reach diagosis.ist of all i will assess severity of problem by asking question like if social acceptance is altered,or is sexuality changing or if fertility is impaired as it will help to reach cause & also to deciede about management.i will ask about progressio n if its rapid in onset as it happens with androgen secreting tumours.i will ask about mensturation if regular & reproductive history as cycle is irregular
it is suggestive of PCOS as it is most common cause of hirsuitism
i will ask about any endocrine disorders like hypothyroidism,diabetes .patient will be enquired about changes in extrimity,head size,facial contour as hirsuitism can be due to acromegaly.drug history will be taken as drugs like phenytoin,reserpine,methyldopa,danazol,testosterone,metclopramide.patient will be asked if she is using any creams causing locao irritaion as that ca n be cause of this hirsuitism.
B)
testosterone level total& free levels will be done.testosteroe level >5 nmol/l should prompt further test of adrenal function.
serum FSH,LH,TSH,(if alopecia is present)serum prolactin (if alactorea).serum 17OH progestrone level to role out CAH,dexamethasone suppression test for cushingS syndrome.
pelvic uss for diagnosis of PCOs & other tumours.
C)
as hirsuitism has psychological morbidity .hair growth on face & breast is distressing so concerned and sympthatic approach is viatl for sucessful managment .treatment is combination of psychological,life style modification,mechanical,& medical therapy.
as no cause is found patientt need s to have realistic approach & expectations that therapy may take 6 months or more to work &she needs to remove existing hair by mechanical ways for good results.patient should remain motivated .patient will be advised to reduce her weight as if she is obese >5% reduction of wt.will improve her FERRIMAN GALLWAY score.in mechanical ways
she can do shaving ,bleaching,plucking,waxing.but these may cause folliculitis,or inogrown hair.patient can have electrolysis efficacy is 15- 50% can have permanent hair loss after repeated t/m.laser treatment is good option for fair skin people but is not
permanent solution.
medical therapy include androgen suppressing agent like COCP which acts by suppressing LH & increasing sex hormoe binding
globulin.progestogens as inectable or oral .
metformin 850 mg bid as it decreases insulin levels so decreases androgens.GNRH analouges ca be given.
other drugs like androgen receptor blocking drugs like cyproteroe acetate ,spiranolactone,flutamide can be used.
patient ca be offered biological modifier of hair growth like efflornithine which blocks production of polyamine building block of hair.it can cause local irritation.hair growth returns to base lie level eight weeks after treatmet cessation.combination of afflornithine plus laser is more rapid process.
Posted by G. K.
GSK
A) The patient should be dealt with sympathy and gentleness since hirsutism is a distressing condition causing depression and issues with body image.A thorough history should be taken regarding the severity of condition. It\'s effect on her quality of life should be explored. She shouldbe asked about any cosmetic or medical treatment which she has tried.A full menstrual history should be taken regarding regularity of cycle and frequency of menstruation since infrequent or irregular periods could point towards polycystic ovarian syndrome (PCOS)which is the most common cause of hirsutism.She should be asked about any history of thyroid problems and Cushing\'s disease, since these conditions are associated with hirsutism. A thorough drug history should be asked since certain drugs like phenytoin, minoxidil, and danazol can cause her present condition.Also the patient should be asked about any milky discharge from the nipple and asociated headaches since a prolactinoma causing hyperprolactinemia can lead to hirsutism as well.
B)
Investigation include serum Testosterone,Androstenedione and sex hormone binding globulin and prolactin levels keeping in mind PCOS and hyperprolactinemia. Thyroid function tests should be done to rule out thyroid disorder.24 hour urinary cortisol should be checked if cushing\'s syndrome is suspected. Also levels of 17 alpha hydroxy progesterone is checked if there\'s suspicion of late onset CAH.A pelvic ultrasound should be done to look for polycystic appearence of ovaries, ovarian tumours such as arrhenoblastoma and adrenal tumours as a cause of her hirsutism.
C)
The patient should be reasured that that there\'s no underlying cause of her hirsutism. Depending on the severity of her symptoms, a variety of management options can be tried. For mild hirsutism (Ferriman Galway score of 8-15) a number of conservative measures can be tried. These include weight loss if the patient is overweight. Use of waxing, threading, bleaching can be recommended. These methods however only control the condition and has to be done on a regular basis. Other methods include destruction of hair follicles by elctrolysis and laser therapy.These methods have better outcomes as compared to waxing and bleaching but are expensive, can be painful and would require a longer duration of treatment. Topical preparation such as eflornithine can be used to control hirsutism. It is used twice a day. Side effects include skin rash and acne.
For moderate to severe hirsutism (Ferriman Galway score >15)Hormonal methods such as combined oral contraceptive pill can be used if the patient is not planning on pregnancy. It increases the level of SHBG and can improve the condition. However the treatment may take 9-12 months before any improvement is seen.Other medications include Spironolactone, a potassium sparing diuretic with antiandrgenic properties, finasteride a 5 alpha reductase inhibitor, and flutamide an antiandrogen can also be tried. Cyproterone acetate a strong antiandrogen combined with ethinylestradiol (Dianette) can be prescribed. It also acts as a contraceptive but is not licenece as one.The patient should be advised to to use an appropriate method of contraception since the use of such medication can feminise a male infant.She should be provivded with information leaflets regarding various options of treatment and adresse of helpful websites given.
B)
Investiga
Posted by SUNDAY A.
sos

