Essay 299 - Hirsutism

a)

Firstly I would take a history. I would ask about her menstrual history as irregular and infrequent periods or a history of subfertility may indicate PCOS, which is the most common cause of hirsutism. I would ask about other symptoms like acne, weight gain, deepening of voice or thinning of head hair; a rapid onset or severe virilising symptoms would raise concern about very high levels of androgens from possible adrenal or ovarian tumours. I would take a drug history to exclude medication causes, for example, high dose steroids, Danazol or Phenytoin. I would also ask about headaches or visual disturbances which are possible signs of intracranial tumours leading to hyperandrogenism. Galactorrhoea would inidicate hyperprolactinaemia.  I would enquire about a family history of hirsutism which commonly runs in families, especially Asian families.  I would ask about personal or family history of thyroid disorder which can also cause hirsutism. I would ask about any skin discolouration she had noticed which may indicate Acanthosis Nigrans.

I would examine this lady. I would assess her hirsutism and grade it using the Ferrimen-Gallway score. Abdominal examination may reveal a mass or evidence of Acnathosis Nigricans. If history revealed significant concern about ovarian tumour I would consider doing a vaginal examination.

b)

I would perform blood tests for total testosterone,  SHBG and free androgen index. Mild elevations in total testosterone would be in keeping with PCOS but levels over 5g/dl would be more likely an adrenal source. I would also test LH, FSH and DHEA-S  to help distinguish between idiopathic, PCOS  and adrenal or ovarian tumours. I would also test TSH to test for hypothyroidism. I would test prolactin levels or 17-Hydroxyprogesterone to exclude Prolactinoma or CAH if history indicated. I would arrange a TVUSS to assess her ovaries for PCOS or isolated tumours. I would consider MRI of her adrenal glands and CT/MRI of her head to exclude adrenal or intracranial tumours.

c)

If she is overweight, I would recommend conservative management in the form of weight loss and exercise.

Cosmetic methods include bleaching and waxing. A more permanent method would be electrolysis.

Hormonal treatments include the COCP for example Yasmin and this would also benefit as contraception if desired. Alternatives would be Cyproterone Acetate or 5-alpha-reductase inhibitors, for example Finasteride

a) It may be that her facial hair growth is familial and I would ask about family history of hair growth and ask about her ethnicity as Asians more commonly suffer from hirsutism.

I would ask about the onset of her facial hair, a rapid onset would suggest an androgen secreting tumour. I would also ask about other symptoms of hyperandrogenism such as deepening of her voice, breast atrophy, acne, alopecia, hirsuitism i.e. unwanted hairgrowth elsewhere on the body.

I would ask about symptoms of PCOS as it can present with symptoms of hyperandrogenism. I would ask her about her periods and whether they were regular. Anovulatory irregular cycles are common with PCOS. I would ask her about her fertility, and whether she has tried to become pregnant without success. I would ask about her weight and whether she feels she has gained weight recently. Many PCOS sufferers struggle to keep their weight down due to their insulin resistance.

I would ask about any family history of Congenital adrenal hyperplasia.

I would ask about her drug history in particular any anabolic steroid use for body building. Or the use of Danazol, high dose corticosteroids, streptomycin, phenytoin.

I would ask about lethargy, feeling cold, dry skin all symptoms of hypothyroidism. I would ask about symptoms of hyperprolactinaemia such as galactorrhoea.

I would ask about any abdominal pain or distension or masses she is aware of in her abdomen which could suggest an ovarian tumour.

I would examine her looking at her hair distrubution using the ferryman-gallway scoring system, a score of more than 8 defines hirsutism.

I would examine her abdomen looking for any masses suggesting an ovarian androgen secreting tumour.

I would measure her BMI, a raised BMI is an indicator of PCOS. I would look for acanthi nigrans which is a sign of hyperinsulinaemia again fitting with a diagnosis of PCOS.

b) I would take bloods looking at her androgen hormone profile, a slightly raised testosterone would suggest PCOS, a level greater than 5nmol/L would suggest an ovarian androgen secreting tumour, a raised dehydroepiandrosterone DHEA level would suggest an adrenal androgen secreting tumour.

I would check her sex hormone binding globulin level and anti-mullerian hormone. A low SHBG and high AMH would suggest PCOS.

I would check her 17 hydroxyprogesterone level to check for congenital adrenal hyperplasia and check her cortisol levels to check for cushings syndrome.

I would thyroid function tests to rule out hypothyroidism, and prolactin levels to rule out hyperprolactinaemia.

I would do a pelvic USS looking for ovarian masses, and also to look for signs of PCOS, ovaries great than 10cm in size or more than 12 cyst on each ovary.

I would do a CT or MRI to look for adrenal tumours.

c) Treatment options of idiopathic hirsuitism include simple hair removal methods like plucking, waxing, shaving or laser hair removal.

Vaniqua cream can be used topically which contains eflornithide hydrochloride to reduce and slow down hair growth.

The combined contraceptive pill with drospirenone levonorgestrel like Yasmin which has anti androgen effects or Dianette with cyprotone acetate an antiandrogen in it.

Spironolactone and Finasteride are 5 alpha reductase inhibitor which have anti androgen effects in the hair follicles.

(a)

Take a history for duration and progression of increasing hair growth as rapid progression may mean an andreogen-secreting tumour. Ask for symptoms of virilisation e.g. voice deepening, clitoralmegaly and reduction in breast size. Take a menstrual hsitory to ascertain LMP to exclude pregnancy and its regularity, flow, duration and volume as irreguler period and oligomenorrhoea may mean underlying PCOS. Some hyperandrogenism can be due to pregnancy related theca-lutein cyst. I will take a gynaecological history for PCOS or ovarian cysts. A drug history is taken for any androgen-containing durgs e.g. exogenous androgen intake, Danazol. I will take a fmaily history for congenital adrenal hyperplasia, PCOS and ovarian cancer as they are potential causes for hyperandrogenism.

Take her height and weight to calculate BMI and check for obesity. Grade and examine the excessive hair growth with Ferriman Galleway staging system; a score >= 8 means significant hirsutism. I will look for acanthosis nigricans. I will palpate the abodmen for massess and perform a vaginal exam for pelvic massess. I will inspect the external genitalia for ambiguos genitalia.

(b) Perform blood investigations for free testosterone, serum SHBG to calculate the free androgen index. I will check for elevated DHEA-S levels to exclude adrenal causes. Dexa suppression test is performed to exclude Cushing's syndrome. ACTH stimulation wtih increased 17-OH progesterone levels may indicate late onset Congenital adrenal hyperplasia. I will perform a ultrasound to exclude ovarian massess; CT/MRI abdomen to look for adrenal massess and urine pregnancy test to exclude pregnancy before starting treatment. I will check karyotpe if there is any signs of virilisation or ambiguos genitalia. 

