MRCOG PART 2 SBAs and EMQs
| Course PAID | ||
| notes | 336 | |
| EMQ | 1502 | |
| SBA | 2115 | |
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ESSAY 182 - HIRSUTISM
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Posted by Sreekala S. |
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| Abnormal facial hair growth is very distressing. A detailed history should be taken regarding the onset, duration, distribution of hair growth on the body, her general well being, acne, alopecia, weight changes, abdominal swellings and menstrual regularity. A detailed drug history should be taken as danazol, testosterone, minoxidil, diazoxide, phenytoin, cyclosporin A and androgenic progestogens can produce hirsutism Family history of Congenital adrenal hyperplasia and PCOS should be noted. Examination should include recording BMI, breast examination, amount, distribution and severity of the body hair growth along with the Ferriman Gallwey scoring. Acne, alopecia, deepening of voice suggest hyperandrogenemia. Acanthosis nigricans may be present in PCOS. Central obesity,facial plethora, easy bruising and thinning of skin, hypertension, striae and proximal muscle wasting suggests cushing?s syndrome. Abdominal examination should be done to look for any masses. External genitalia should be examined for the presence of clitoromegaly. Bimanual examination should be done to look for any adnexal masses. The differential diagnosis includes PCOS, Late oneset Congenital adrenal hyperplasia, androgen producing ovarian tumours, adrenal tumous, cushings syndrome and Idiopathic. Investigations should be performed to find out the cause. Serum LH, FSH, Testosterone, androstenedione, Free androgen index, Serum prolactin, SHBG, 17- Hydroxy progesterone, Cortisol and ACTH. Serum testosterone is poorly correlated with the severity of symptoms but it is the most useful indicator of serious pathology. Levels more than 5nmol/l should prompt further tests for adrenal function. A positive synacthen test with elevated 17 hydroxy progesterone levels before and after administration of ACTH suggests Congenital adrenal hyperplasia. Cushing?s syndrome can be diagnosed a high 24 hr cortisol levels and dexamethasone suppression test. Transvaginal scan should be done to look for the presence of polycystic ovaries, androgen producing ovarian tumours and an ultrasound abdomen for adrenal tumours. Treatment should be commenced depending on the immediate desire for child bearing and the underlying cause . Weight reduction should be advised if the BMI is high, as obesity is associated with low SHBG values and high free androgen levels. Bleaching, plucking, shaving can be tried but are temporary measures which need to be repeated depending on the hair growth. Electrolysis is expensive and time consuming although it is associated with good results. Application of Vaniqua cream(Eflornithine hydrochloride) can be used twice daily., but it is associated with skin erythema, burning sensation and tingling with return of hair growth by 8 weeks of stopping the treatment. She should be counselled that any medical treatment needs to be taken atleast for 3-6 months or longer to be effective. Oral contraceptive pills containing estrogen and progestogens can be prescribed as both the components have been shown to be improving hirsutism but are associated with the risk of VTE. Contraceptive pills containing cyproterone acetate(Dianette) or Drosperinone(Yasmin) can be given. Cyroterone acetate should not be prescribed without any contraception as it can cause feminization of a male fetus. Depression, fatigue, mood changes , weight gain and hepatotoxicity can occur and LFT s need to be monitored. GnRH analogues are generally not prescribed for hirsutism as they are expensive and have side effects.bSpironlactone is an aldosterone antagonist and needs monitoring of BP and electrolytes in the first few weeks of treatment. Hypotension and hyperkalemia are the side effects. Flutamide is a non-steroidal anti-androgen and is associated with hepatotoxicity. Finasteride is 5alpha reductase inhibitor and effective contraception is required as it is known to cause feminization of male fetus. Ketaconazole is generally not prescribed as it is associated with hepatotoxicity. Glucocorticoids are indicated in the presence of ACTH mediated androgen excess. Surgical excision of the ovarian tumour is required in the presence of androgen producing ovarian tumours.In the presence of Cushings syndrome, congenital adrenal hyperplasia or adrenal tumours should be referred to an endocrinologist. |
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Posted by Srivas P. |