a) I would ask about her menstrual periods including history of amenorrhea or oligomenorrhea in the last 12 months which may indicate polycystic ovarian syndrome( PCOS) which is a major cause of hirsutism. History of weight gain, acne, and virilising symptoms such as voice change should be ascertained as they are associated with PCOS and other causes of hirsutism. The Presence of abdominal swelling may indicate an adrenal pathology which needs urgent investigation. The severity of symptoms including involvement of the limbs, trunk, back of the neck, upper thigh should be noted in the history as this may have implication on the type of treatment offered. Moreover, patient should be asked of how the symptom is affecting her quality of life because hirsutism may be associated with psychological and emotional trauma particularly in a young lady and those who may have distorted body image. The use of medication that can cause hirsutism should also be noted in the history such as steroids .
b) FSH/LH , Testosterone, SHBG (sex hormone binding globulin) levels can be requested. An increase in the LH levels, Testosterone and SHBG may point towards hyperandogrenism and PCOS. A abdomino-pelvic scan can pick up polycystic ovaries and adrenal tumours and point toward the cause of the hirsutism.
c) The treatment option would take into consideration the severity of the symptom using the ferriman-Galway scoring system . If the score is less than 8 ( mild) , a conservative approach with reassurance and use of hormonal treatment may be all that is required. The combined contraceptive pills containing cypoterone acetate ( Yasmin) can be prescribed. Use of depilatory cosmetic cream, hair plucking can also be recommended. However hair shaving should be discouraged has it leads to folliculitis.
For severe hirsutism ( score> 8), physical agents such as electrolysis , thermolysis for hair removal can be recommended. Use of hormonal agents such as GNRH analogue- Danazol can be used but patient must be on effective contraception while on this medication. Finasteride, Spironolactone can also be used with varying success rate. Use of vaniqa ( ethinodrate) is associated with a high rate of symptom control. The patient should be counselled of the need to be patient while on medical treatment as the clinical effect may take up to 3-6 months to be apparent. Most of the time a combination of cosmetics or physical agents with hormonal manipulation brings the greatest symptom control.
Posted by Atashi S.
( a) As it is a distressing condition I will take history in a sensitive way. Its impact on quality of life is to be asked. Onset and rate of progression of excessive hair should be asked. Rapid progression associated with amenorrhoea, acne , voice change,increase muscle bulk, reduce breast size is to be asked as it is associated with androgen producing ovarian or adrenal tumor.Details menstrual history including age of menarche, LMP,cycle, oligomenorrhoea, infertility, contraceptive history is to be asked. Irregular cycle, oligomenorrhoea, infertility suggestive of polycystic ovarian syndrome.Obstetric history including history of recent pregnancy is to be noted as luteoma in pegnancy may be a cause. Presence of abdominal striae, hyperpigmentation, moon face, pleothora need to be asked as cushing syndrome may be a cause.Family history of hirsutism is to be taken as late onset congenital adrenal hyperplasea may ran in the family.Drug history including intake of danazole, testosterone,anabolic steroid, androgenic progesterone should be taken to identify the cause. Swelling of abdomen to identify any abdominal mass is to be noted.

( b )The aim is to confirm biochemical hyerandogenima and identify the source of excess androgen production.Serum testosteron and sex hormone binding globulin is to be tested . Free androgen concentration is important.DHEA and DHEAS.DHEAS is almost exclusively adrenal in origin.21-OH progesterone is to be tested for late onset congenital adrenal CAH.LH and FSH ,prolactin,TFTare particularly relevent if amenorrhoea. Pelvic USS for polycystic ovary. Abdominal USS or MRI if adrenal tumour is suspected. Karyotyping if virilization .

( c ) Explanation should be given to the patient regarding the condition and discuss expectations, liklyhood of successful treatment and length of time between commencement of therapy and clinical improvement.It will take at least 3months and usually 6 to9 months. She should be reassured that she has no underlying pathology.If she is overweight wt loss should be encouraged as it reduces peripheral conversion of androstenidion to testosterone.Physical method Bleaching may lead to skin discolouration.Shaving does not affect rate of hair growth. May lead to irritation / pseudofolliculities.Eletrolysis/ laser therapy is another option.Pharmacological methods oral contraceptive pill cotaining anti androgenic progesterone. It supress LH production and ovarian androgen synthesis, increase SHBG production and progesterone inhibits 5alpha reductase activity.Medroxy progesterone acetate , spironolactone, flutamide, finasteride is another pharmacological option.Topical tratment includeEflornithine hydrochloride(VANIQA) -inhibits skin ornithine decarboxylase which is necessary for synthesisof polyamines and normal hair growth.