(C) I will explain the condition to the patient in the sensitive mannder and assure that life-threatening patholgies has been excluded in idiopathic histutism. The underlying cause is increased 5-alpha-reductase activity in hair unit. I will assure her that her appearance is not as bad as she perceive. I will advise her on weight loss if she is obese as this can help reduce androgen production. I will advise her on hair removal treatments e.g. shaving, plucking, bleaching, laser or waxing. The latter is preferred as waxing and bleaching can irritate the skin. I will offer a course of Combined contraceptive pill as first line as it helps to reduce LH levels with subsequent decrease in androgen production from theca cells. Androgen antagonist includes crypterone acetate, spironolactone, flutinamide and Flinasteride as second line treatment and I will advise effect contraception as they are associated with feminising of the male fetus. They are also advised on associated drug side effects. I will offer Topical Eflornithine (Vaniqa) but advise that effects may take 3-6 months to take effect and may recur after 8 weeks of treatment withdrawal. This drug has to be supplemented with hair removal techniques. I will advise the patient to persist with the above treatments for at leasat 3-6 months to allow it to take effect. I will provide written information on her treatment options. 

a) I ll do assessment by history and examination.Regarding history I ll ask for duration and severity of hirsutism and rate of progression.I ll ask for other symptoms like acne,menstrual irregularity,infertility,weight gain to rule out polycystic ovarian syndrome.I ll ask for breast atrophy,clitoral enlargement,deepening of voice to look for virilism.I ll ask for symptoms of hypothyroidism and cushinoid symptoms.I ll ask for drug history as danazole,steroid,phenytoin,minoxidil,streptomycin.I ll ask for headache or galactorrhoea.I ll ask for family history of hirsutism and diabetes mellitus.I ll check hirsutism on examination and measure its severity by Ferriman Gallway scoring system.I ll check BP and BMI.I ll look for thyroid enlargement,striae,acanthosis nigricans,acne,clitoromegaly.I ll do aabdominal examination for masses.  b)  I ll do serum testosterone measurement.It may be normal in about half of patients with hirsutism but levels >5mmol/lit indicate some androgen secreting tumours.I ll measure free androgen index(FAI) as sex harmone binding globulin level ll be low in cases of PCO.I ll check for FSH, LH and S.prolactin.I ll check for insulin resistance by OGTT as it ll be high in case of PCO.I ll check for 17-OH progesterone levels as it ll be high in late onset congenital adrenal hyperplasia.I ll do dexamethasone suppression test or 24 urinary cortisol if there are signs and symptoms of cushing syndrome.I ll do ultrasound to look for PCO or ovarian or adrenal tumours.CT scan or MRI may be done for tumours if needed.     c)  management consists of explanation of condition to patient and reassurance.I ll offer her treatment options like cosmetic in the form of bleaching,waxing,threading and depilatory creams.Laser or electrolysis is effective.I ll explain these are temporary methods and can be used while waiting for effect of medication. Combined oral contraceptive pills may be used to decrease the level of androgens and its effects.COCP with antiandrogenic properties like dianette with cyproterone acetate or yasmin with drospirenone should be used.COCP with 3rd generation progesten like desogestrel,gestodene,norgestimate have antiandrogenic properties.In severe and resistant cases high doses of cyproterone like 50 mg may be used.Spironolactone is antiandrogen used for hirsutism but may cause hypotension and hyperkalamia.Flutamide is androgen receptor blocking agent and may cause hepatotoxicity.Finasteride is 5-alpha reductase inhibitor and used for hirsutism but may cause hepatotoxicity.Medroxyprogesterone acetate may be used for patients where COCP is contraindicated.GnRh analogue reduces LH levels and in this way androgen production but causes reduction in bone mineral density.Weight reduction have beneficial effects in obese patients.Metformin decreases insulin resistance and reduces androgen production in return.Eflornithine is for local use and inhibits enzyme ornithine decarboxylase and in this way controls hirsutism but there ll be recurrence after 8weeks of stopage of treatment.

A 30 year old nulliparous woman has been referred to the gynaecology clinic because of increasing facial hair.

(a)    Discuss your clinical assessment (7 marks).

I will ask her about the onset, course and duration of her symptoms, an acute onset, rapidly progressive over short duration as weeks is suggestive of androgen producing tumor while a gradual onset, slowly progressive course over a long duration makes chronic causes as polycystic ovary syndrome more likely.i will ask about the menstrual history regarding LMP, regularity and duration as oligomenorrhea or amenorrhea is suggestive of PCOS while heavy periods can be due to hypothyroidism.i will ask if she previously tried to conceive as a period of subfertility is suggestive of PCOS,I will ask about contraceptive history since progestogen only injections and combined pills containing levonorgestrel or norethisterone can cause hirsutism.i will ask about medications as steroids and danazol that can cause hirsutism.i will ask about medical comorbidities as cushing disease or hypothyroidism that can cause hirsutism.i will ask about virilising symptoms as deepening of voice which is suggestive of androgen producing tumors.examination include general examination for BMI as obesity could be a feature of PCOS or cushing disease,blood pressure can be elevated with caushing disease,ferryman-galleway scoring system can be used,a score of more than 8 is indicative of true hirsutism however it ignores some androgen sensitive areas and doesn’t take focal hirsutism into account.acanthosis negricans can be present in neck,groin and axilla and are due to hyperinsulinemea,abdominal examination for striae of cushing disease and abdominal masses.pelvic examination for clitoromegaly and masses.

(b) Discuss and justify the investigations you will undertake (7 marks).

Biochemical investigations include a hormonal profile as FSH & LH, inverted ratio makes PCOS likely however isn’t a diagnostic criterion,serum testosterone level is normal in 50 % of mild cases and doesn’t correlate to severity however a level of more than 5 ng/ml makes androgen producing tumors more likely.free androgen index (FAI) gives more information about free androgens and also about sex hormone binding globulin which decreases in PCOS making free androgen levels higher. I will do a 17-OH progesterone, androstenedione and dehydroepandrosterone levels to diagnose late onset congenital adrenal hyperplasia. ACTH stimulation test and free urinary cortisol to diagnose cushing syndrome.TSH,T3 & T4 to diagnose thyroid dysfunction.imaging include a pelvic us scan to diagnose PCOS or ovarian masses.abdominal CT scan or MRI for adrenal tumors.

(c) Discuss the treatment options for idiopathic hirsutism (6 marks).

Treatment options include reassurance that no cause could be found. Physical methods of hair removal as waxing,shaving and laser treatment can be of value and cause no side effects.first line medical treatment is combined oral contraceptive pills ( except second generation pills containing levonorgestrel and norethisterone),they act by increasing SHBG level so reducing free androgens,decreasing LH stimulated androgen release by theca cells & partial blocking of androgen receptors.options include Dianette (35 microgram EthinylEstradiol + 2 mg cyproterone acetate) used continuously or cyclic, Yasmin (35 microgram EthinylEstradiol + drosperinone) used continuously or cyclic,both have additional benefit of being contraceptives.cyproterone acetate 50 mg -100 mg can be used however should be accompanied by effective contraception to avoid feminising a male fetus and due to its long half life should be used in a reverse sequential regimen (from Day 5 to Day 15 of the cycle + EthinylEstradiol from day 5 to day 25) and the dose can be reduced to 5 mg/day after initial response.antiandrogens can be used either as second line monotherapy or in addition to COC in severe cases,they act by blocking androgen receptors and inhibition of 5 alpha reductase enzymes,they have to be used with potent contraception to avoid feminising a male fetus,theses include spironolactone which has the side effects of postural hypotension,hyperkalemea,dieuresis and reduced libido.flutamide which is equal in potency to spironolactone plus Yasmin but increases hepatic toxicity,finasteride which has the side effects of dry skin and reduced libido. Other option is local antiprotozoal as eflornithine,it inhibits ornithine decarboxylase enzyme in the hair follicles so reduces its response to androgens,it has the advantage of producing a visible effect in few weeks and improves response to laser treatment however hair regrows once treatment is stopped and it blocks sebaceous glands causing acne.a last medical option would be GNRH analogues which produce profound ovarian suppression however it is associated with menopausal symptoms and reduction of bone mineral density and if used more than 6 months add back HRT should be added to treatment.