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| Hirsutism or excessive growth of terminal hair can be socially embarrassing and emotionally upsetting for the woman and this has to be handled sensitively. Once an underlying cause is identified, Hirsutism has to be dealt with in totality taking care of her underlying etiology when identified along with treating her major symptomatic complaint ?Hirsutism. Clinical assessments involve taking her height weight, BMI to note Obesity which could be underlying cause of hyperinsulinism and hyperandrogenism. She should be examined for signs of virilism?cliteromegaly, breast atrophy and should be scored for hirsutism using Ferriman Gallwey scoring. Scoring helps assess degree of hirsutism and assess response to treatment. Endocrine disorders like Cushings Syndrome may be suspected by moon like face, buffalo hump, central distribution of fat, easy bruising , abdominal striae, hirsutism, alopecia, acne and occasionally virilization. Classic signs of Acromegaly may be noted if that is the basic underlying cause of Hirsutism. This includes headaches, carpel tunnel syndrome, increase in size of skull, supra orbital ridges and jaw and Kyphosis due to excessive growth of spine. Breast should be examined for galactorrhoea. Pelvic exam should be done for ovarian tumors and her BP should be taken. Most important investigations are Pelvic Ultrasound to see ovarian morphology ?identify PCO and rule out androgen secreting ovarian tumor and serum testosterone levels. If serum testosterone is more than 5nmol/litre, it is unlike to be due to PCO or idiopathic hirsutism. Further tests will then involve tests of adrenal function, CT MRI imaging for adrenal tumors. LH and FSH levels should be done to see increased LH/FSH levels in PCO, along with obvious USG features of PCO. Short synacthen test followed by increased levels of 17-alpha hydroxyl Progesterone helps diagnose congenital adrenal hyperplasia. Most important screening test for Cushing?s syndrome are 24 hr urine free cortisol and ACTH measurements. ACTH producing tumors may be identified if suspected following dexamethasone suppression test, by CT and MRI imaging of adrenals, chest, and pituitary. Acromegaly may be identified by incresed GH levels, skull x-ray and CT and MRI of pituitary. Whatever the cause of hirsutism the therapy may take 6 months to take effect. Non pharmacological treatments give immediate relief and should be tried first. This includes waxing, plucking, bleaching laser treatment. Electrolysis gives permanent treatment but is expensive. Underlying cause of hirsutism if identified should be treated. Antiandrogens are the main therapy to control hirsutism and most of them used in practice can feminize a male fetus. Hence the woman should be advised concurrent contraception. Cyproterone acetate is the most widely prescribed usually as Dianette (in combination with ethinyl estridiol+2 mg CPA) in a reverse sequential regimen, which is cyproterone given for first 10days of the 21 day treatment. In severe cases with Ferriman Gallwey score more than 10; higher does of CPA 25-100mg, may be required. Other antiandrogens include Spironolactone which is an aldosterone antagonist is equally effective but is not licensed in UK for hirsutism. It can cause feminization of male fetus and should be used with effective contraception. Flutamide an antiandrogen when used with oral contraceptive may be as effective as spironolactone. Use of Ketoconazole which reduces ovarian and adrenal steroidogenesis is controversial due to side effects like alopecia and asthenia. Third generation contraceptive pills containing desogestrel and gestodene may be better than 1st generation contraceptives at controlling hirsutism due to lower androgenic effect of progestogens in them but may have higher thromboembolism risk. Its effectivity in controlling hirsutism is lower than with CPA and is not first line drug for hirsutism. GnRH analogue is effective in controlling moderate to severe hirsutism but vasomotor side effects and risk of osteoporosis limit its use. This side effect may be minimized by add on therapy with estrogen. Cost is still very high. Other medical options include Finasteride a 5-alpha reductase inhibitor may help if increased end organ sensitivity is suspected by family disposition to increased hair growth. Dexamethasone may help with late onset CAH. Surgical options include ovarian wedge resection for PCO to decrease testosterone level but the effect is short lived and may also cause adhesions and subsequent infertility and is not favored for this patient. It is not favored especially when medical treatment is very effective. The woman should have psychological support especially if response to treatment is slow and she must get leaflets explaining the treatment schedule and plan of management. A photograph taken pretreatment and shown now may give reassurance of improvement. Ferriman scoring too should be done to assess improvement. |