a. I would establish the onset and duration of symptoms, rapid onset of hirsutism is suggestive of an androgen secreting adrenal or ovarian tumour, slow onset is more in keeping with PCOS. I would ask if there is increasing hair growth anywhere else, as well as the face, such as chest, abdomen and thighs.  I would ask about associated symptoms of virilisation such as noticing a change in her voice (hoareness/or deepening), loss of hair in keeping with male batern baldness, increase in clitorus size as these virilising features are suggestive of an androgen secreting tumour or congenital adrenal hyperplasia.  I wwould ask about her menarche, as late onset menarche may be associated with congenital adrenal hyperplasia, which can be a cause of hirsuitism,  I would establish her menstrual cycle, if irregular cycle or oligomenorrhoea present, this may be due to PCOS, and estblish if there is associated subfertility, this may also be due to PCOS.  I would enquire about systemic symtoms such as weight loss (tumour), weight gain (PCOS), abdominal pain, swelling or distension (ovarian tumour), galorrhoea (raised prolactin, may be a feature of PCOS or central cause of hirsuitism), headaches, visual disturbance (central/pituitary tumour resulting in increased ACTH and increased andrgens), symptoms of Cushing syndrome (tiredness, easy bruising, muscle weakness) in keeping with a pituitary tumour.  A drug history, including over the counter preparations and illicit use, such as anabolic steroid should be taken as may be the cause.  A family history of CAH or PCOS would be highly suggestive of the cause in this lady.

I would perfrom a thorugh general examination looking for the distribution of hair, any signs of virilisation (male pattern baldness, deep voice).  I would look for clinical features of Cushing syndrome (straie, buffalo hump, easy bruising).  If neurological symptoms I would perform a visual field assessment and if complaining of muscle weakenss a full neurological examination would be done.  I would palpate the abdomen to feel for pelvic mass and ascites.  I would perform an examination of the external genitalia looking for ambiguous genitalia ( CAH) or clitormegaly (androgen excess).  I would perform a speculum and bimanual examination to feel for adnexal mass which may be a androgen secreting ovarian tumour.  The height and weight should be measured to calculate BMI (often raised in PCOS), and the BP should be measured as hypertension associated with CAH.

b.  Investigations include blood tests for androgens including free testorterone and DHEAS (DHEAS is usually very elevated in androgen secreting adrenal/ovarian tumours), free testosterone index can be calculated and will be raised in CAH, androgen secreting tumour and mildly raised in PCOS.  The sex hormone binding globulin can be measured and this will be low in PCOS.  LH and FSH can be measured and a raised LH/FSH ratio is suggestive of PCOS, but not diagnostic.  If galactorrhoea present then prolactin should be formally measured to rule out a prolactinoma.  If features of CAH then 17 hydroyprogesterone measured, as if high is diagnostic of CAH then further genetic testing can be carried out.  A transvaginal ultrasound should be done to look for polycystic ovaries, in keeping with PCOS or an ovarian tumour, which may be androgen secreting.  Further imaging depends on blood test results and CT adrenal glands is indicated if raised androgens on bloods tests, or features suggestive of adrenal tumour/CAH (rapid onset virilisation).  Similarly if clinical features are suggestive of neurological cause a CT/MRI brain should be performed looking for a pituitary tumour.  If clinical features of thyroid disease then thyroid functioning tests, if clinically features of Cushing disease then ACTH suppression test may be indicated.

c.  Treatment of idiopathic hirsutism is challenging and results may be suboptimal and treatment can take time to decrease hair growth.  Hair removal can be done locally by waxing, plucking, shaving and using hair removal creams.  This may or maynot be acceptable treatment to the lady, but may form a key component while medical treatment is starting.  Laser hair removal is very effective a treating and preventing further hair growth, though expensive and not available on NHS currently.  Medical treatment include the combined oral contraceptive pill dianette as this has anti-androgen properties and good if women requires contraception, but no good if trying to conceive.  Spironolactone derivatives may decrease hair growth over time.  Finasteride can decrease testosterone levels and may improve hirsutism.  Metformin is only indicated in PCOS, and can decrease hirsutism over time if PCOS the underlying cause, no place for use outside of PCOS.

A.THE INITIAL ASSESSMENT SHOULD INCLUDE A DETAILED HISTORY, THE ONSET OF SYPMTOMS WHETHER RAPID AND PROGRESSIVE HIRSUTISM ( SUGGEST ANDROGEN SECRETING TUMOURS ) , OTHER ASSOCIATED VIRILIZATIONS SYPTOMS LIKE VOICE CHANGES, CLITOROMEGALY. THE DISTRIBUTION OF HAIR  ON THE FACE ONLY OR OTHER ARES OF THE BODY ( WTHETHER TOPICAL TRETMENT ONLY CAN BE OFFERED).THE IMPACT OF THE SYMPTOMS ON THE WOMAN QUALITY OF LIFE AND PSHOLOGICAL ATITUDE AND BODY IMAGE.FAMILY HISTORY OF HIRSUTISM IS COMMON IN IDIOPATHIC HIRSUTISM.DRUG HISTORY TO EXCLUDE ANY EXOGENOUS ANDROGENS ( LIKE ANDROGENIC PROGESTOGENS, ANDROGENIC CONTRACEPTION) WHICH CAN BE MODIFIED OR STOPPED. OTHER ASSOCIATED SYMPTOMS OF MENTRUAL DISTURBANCES LIKE OLIGOMENORHEA OR AMENORHEA ( PCOS IS ONE OF THE COKMENEST CAUSES).CONTACEPTIVE HISTORY AND WHTETHER CONTRACEPTION IS REQUIRED WILL AFFECT THE TREATMENT OFFERED. OTHER SYMPTOMS OF THYROID DYSFUNCION, OR  SYMPTOMS OF OVARIAN OR ADRENAL MASSES SHOULD BE ENQUIRED ABOUT. EXAMINATION SHOULD BE IMING TO EXCLUDE SERIOUS CAUSES AND QUANTIFY THE DEGREE OF HIRSUTISM USING A SCORING SYSTEM TO ASSESS THE RESPONS TO TREATMENT, PICTURES CAN BE HELPFUL IF APPROPRIATE. BMI AND B.P. SHOULD BE MEASUERD. ABDOMINAL AND PELVIC EXAMINATION LOOKING FOR MASSES. GENERAL EXAMINATION TO EXCLUDE ACANTHOSIS NIGRICANS, CLITORMEGALY IF SUSPECTED ANDROGENIC TUMOUR. SENSITIVE COUNSELLING IS IMPROTANT.        

B.  INVESTIGATIONS SHOULD AIM AT RECOGNIZING THE CAUSE (MOSTLY PCOS ) ,ALSO TO EXCLUDE SERIOUS ANDROGEN SECRETING TUMOURS AND SHOULD BE DIRECTED BY THE HISTORY AND EXAMINAION FINDING. SERUM ANDROGEN ASSAYS , FREE ANDROGEN INDEX, SERUM TESTOSTERONE LEVELS ( LEVELS MORE THAN 5NGM/ML MAY SUGGEST ANDROGENIC TUMOURS. SERUM  DHEA-S IS ADRENAL ANDROGEN AND IF ELEVATED MAY INDICATE AN ADRENAL TUMOUR. SERUM LH/ FSH MAY BE ELEVATED IN PCOS. THROID FUNCTION TO EXCLUDE HYPOTHYROIDISM. RENAL AND LIVER FUNCTIONS AND SERUM U& E  MAY INFLEUNCE THE DRUG CHOSEN.PELVIC US CAN DIAGNOSE PCOS, OR DETECT OVARIAN MASSES.ABDOMINAL US OR RARLY MRI ABDOMEN TO IDENTIFY AN ADRENAL TUMOUR.SOMETIMES NO CAUSE CAN BE IDENTIFIED IN THE MAJORITY OF IDIOPATHIC CASE...        

Treatment options should include senistive counselling as treatment may take long time, and improvement can be not apparent before 6 weeks, use of picture to assess the effect of treatment should be offered.The treatment depend on the severity, whther on face only (topical treatment or physical methods)or more wide spread, and contraceptive requirment. IF  a drug causeis identified , simple stoping can improve the symptom.physcal method of hair removal like plucking, bleaching should be encouraged. Overwt or obese shouod be encouraged to lose weight as this alone cane improve syptoms.laser electrolysis may be beneficial for localized facial hirsutism but may cause thermal burns, erythema. Contraceptive pill with antiandrogenic progestogen like CO-CYPRINDIOL  can be offered if requesting contracption , or asociated menstrual disturbance.  Topical facial eflornithine cream is liscenced for facial hirsutism, but improvment may take 6 weeks and is not to be used long term. Other antiandrogenic drugs like  Finasteride, Flutamide  Spirolonlactone antagonists may be offered in resistant cases but need frequent live function and serum electrolyte monitoring and limited by their side effects.follow up apointment shold be scheduled to check response to treatment, side effects.

A 30 year old nulliparous woman has been referred to the gynaecology clinic because of increasing facial hair. (a) Discuss your clinical assessment (7 marks). (b) Discuss and justify the investigations you will undertake (7 marks). (c) Discuss the treatment options for idiopathic hirsutism (6 marks).

a) I would ask her regarding onset, duration and severity of symptoms as rapidly progressive or severe hirsutism may be associated with androgenic tumours particularly when it is associated with virilism.  Enquiring regarding menstrual history and fertility may point to polycystic ovarian syndrome(PCOS) as the cause.  History related to other endocrine disorders such as hyperthyridism, cushing syndrome and congeintal adrenal hyperplasia (CAH) are of value in pointing out the causes.  History should also include any intake of androgenic drug or sterioid therapy as those can cause iatrogenic hirsutism.

On examination, I would evaluate the severity by using Ferrimane gallway scoring system and the score of more than 8 is needed to diagnose.  I would look for acne, deepening of voice and clitoromegaly as these can point out to androgen secreting tumour or hirsitism cause by iatrogenic drug intake.  Signs such as tremors, tachycardia, enlarged thyroids and high blood pressure, central obesity, straige nigra would point towards endocrine cause such as hyperthyroidism, PCOS and CAH.  Pelvic unltrasound is necessary in severe case of hirsutism to exclude any androgen producing ovarian tumours.

b) I would do investigation such as testoterone level and free androgen index. Testosterone level correlate poorly with severity of the hirsutism.  Testosterone concentrations (>5 mmol/l) should prompt further investigations such as pelvic imaging (CT and MRI) to exclude the possibility of ovarian or adrenal androgen-producing tumour.

Baseline 17 hydroxy progesterone (17 HO Progesterone)  measurements should be performed as a screening test for late onset congenital adrenal hyperplasia. Equivocal results need to be confirmed using a short Synacthen test.  A significant rise is diagnostic of CAH.

Adrenal androgens such as DHEA may be measured in women where an adrenal cause is suspected.

Dexamethasone suppression test or 24 h urinary free cortisol for suspected cases of Cushing’s syndrome.
Pelvic ultrasound should be done to exclude any ovarian tumour if history is suggestive.

c) She should be explained regading likelyhood of sucessful treatment and respond of the treatment may take at least about 3 months or more.  Objective menthod such as pohtograph to assess progess is useful. 

Physical method includes cosmatic measure such as waxing, plucking or shaving will not treate the existing hair and it can lead to  irritating and peudofolliculitis.  Bleaching may lead to skin discolouration.  Electrolysis and laser therapy can be tried. 

If she wish for contraception, Oral contraceptive pill would be the choice.  when using OCP, androgenic progestogen such as norethisterone or levonogestral should be avoided.  Cyproterone acetate can also be used as the treatment however it should be used with effective contraception as it can emasculate a male fetus.  Side effect such as weight gain, nausea, breast tenderness, headache should be discussed with patient.

In women with COCP are contraindicated, medroxyprogestrone acetate can be tried.  Spirionlactone is also effective drug in hirsitism however patient need to be mornitor on blood pressure and electrolytes as hypotension and hyperkalemia are side effects.

Flutamide can be used.  side effect include hepatotoxicity and Liver function test should be mornitored.  Finasteride are also effective but effective contraception is needed as it can emasculate male fetus.  Metformin may improve hirsutism through improvement in insulin resistance.  GnRH agonists can be used in severe cases resistant to treatment.  Women should be informed regarding associated menopausal symptoms and long term treatment is not recommended due to negative impact on bone density.  

a)I will ask her about the onset and rate of progression of  hair growth as  a rapid growth suggests an ovarian or adrenal tumour.I will ask her drug history whether she is taking any androgenic medications like danazol,testosterone,androgenic progestogens,drugs like minoxidil,phenytoin as these may lead to hirsutism.I will ask in detail about her menstrual history ,if irregular cycles it is suggestive of PCOS and it is a common cause of hirsutism.I will ask her about diabetis mellitus to know about hyperinsulinemia and insulin resistance as it is associated with hirsutism.I will ask family history of congenital adrenal hyperplasia as it is autosomal recessive condition.I will ask about any mood changes like change in libido,aggression to detect virilisation.I will ask about any history of virilisation like reduction in breast size,change in physique,deeepening of voice,male pattern baldness to rule out any androgen secreting tumours.I will ask her about any thyroid disorders and galactorrhoea as these are related to hirsutism.I will ask her about ant recent weight changes.