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Posted by adnan S. |
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| Growth of terminal hair on the body of a woman in the same pattern and sequence as that which develops in the post-pubertal male.The main aim of the initial assessment & investigations is to exclude serious cause that may be dangerous like ovarian &adrenal tumours.Facial hairs may be associated loss of self ?esteem and psychological morbidity hence approach should be sensitive ,supportive with empathy.Detailed history is taken regarding the onset facial hairs,speed of progression like gradual or sudden onset, severity of growth like frequency of plucking,shaving as androgens are the principle regulators of terminal hair growth .Menstrual history is taken like irregularity of periods ,oligomenorrheoa .h/o increase in body weight .Family h/o hirusitism .H/o recent change in voice .H/o drug intake previously or currently like COCPills,danazole phenytoin . Examination include height ,weight to calculate BMI,acanthosis nigricans marker of hyperinsulineamia should be checked . obesity along with menstrual irregularities, acanthosis nigricans suggestive of PCOS.Central obesity with abdominal strea moon face ,hypertension suggestive of cushings syndrome.Signs of virulisation like deepening of voice ,breast atrophy ,clitoral hypertrophy with rapid progression of hirsutism point towards ovarian or adrenal tumours.Abdominal examination is done to look for any mass.An assessment of amount,distribution and severity of hirsutism is done by modified Ferriman ?Galllway scoreIt is helpful in both baseline assessment and subsequent monitoring of response to treatment.Pelvic examination is done to exclude cliteromegly &to palpate the adenexa for ovarian tumours. Investigations should be under taken urgently if an androgen secreting neoplasm is suspected.Serum testosterone is poorly correlated with severity of symptoms,but is the most useful indicator of serious pathology.Very high levels would be suggestive of an androgen secreting tumours.Measurement of free testosterone is not necessary.DHEA-sulphate almost exclusively produced by adrenal cortex therefore elevated if hyperandrogenaemia is adrenal in origin.17-hydroxyprogesterone is elevated in CAH.Serum prolactin ,and thyroid function test exclude other causes of an ovulation .TSH measurement particularly important if alopecia is presnt.Cushing syndrome is excluded using 24h urinary free cortisole excreation or overnight dexamethasone suppression test.GGT especially if over weight as there is association between insulin resistance or hyperinsulineamia&hyperandrogenism with periodic surveilence for early detection of NIDDM.Ultrasound scan of ovaries to exclude polycystic ovaries,&ovarian tumours .MRI of adrenals if rapidly progressive hirusitism or markedly elevated androgen levels.Measurement of SHBG and free androgen index donot influence management. Urgent laparotomy at cancer center if androgen secreting tumours identified If CAH refer to endocrinologist..If no pathology detected I will reassure her ,and discuss expectations,likelihood of successful treatment and length of time between commencement of therapy and clinical improvement at least 3months,usually6-9months.Weight loss if over weight or PCOS reduces insulin resistence ,reduces androgen levels&improves ovulation.COCP-inreases SHBG and therefore decreases free testosterone,suppress LH production &androgen synthesis,progesterone inhibits 5-alpha reductase activity.COCP with cyproterone acetate an anti-androgenic progestogen is consider .cyproterone acetate should not be used alone without effective contraception as it can emasculate a male fetus.Side effects of cyproterene acetate includes weight gain fatigue breast tenderness GIupset headache,risk of VTE& ,hepatotoxicity LFT should be moniterd if used for >6months.New COCP yasmin containing drosperinon a derivative of spirinolactone can also used.Medroxy progesterone acetate is effective if COCP is contra-indicated or if does not contraception.Spironolactone, Flutamide Finasteride Ketoconazole are notwidely used because of the side effects.Physical treatments like waxing bleaching ,electrolysis may be helpful while waiting for medical trearment to work. |
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Posted by Aroosha B. |
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| Initial assessment will be done by taking a detailed history and examination. In history the duration, rapidity and severity of symptoms should be asked as a history of rapid onset of symptoms indicates an underlying androgen secreting tumors and can result in deepening of voice and enlargement of clitoris and needs prompt treatment. History of acne and menstrual disturbances should be asked. Along with history of drug intake as danazole and glucocoriodus result in increase facial hair. History of recent weight gain should be inquired. A detailed examination should be carried out and severity of hirsutism should be assessed by using ferriman gallway score. Her BMI should be calculated and presence of nigricams acanthosis should be checked which is a marker of hyperinsulinaemia. Symptoms and signs of causing syndrome, such as central obesity facial plethora, thin skin and proximal muscle wasting should be looked for. A pelvic examination should be done for the presence of clitromegaly and bimanual examination to look for the presence of any ovarian mass. Investigations which are to be carried are serum testosterone and USG. Although serum testosterone level correlate poorly with the degree of hirsutism, a value greater than 5 n mol, indicates an androgen secreting tumors. UGS should be done for any ovarian tumors and it will also delineate ovarian morphology in case the cause is PCOS. Further investigation are done to rule out CAH is the measurement of 17 hydroxy progesterone and cortisol after dexamethasone suppression test . For cushing syndrome, 24 hour free cortisole level and low dose dexamethasone suppression test is done if these are +ve than high dose dexamethasone suppression test should be carried out. The treatment options are given after giving detailed information to the patient. The medical and surgical treatment result in rapid decrease in testosterone level and suppress hair growth but the effect is not evident until 3 to 6 months. The patient should be advised to continue cosmetic treatment like bleaching, waxing depilatory creams and electrolysis. In case BMI > 25 the patient should be advised to loose weight along with medical treatment. Treatment is according to cause. Medical treatment are cyproterone acetate , it is a competitive androgen receptor blocker and is most widely used in UK. It is a strong progestrogen and given in a reversed sequential sequence along with ethinyl estiadwl 35 μgm a dose of 2 mg or 75 mg depending upon severity., Side effects are weight gain, depression, mood changes, . LFT?s should be monitored during treatment. Contraception is mandatory during treatment. Spiranolactane is aldosterone antagonist and is not used for this purpose in UK. Flutamide is also used in treatment but is associated with considerable side effects and LFTS should be monitored during treatment. Ketocenazole inhibits androgen production by blocking enzymes but causes hepatotoxicity and needs LFTS monitoring. COC is very simple , effective and suppresses androgen production by by decreasing LH and increasing SHBG production. GmRH also suppress ovarian steridogenesis but are not widely used for undesirable side effects which causes estrogen deficiency. For CAH gluco corticoieles are given and patient should be referred to endocrinologist. Finasteride is also effective for the treatment of idipopathic hirsutism and decreases 5 α-reductase activity. Eflornithine cream is a new topical preparation which reduces hair growth but there is repid return of symptoms once treatment is stopped. Ovarian and adrenal tumor should be surgically excised. Laproscopy ovarian drilling should be restricted for management of anovulatory infertility as fall in androgens is short lived. Hirsutism is extremely distressing condition both cosmetically and psychosexually. For this reason woman asking for medical help should always be investigated and counseled and offered medical treatment. In more severe case additional psycho therapy sessions may be considered. |
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Posted by BAHAA-Uddin BOR B. |
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| A full detailed history should be taken with particular reference to the onset of increasing facial hair and speed of progression.Its slow progression is more consistent with PCOS or late onset CAH,whereas rapid progression is suggestive of adrenal and ovarian secreting tumour.Menstrual pattern will aid in the differential diagnosis of various syndromes associated with hirsuitism and correlates roughly with the degree of hyperanrogenaemia.History of drug intake such as danazol ,anabolic steroids and androgenic progestogen as Norethisterone in high dosage. History of thyroid dysfunction and galactorrhoea ,as hyperprolactinaemia can be accompanied by increased adrenal androgens. Careful family history can be rewarding ,family history of CAH may be positive. Examination should include weight ,height and BMI for obesity.On physical evaluation ,attention should be directed toward quantifying the hair.Various methods have been proposed to assess the severity of hirsuitism,such as the semi-quantitative scale by Ferriman and Gallwey . A simple facial scoring system scoring system was devised by Bardin and