I will do a general examination to detect acne, any signs of virilisation and also exclude any abnormalities of external genitalia like clitoromegaly..I will look for any thyroid enlargement and galactorrhoea.I will check her blood pressure and height,weight and calculate her BMI.I will try to identify any signs of cushings syndrome like moon face,increased pigmentation,central obesity,proximal muscle wasting and hypertension.I will look out for signs of acanthosis nigricans such as velvety pigmented skin patches in groin,neck,axilla as these point towards insulin resistance.I will do abdominal and pelvic exam for detecting any abdominal,pelvic tumours.

b)Serum testosterone levels if increased points towards ovarian cause,Increased DHEA S levels point to an adrenal cause.I f the testosterone levels are markedly elevated then virilising tumour may be a cause.SHBG levels are decreased in PCOS.Androstenedione levels and free androgen index gives idea about androgen levels.If history and examination suggestive of cushings syndrome,then an overnight Dexamethasone suppression test needs to be done to confirm.17 hdroxy progesterone levels  after ACTH stimulation test to detect late onset CAH.Pelvic ultrasound scan to detect any ovarian tumours.An abdominal CT scan or MRI to detect any adrenal tumour.I f there are signs of virilisation a karyotype may be considered.GTT and insulin concentration to detect any insulin resistance.Thyroid function tests to detect any thyroid disorders.

c)She should be managed with the help of gynaecologist and an endocrinologist involvement will be beneficial if there is moderate hirsutism.I will explain to her about the condition and likelihood of successful treatment,the time period between starting therapy and clinical improvement.I f she is obese ,I will advise her to reduce weight as this reduces peripheral conversion of androstenedione to testosterone.Physical  methods  give immediate effect but thesea re temporary.Bleaching may lead to skin discoloration,shaving may lead to pseudofolliculitis.Electrolyis and laser therapy may also be considered.

Various medical methods can be tried.COCP suppresses LH production and ovarian testosterone synthesis,increases SHBG production.In PCOS ,it reduces risk of endometrial hyperplasia.Cyproterone acetate is antiandrogenic  progestogen can be used,but as it can emasculate a male fetus ,effective contraception should be used.Hepatotoxicity,headache,fatigue and weight gain are some side effects.

Medroxyprogesterone acetate inhibits LH production and ovarian steriodogenesis,can be used in women with contraindications for COCP.

Spironolactone acts as antiandrogen and aldosterone antagonist.Side effects are hypotension and hyperkalemia and B.P ,electrolytes need to be monitored.Flutamide is a non steroidal antiandrogen.Finasteride is a 5 alpha reductase inhibitor,but effective contraception needed as it can emasculate a male fetus.Metformin increases insulin sensitivity and useful in PCOS and obese patients.Topical treatment eflornithine  hydrochloride useful in facial hair.

A full and comprehensive history should exclude PCOS, Androgen secreting tumour, cushings, late onset CAH, exogenous androgen use and idiopathic.

A detailed menstrual history should include age at menarche, menstrual cycle, identify oligo/amenhorrohea and use of contraception.

The speed of onset of symptoms and preence of other virilising symptoms should be discussed. Rapid onset may suggest an Androgen secreting tumour as a cause..

Past medical history should include intersex problems at birth, famility history of CAH or type 2 diabetes mellitus. Drug history should identify potentially androgenising medication or use of exogenous androgens.

The effect on body image, previous cosmetic procedures and future fertility intentions should be discussed as this may suggest additional therapies and highligh other issues.

Examination should include a systemic examination for signs of cushing (moon face, telangectasia, increased pigmentation), other signs of virilisation or hallmarks of PCOS (Central obesity, Acnthosis nigricans). BMI and BP should be noted. Hirituism may be graded using the ferriman-galliway system.

(B)

LH/FSH levels may identify an altered ratio suggestive of PCOS, however Free androgen index and SHBG would offer better biochemical evidence of hyperandrogenism. Ultrasound examination would help fulfill the rotterdam criteria for diagnosis of PCOS which includes great than 12 follicles or increased ovarian size (>10cm3). 2 out of 3 creteria of hyperandrogensim, ultrasound markers and amenorrhoea, anovulkation should be met for the rotterdam crieria.

Anovulation may be confirmed by a midluteal progesterone 7 days before the expected date of menstruation (i.e day 21 of a 28 day cyle)

DHEA, DHEAS should be taken to further assess the levels of androgen in the body.  17 hydroxyprogesterone should be assessed to exclude late onset CAH. .

low cortisol levels would suggest cushings.An ultrasound scan will also help exclude androgen secreting tumours, although CT/MRI may be of greater use if this is suspected.

(c)

Lifestyle modification advice including weight loss and dietry advice should be given.

Cosmetic treatments for idiopathic hirituism are reasily available and give the patient control over her symptoms. Electrolysis and laser offers a permenant method of hair removal but may be expensive and require multiple treatments. Bleaching and shaving are affordable, easy to implement, however, shaving is often associated with a stigma although can be effective.

Topical pharmocological agents such as efloquine are efficacious, although other pharmocological treatments such as spironolactone, finasteride may be prescribed.

Cyperone acetate is useful in treating hyperandrogenism, and this may be given in with contraception in the form of diantte. Use of the COCP will help promote levels of SHBG and reduce circulating free androgens.

Particular attention should be made to the effect of hirituism on body image. Counselling should be sensitive and involvement of psychotherapists may be required if severe. 

a/

Ensure sensitive approach to the patient as this will be very distressing. It is important to ask her about any other associaed symtoms and signs eg. menstrual irregulaties, raising the possibility of PCOS. Ask about onset of hirsuitism, if rapid and excessive hair growth associated with deepened voice and breast atrophy, it may make you think of adrenal tumour. In addition, is there any family history of a similar presentation, suggesting possibility of late onset congenital adrenal hyperplasia. Check for signs of skin thinning or bruising and central fat distribution (buffalo hump) suggesting Cushing's disease. Enquire regarding weight gain, alopecia, clitoromegaly. Score hirsuitism using Ferriman-Gallwey score. Check BP/BMI. Take a drug history to exclude exogeneous steroids or drugs such a danazol. Ask her main concerns and if any treatments have been tried to reduce hirsuitism.

b/

Exclude/confirm PCOS using the Rotterdam criteria: there would be a positive diagnosis if 2/3 of the following: oligomenorrhea, signs/biochemical evidence of hyperandrogenism (check LH/FSH ration as well as FAI (free androgen index) and SHBG), carry out TV USS (this would demonstrate >12 peripheral follicles or ovarian volume> 10cm3).

Perform BMI/BP.

Check free testosterone level-if >7mmol/l, strong probability of andogen secreting tumour. Blood tests for 17-hydroxyprogesterone to exclude CAH. Check DHEA/DHEA-S, androstenidone as they may help distinguish ovarian or adrenal cause of raised androgens. if suspiscion of adrenal/ovarian tumour, may carry out MRI/CT.

Check cortisol levels ot urinary ketosteroids if suspicion of Cushing Syndrome.

c/

Ensure sensitive approach and counselling if required. Encourage simple measures such as weight loss, which may improve symptoms.

Can try cosmetic measure such as bleaching/waxing/threading/electrolysis, which as easy to implement with quick results.

Try OCP cyptroterone acetate which can reduce signs of hyperandrogenism aswell as being an effective contraceptive. Can also try Yasmin, which has anti-mineralcorticoid action, as well as spironolactone.

Creams such as Vaniqua (efloquine) which have been shown to be effective but can take several months to take effect. 

In addition can try measures such as finasteride, flutamide.

A)Duration  and progression of her  symptoms is enquired,as rapidly progressing hair growth in a short period of time may be due to androgen secreting tumors .

 Associated symtoms of virilisation such as deepening of voice,breast atrophy and male type of baldness may found  in such cases  and also in case of abnormal karyotype.Presense of acne,mood changes and reduced libido may be due to hyperandrogenism.Any weight changes  is enquired as associated obesity is suggestive of PCOS and abnormal distribution of fat,moon face and central obesity is associated with Cushing;s syndrome

Woman’s perception of severity and impact on  quality of life is asked.

Menstrual history is taken regarding age at menarche,LMP ,cycle regularity any oligomenorrhea or amenorrhea,as menstrual irregularity is found in PCOS.Contraception history and type of contraception.

Obstetric history about any period of infertility or pregnancy loss is asked ,as this may suggest PCOS.Her fertility intentions is important in planning her treatment options.

Family history of hirsutism is enquired as it has strong familial predisposition.

Drug history is taken about prescribed or over the counter drugs as this may be cause of exogenic androgens.

On examination height,weight and BMI is noted.Severity of facial hair growth may be assessed by Ferriman-Galway method.Presense of acne, male pattern baldness is noted.Breast exaimined for any atrophic changes.Abdominal examination for any abdomino pelvic masses and pelvic examination  any clitoromegaly is noted, bimanual examination for ovarian masses is done.

B) Investigations include serum testosterone (total nd free)>Testosterone <2nmol/l is seen in idiopathic hirsutism .Levels >5-6nmol/l  should prompt further investigations for any androgen secreting tumor by CT orMRI.SHBG  level  for free androgen index.DHEA and DHEA-S ,elevated levels indicate the source ,as these are secreted by adrenals.

17-OH progesterone,elevated  in late onset CAH. Dexamethasone suppression test of 24hr free cortisol for cushing;s syndrome.

Pelvic USS for polycystic ovaries or ovarian mass.

Karyotype may be indicated if signs of virilisation are present.

C)Treatment options include sympathetic counseling and reassurance  her symptoms can be treated,although it may take  a long time in some cases.This may be sufficient if there is no significant impact on QOL.

Weight reduction is advised if she is obese,as even 5-10% of weight loss will help reduction of facial hair.Mild cases may be treated by physical methods such as shaving,bleaching electrolysis or laser.These methods are also helpful while medical treatment takes effect ,which may be

 6-9months. COCP containing cyproterone is effective in more than 70% cases.It is appropriate if she is not planning a pregnancy.Topical treatment with eflornithine hydrochloride is effective in 4-8wks,but it causes skin irritation and hair may regrow after stopping the treatment.

Second line treatment with anti androgens include prironolactone,flutimide and finasteride.These require effective contraception during treatment.

A,History of severity of symptoms and its effect on QOL should be asked. Onset , duration and rate of progression  of symptoms should be asked as sudden and rapid progression would point towards adrenal or ovarian tumours. History of hair growth on other parts of the body and other features of hyperandrogenism  such as acne,maletype  baldness,deepening of voice,breast atrophy , clitoromegaly  should be enquired.. Drug history of taking exogenous androgens, danazol, minoxidil, diaxoxide asked.Menstrual history should be taken regarding LMP, cycle regularity,loss asked . Family history of hirsutism should be asked as PCOS and delayed onset og CAH will occur in families.

Height weight and BMI calculated. Severity of hair growth should be assessed by Ferriman Gallway score.Bp shold be checked and other features of cushings syndrome like moon face, truncal obesity, striae, proximal muscle wasting. should be noticed. Acanthosis nigricans will indicate hyperinsulinaemia.Abdominal examination should be done to detect  any mass. pelvic examination to  detect clitoromegaly and pelvic masses.

B, Investigations include, serum testosterone, total and free, DHEA and DHEAS, prolactin, FSH and LH to detect hyperandogenaemia and source of excess androgens. DHEA and DHEAS  are andogenic in origin.

17 oh progesterone should be measured as it is raised in congenital adrenal hyperplasia

mild elevation of testosterone and low SHBG are characteristics of pcod,High levels of testosterone point towards adrenal or ovarian tumours. 

Cortisol levels should be meassured and increased levels suggest cushings syndrome or disease.

Abdonimal usg should be done to detect PCOs and other ovarian mass. 

CT or MRI abdomen should be performed if any adrenal or ovarian tumour suspected/

Karyotyping should be done if signs of virilisation and presenting with primary amenorrhoea

C,.If mild hirsutism and does not have significant impact on QOL reassurance will help.

Weight reduction should be advised in obese PCOS as it  reduce the conversion of testosterone to androstenedione.

Physical  methods like shaving , depilation,laser and electrolysis can be tried.It is associated with scarring and folliculitis.

Medical methods should be started with proper counselling as it will take 6-9 months for effect. Meanwhile other physical methods can be continued.

Cocp is used in the usual preparation or estrogen and cyproterone acetate combination. Side effects of cocp 

are weight gain mood change and depression Cyproterone is hepatotoxic and cause emasculation of male fetus ,.Androgenic progestogens like levonorgesterol and norethisterone should be avided. New preparations containing drospirenone with anti androgenic and anti minerelocorticoid is helpful. 

Other androgenic preparations are Flutamide and Finasteride . Use is limited by hepatotoxicity.These also cause emasculation of male fetus and adequate contraception is required.

Spironolactone reduces hirsutism . Side effects are hyperkalemia and hypotension.

Efflonithine is a topical cream which  slows the hair growth. Results are evident by 8 weeks but reappears after stopping therapy.Some individuals experiance allergy and skin irritation.

Above all good psychological support is needed.

a) I will approach the patient in a sensitive manner in view of issues with body image. I will take a menstrual history for age of menarche, last menstrual period and regularityof menses. I will ask for the onset and progression of symptoms as rapidly progressive hirsutism may indicate malignancy. I will ask for intention for fertility. I will ask if she has a past history of Cushing Syndrome or thyroid disorders. I will askk a family history of hirsutism and late onset congenital adrenal hyperplasia. I will ask a drug history for exogenous androgens. I will ask her how symptoms are impacting her quality of life. I will measure her blood pressure for hypertension and her body mass index. I will examine for acanthosis nigricans which is a sign of hyperinsulinemia. I will grade the severity of her hirsutism with Ferriman Gallwey System. I will examine for signs of Cushing Syndrome like moon facies, truncal obesiy and proximal muscle wasting. I will examine for other signs of hyperandrogenism like acne. I will examine for signs of virilisation like clitoromegaly, male pattern balding and reduction in breast size. I will perform an abdominopelvic examination  for pelvic or abdominal masses.

b) I will measure serum testosterone and calculate free androgen index for hyerandrogenism. If the serum testosterone is more than 5 nmol/L, we should suspect androgen secreting tumors. Ultrasound pelvis should be performed to exclude ovarian tumors and CT adrenals should be performed to exclude adrenal tumors. Serum dehydoepiandrosterone and dehydroepiandrosterone sulphate should be performed to exclude adrenal cause of hyperandrogenism. 17 hydroxyprogesterone should be performed as increase in levels may indicate congenital adrenal hyperplasia. Dexamethasone suppression test should be done to exclude Cushing Syndrome if there are signs. Fasting glucose and glucose tolerance test should be done to exclude insulin resistance. 

c) patient should be counselled that it takes at least 3 months and usually 6-9 months for treatment to take effect. She should be advised to lose weight as it reduces peripheral conversion of androstenedione to testosterone. She should be offered physical treatments like hydrolysis, laser, plucking and waxing as pharmacological treatment does not remove preexisting hair. First line pharmacological treatment is combined oral contraceptives. Avoid androgenic progestogens like norethisterone and levonorgestrel. Antiandrogenic progestogens like cyproterone acetate should be used. It suppresses lutenising hormone actvitiy and ovarian androgen production and progestogen inhibits 5 alpha reductase activity. Progestogens like medroxyprogesterone acetate is an alternative to combined oral contraceptive. Second line treatment includes antiandrogenic drugs like spironolactone, flutamide, finasteride and ketoconazole. Effective contraceptive should be given as antiandrogen medicine will emasculate a male fetus. Elfornithine hydrochloride (VANIQA) can be used and results usully show after 4 to 8 weeks of treatment. Relapse will occur after discontinuing the treatment. 