Lipsett, for the presence (1+)of facial hair in three regions : upper lip,chin and sideburn ,with a full beard assigned a 4 +..and photography can be a useful adjunct. Abdominal and pelvic examination for abdomino-pelvic masses. The physical examination should also include a search for cushingoid features like ; central obesity with abdominal striae.,signs of virilisation as deepening of voice,breast atrophy and clitorial enlargement. Investigations should be undertaken: a TV.U/Scan for ovarian morphology ,( PCOS ) or Ovarian tumour. Source of androgens should be identified ,very high levels of serum testosterone >6nmol/ L would be suggestive of an androgen secreting neoplasm and should initiate thorough search for underlying lesion.. DHEAS is almost exclusively secreted by adrenal gland ,so in the presence of a raised serum testosterone concentration, a normal value implies an ovarian source of testosterone., however measurement of SHBG or free serum testosterone are rarely required and do not influence the management. Elevated 17-hydroxyprogesterone indicates late onset CAH. An elevated serum LH concentration taken on day three of the cycle suggests PCOS and also LH : FSH may aid diagnosis of PCOS. On the basis of the results ,the vast majority ( 95 % of women who complain of hirsuitism have either idiopathic hirsuitism or PCOS ). A small group of patients will require further investigation which may include CT/ MRI of the adrenal gland. Urinary steroids cortisol , , overnight dexamethazone suppression test to exclude Cushing\'s syndrome. Treatment depends on the cause: Asympathetic approach must always be maintained Advice about weight loss and ideal BMI if overweight as it reduces peripheral conversion of androstendione to testosterone. The patient should be counselled that treatment must be ideally continued for a minimum 3 months and usually 6-9months,side-effects profile,contraception whilst on antiandrogenic medications. Various options are available starting from very simple methods of hair removal to medications. The motivation of the patient is important in the choice of the treatment. Mechanical methods will be shaving,it does not affect rate of hair growth.If it is unacceptable plucking and waxing could be considered .These are cheap and effective but require repeated application.Laser treatment and Electrolysis is thought to be the only permanent way and gives best cosmetic result.,however it is expensive. Medical options: the first will be a combination of cyperoterone acetate (antiandrogen) and ethinylestradiol [ Dianette ].,this offers effective contraception and corrects any menstrual abnormalities.,it is cheap ,but compliance may be problem., side effects of which include depression ,weight gain,breast tenderness, it is also associated with venous thromboembolism and must be used with caution. COCP suppressLH and ovarian androgen synthesis, increases SHBG production,and progesterone inhibits5-alpha reductase activity.If this is contraindicated, Medroxyprogesterone acetate inhibit LH production and ovarian steroidogenesis. If it is not acceptable Spironolactone ( an aldosterone antagonist with androgen receptor-blocking activity)may be used with side-effects hypotension and hyerkalaemia,BP and electrolyes should be checked .Spironolactone is not the drug of choice because of its cost .Flutamide is non-steroidal antiandrogen may be used with rare side effect,hepatotoxicity.LFTs should be checked. Finasteride is 5-alpha reductase inhibitor ,should be used with effective contraception as can emasculate male fetus.Metformin is effective in reducing hirsuitism in PCOS and is increasingly popular but unlicensed for this indication . Other less effective options like Ketoconazole and with significant hepatotoxicity. Vaniqa ( Eflornithine ) is very effective for facial hirsuitism and has recently been licensed in the UK. An important aspect of management is reassurance and encouraging the patient to have a more positive image of herself to assess the progress. |
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Posted by Vaani M. |
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| Initial assessment would include detailed history of her complaint including duration, severity and extent of hair growth. History of other symptoms like acne, hairfall, voice changes, and features of masculinisation should also be checked. Her parity, wishes for future fertility plans, delayed fertility should be checked as polycystic ovaries are commonly associated with hirsutism. Family history of similar problems should be enquired. History of drug intake as danazol, testosterone, androgenic progestogens should be taken. Examination would include general examination for extent of hairgrowth. Modified Ferriman Galliway scoring would help assess severity of hairgrowth