Clinical assessment. Duration of her      symptoms rapid progress of symptoms   suggest androgen secreting tumors . Any   change in her voice and balding  and family    history of hirsutism . Menstrual cycle     irregularities may suggest pcos        .Glactorrhea is associated with hyperprolactenemia   . Weight gain , lethargy and cold intolerance are  suggestive of  hypothyroidism . Medications as glucocorticoids , phynetoin, cyclosporine these drugs cause   hypertrichosis. History of use of cocs with androgenic effect .Examination BMI increase in pcos  bp  high in cushing disease and acromegally decrease In hypothrodism and late onset adrenal hyperplasia . skin pigmentation at neck ,axillae and groin sign of  acanthosis nigricans .Hair distribution according to Ferriman –Gallwey score if score more than 8 is considered androgen excess. Clitoromegally is a sign of hyperandrognism.                                                                                                          

Investigations.  Serum testosterone increase in pcos and adrenal tumor.    LH and FSH ratio more than 2  increases  in pcos. TSH high in hypothyroidism .level of sex hormone binding globulin is decreased in pcos , hypothyroidism , hyperprolactonemia  . 17oh progesterone increase in  CAH.DHEAS is increase in adrenal  tumor . OGTT increase  in insulin resistance .  Abdominal and pelvic ultrasound to detect any adrenal or      ovarian  tumor or polycystic ovaries                                                                                                                                  

Treatment .Explain to her about the nature of her problem and the clinical improvement will take 4-6 months  . Non medical treatment as waxing  shaving or using bleaches are effective. Permanent measure as .Life  style modification as exercise is effective .  laser or electrolysis                                                                                

First line therapy  cocp is treatment of choice in women not trying to conceive progestational component suppress LH and inhibit 5alphareductase  enzyme and estrogen component increase sex hormone binding globulin . Dianette is ethinylestradiol + cyproterone acetate  is effective in treatment of hirsutism and is not use as contraception . Second line treatment  spironolactone inhibits ovarian and  adrenal androgen it competes for androgen receptor in the skin slow onset at least 6 m it cause hyperkalaemia, contraceptive method must be used as it causes feminization of male fetus.Finasteride inhibit 5alpha reductase .Flutamide is antiandrogen . Eflornithin hydrochloride reduces hair growth ,works within 8 weeks.    

A)     The women’s menstrual history of irregular menstrual cycles, oligomenorrhoea , increased cycle length, acne, hirsuitism, is suggestive of polycystic ovarian syndrome, her Last menstrual history is noted to direct treatment. Time since the increase is noticed is  essential  , as  shorter the duration more the suspicion of acute pathology ,hence history of drug treatment is essential ( drugs like androgenic steroids, androgenic  progesterogens  , Phenytoin  sodium,Danazol, actually drugs cause hypertricosis  not exclusively hirsuitism). Suspicion of androgenic  tumors like hilus cell tumor, arrehenoblastoma, ledig cell tumor though rare,if  history is suggestive of virilism like hoarseness of voice ,breast hypotrophy to note the severity of the problem,the same history  favours a suspicion of late onset adrenal hyperplasia. usually increase in weight, straie ,easy bruising and hirsuitism is suggestive of Chusing’s syndrome. Cold intolerance ,irregular cycles ,increase in weight is suggestive of hypothyroidism. Her desire for fertility will guide treatment issues. Family history of hirsuitism  suggests  idiopathic etiology. On examination the womens habitus and hair distribution (ferriman Gallway scoring ) is documented and sometimes photographs will help the women ,notice the difference after treatment .Her Bloodpressure , BMI, is documented to advice appropriately. Acanthocis nigricans is a feature in hyperinsulinemia ,and polycytic ovaries. Central obesity, proximal muscle wasting, abdominal straie are clinical features of Chusingssyndrome. Male pattern of hair distribution and clitoromegaly are examined to investigate appropriately.

B)      Investigations: Free testerone :Testosterone levels(free) if increased, SHBG: Serum hormone binding levels when decreased, along with Transabdominal / Transvaginal Ultrasonogram for features of Polycystic Ovaries are suggestive of Polycystic ovarian disease. Increase in 17 –hydroxyprogesterone ,  Dehydroepiandrosterone sulphate (DHEAS) are indicative of late onset adrenal hyperplasia. Dexamethasone suppression test and free cortisol in the 24 hour urine will help in the diagnosis of  Chushing’s syndrome. Karyotyping is advised ,only if clinical features are grossly virile .CT OR MRI of the abdomen can detect tumors of the ovary or adrenal.Thyroid profile is done to exclude thyroid disease.

C)      Discussion regarding fertility issues are required ,as without appropriate contraception the pharmacological drugs with antiandrogenic properties will emasculanise a male fetus.If she is overweight , weight reduction is advised to reduce the peripheral androstenedione levels. The physical  methods like shaving, waxing, tweezing depilatory creams play an important role cosmetically until the pharmacological treatment takes action.Electrolysis and Laser are permanent methods but require time and increased cost.Pharmacological treatment are several with different adverse effects, and that long duration of treatment to notice effective results.Hence a cautious supportive approach is recommended. Combined oral contraceptive pills which are not androgenic(levonorgestrel,norethisterone),are advisable as they reduce the free testosterone levels,increase the SHBG,the progesterogens reduce the luteinsing harmones and thereby reduce the androgen secretion from the ovary.When COC pills are contraindicated then medroxyprogestogens injectales are advisable. A  combination of ethinyl estradiol and cyproterone acetate as a combined contraceptive pill for short term can be advised, risk of venous thromboembolism is increased.Antiandrogens Flutamide is advisable but they are hepatotoxic, hence liver function tests needs monitoring. Finasteride a 5 alpha reductase inhibitor may be used but an effective contraception is also advised as they may emasculanise a male fetus. Spiranolactone  is an anti androgen and an aldosterone antagonist ,they increase the potassium levels and alter the serum electrolytes. Hence a close watch on the potassium and the electrolytes are essential. Eflornithine (Vaniqa) is a inhibitor of ornithine decarboxylase ,is used to treat hirsuitism ,is found to be effective after a course of 3-4 weeks ,effects declines when the treatment is stopped. An appropriate patient informationIs provided at the end of the consultation.

a) Ask about duration of hair growth and severity and rapidity of problem as rapidly growing hair may indicate an androgen secreating tumours. Ask other signs of hyperandrogenisation like acne, voice changes and increased hair on other body parts. Effect of hair growth on quality of life and frequency of need for hair removal. Recent history of excessive weight agin is important. Menstrual history regarding regularity of cycles. Obstetric history for infertility or use of contraceptive pills is important as androgenic progestogens may cause increased hair growth. Drug intake like danazol, phenytoin or minoxidil may increase hair. Check her weight and BMI. Examine other body sites for increased hair growth and assign Farrimann Gallway score accordingly. Per abdominal examination for any abdomino-pelvic mass. External genitalia for clitoromegaly and pelvic examination for adenexal mass.

b )Investigations will be directed by history and examination. It includes S. testosterone and free androgen index as very high levels may indicate androgen secreating tumors. If polycystic ovaries are sustected, check S. LH, FSH, Insulin and prolactin levels. If late - onset congenital adrenal hyperplasia is suspected, check for 17-OH progesterone, androstenedione and DHEAS as these are primarily  adrenal androgens. Imaging studies like USG will be requried for assessment of PCO or ovarian/ adrenal tumors. CT scan may be requird for further assessment if tumors are a possible diagnosis.

c) For managemnt of idiopathic hirsutism, counselling is very important as patient needs to be reassured that there is no pathology in the body. Whatever medications are started, it takes minimum of 6-8 months to observe the response, so strict adherence to the treatment is very important.If patient is overweight, weight loss maiy help. Physical measures for hair removal like shaving, epilation, electrolysis and laser may be tried. Pharmacological treatment include antiandrogens like cyproterone acetate 2 mg per day. contraception needs to be maintained as it can cause demasculinisation of the male fetus. liver function needs to be monitored every 6 months. Another option is to use contraceptive pills containing ethinyl estradiol with cyproterone acetate. Other second line agents include flutamide ( androgen receptor antagonist), finasteride ( 5 alpha reductase inhibitor) and spironolactone ( antiandrogenic diuretic). potassium levels needs to be monitored with spironolactone 

sir please correct my essay ,before dr.geetha.

thank you,

celine

a)       i would like to know more about the onset of hirsutism as its progression as rapidly progressive development indicates more towards androgen secreting tumors. Its severity will be asked. Its relationship with menstruation is to be obtained as oligomenorrhoe will be pointing more towards PCOS where as delayed menses may suggest element congenital adrenal hyperplasia. History of infertility will be obtained as it may poit to PCOS.Family history is to be noted as it can run in the family. Drug history is to be elicited as some medication like danazole is known for its androgenic side effects. Any significant past medical history is to obtained like epilepsy in which she may be on phenytoin which is known to cause hirstutism. Any change of voice like its deepening and breast under development with clitromegaly will be elicited as it indicates towards virilizing tuomor. Any increase in weight will be asked as it suggests to be associated with PCOS. On examination I will get her BMI as high BMI is one of the commonly associated features of PCOS. Her blood pressure will be measured. Hair distribution will be noted. Breast will be examined for any evidence of atrophy. Acanthosis nigricans will be looked for as it points insulin resistance. Abdominal and pelvic examination will be performed to look for any masses.  Any evidence for cliteromegaly will be noted.

b)       I would perform Ulrasound abdomen pelvis looking for evidence of PCOS and ovarian tumor as well as adrenal tumors. CT/MRI abdomen may be needed to clearly identify th adrenal and ovarian tuomurs.

 plasma free testosterone levels will be taken as levels more than 5mmol/l will suggest an androgen producing tumor. Sex hormone binding globulin will be measured as it is usually low in PCOS. Baseline 17-OH progesterone measurement should be done to screen for suspected late onset congenital adrenal hyperplasia(CAH) as it will be raised in CAH. 24hour urinary free  cortisol or dexamethasone suppression test is to be done for suspected cases of cushing syndrome.

c)       The treatment options for idiopathic hirsutism include non pharmacological and pharmacolical measures.  non pharmacological options include  reduction of weight,bleaching to disguise the pigmented hair, shaving, plucking and waxing. Electrolyisis and laser application are effective means of permenatn hair removal but time consuming and expensive. Pharmacological options include use of combined oral contraception like Yasmin which contains drospirenone as progestogen known for its anti androgenic property may be used. Dianette ( cyproterone acetate 2mg and ethinyl estradiole 35mg) is considered first line for those not willing to conceive. However patient should be informed that the effect may not be seen  till 6-9 months of initiating the treatment. Finestride a 5 alpha reductase inhibitor can be used however the patient should be on effective contraception as it is teratogenic. Topical eflornithine which is antiprotozoal drug that inhibit hair follicle growth can be used. Improvement can be visible within 8 weeks of its use however, its indefinite use is needed to prevent regrowth.

a)

Her menstrual history should be obstained. History of irregular menses and oligomenorrhea with hirsutism is suggestive of PCOS. Rapid onset of hirsutism, associated with virilizing symptoms, such as deepening of the voice and clitoromegaly would be very suggestive of an androgen secreting tumour. History of drug use, such as Danazol, Diaxozide or Phenytoin, should be ascertained as this could couse hirsutism. Family history of hirsutim should also be asked. Familial hirsutism is predominant in South Asians families, and could be a normal finiding in her.  Family history of congenital adrenal hyperplasia should also be ascertained. Presence of hypertension, truncal obesity and buffalo hump is highly suggestive of Cushing's syndrome.

Her BP should be taken to exclude hypertension. Her BMI calculated, and examination of truncal obesity and buffalo hump to exclude Cushing's syndrome. Her hair distribution should be assessed with the modified Ferriman-Galway System. Abdomen palpated for abdominal masses. Genitalia examined for clitoromegaly.

b)

Blood investigations should include serum testosterone, SHBG and free andogen index to look at her androgen levels. FSH & LH levels to exclude PCOS and hypogonadotropic causes of causes of menstrual abnormalities.Increased FSH/LH ratio would suggest PCOS. Serum 17-hydroxy progesterone levels teken to eclude congenital adrenal hyperplasia. 24H urinary cortisol or Dexamethasone suprression test to exclude Cushing's syndrome.  DHEAS to exclude adrenal causes of  hirsutism.

Pelvic ultrasound should be done to look for adrenal masses and to look at the ovarian morphology for polycystic ovaries. CT scan or MRI to look for adrenal tumours.

c)

She should be counselled in the most sensitive matter, as her condition is distressing to her. Written information should be provided for her and her treatment should be tailored to the individual patient. Cosmetic hair removal, such as waxing, bleaching and shaving, are easily available and cheap. However, she would need to do repeated perform them when her hair grows back. Electrolysis is a more permenant way of hair removal, however, it is expensive, and complications, such as skin burns have been reported. Combined contraceptive pills and medroxyprogesterone inhibits LH and ovarian androgen production. Its readily available and patients can be buy them over the counter, however, there are unwanted side effects, such as PMS-like symptoms, VTE, and mood swings. Cyproterone acetate inhibits alpha reductase activity in the skin, thus reducing hair growth. It also helps with acne. Eflornithine hydrochloride is a topical preperationg, which is effective in  inhibiting hair growth in the skin. However, she should be advised that it is a long term term treatment, and it may be up to 12 to 24 months before she could see any improvement in her condition. Finestiride is an alphoe reductase4 inhibitor that can also be used, however, she should be advised to have effective contraception, as it could emasculate the amel fetus. Flutamide in a non steroidal anti androgen that inhibits androgen production, hoewver, its use is limited by hepatotoxicity. Ketoconazole is another option for treatment, however, its use is also limited by hepatoxicity.