and response to treatment. Height, weight, and BMI should be checked. Abdominal examination for ovarian or adrenal masses may be done. Genital examination for clitoromegaly, signs of virilisation should be noted. Investigations would be ultrasound abdomen to look for polycystic ovary morphology, ovarian or adrenal tumours. Serum testosterone has to be assessed. If raised above 5nmol/l other serum investigations as 17-hydroxy progesterone, and coritsol would be required to rule out late onset congenital adrenal hyperplasia, and androgenic tumours as adrenal and ovarian tumours. The woman would be very distressed and a sympathetic approach is essential. Reassurance is essential with explanation of condition, investigations and treatment plan to the woman. If a tumour is present it needs to be removed surgically. Cosmetic treatment is advised as waxing or shaving as all drug treatments would take about 6 months or more to be effective. Advise regarding weight reduction to reduce peripheral conversion of androstenedione to testosterone and increase SHBG should be given. Drug treatment would be with the anti androgenic agent cyproterone acetate alone or in combination with ethinyl oestradiol as in dianette. It is associated with side effects of fatigue, dizziness, emasculinisation of male fetus. Contraceptive use is essential with cyproterone during treatment and for three months after. Oral contraceptive pills could be used with less androgenic progestogens as laevonorgestrel or norethisterone. Spironolactone may be used as an anti androgen with aldosterone antagonist action, with watch for hypotension and hyperkalaemia. Drospirenone with aldosterone antagonist action is used in the contraceptive yasmin and may be useful. If the woman wishes fertility with polycystic ovaries ovulation induction and treatment of polycystic ovaries with metformin or ovarian diathermy may be tried although these are of less benefit in the treatment of hirsutism. GnRH analogues may be used for a short term for the treatment of hirsutism with its menopausal side effects. Finasteride a 5 alpha reductase inhibitor would be helpful.Counselling of the woman and her choice should be considered during treatment. |
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Posted by hala M. |
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| The initial assessment of this patient is by taking a detailed history of the complaint with reference to the severity, onset and duration of hirsutism and the association of androgenic symptoms such as acne, seborrhoea and oily skin. I also need to ask about any menstrual disturbances like oligomenorrhoea /amenorrhoea. Asking about any symptoms of virilisation (deepening of the voice, clitoral hypertrophy and breast atrophy) raise the suspicion of virilising tumours (adrenal and ovarian). History of ingestion of Danazol, phenotoin and anabolic drugs might cause the excess hair growth The examination would include the weight, height, BMI and blood pressure. Central obesity, hypertension and abdominal skin striae suggest the possibility of Cushing syndrome. The severity of the excess hair growth can be assessed objectively using the Ferriman Gallway scoring. Abdominal examination helps in the detection of palpable mass. Genital examination would detect clotiromegaly and pelvic masses The investigations need to be directed according the finding in the history and the examination. Hormonal assay includes the follicular phase LH/FSH, free testosterone. Androstendion, free androgen index, SHBG, DHEAS, cortisol and 17 hydroxy progesterone17 HP. Pelvic USS would confirm the presence of ovarian tumours and helps in the diagnosis of poly cystic ovary. Abdominal CT scan is necessary in confirming the presence of adrenal tumours. In the suspicion of Cushing syndrome then further test of 24 hours urine cortisol and dexamethazon suppression test need to be carried out. In case of high 17HP suggesting late onset congenital adrenal hyperplasia CAH a synactin stimulating test needs to be performed. The treatment options are surgical removal of tumours which is curative and lifesaving. Cushing treatment is dexamethazon. CAH is treated by cortisone. In case of negative findings then the hirsutism is idiopathic. Weight loss can correct the hormonal disturbance (it reduces the peripheral transfer of ASD to testosterone) and improve the skin condition but it needs a great degree of patient?s motivation. Cyproteron containing C.O.C helps in improving the skin problem ( inhibits LH , androgen and increases SHBG) but it might be refused/contraindicated or associated with the side effect of fatigue, weight gain and breast tenderness. It needs to be used more than 6 months in order to give results. Medroxy progesterone acetate is an alternative to COC but it might cause amenorrhoea. Sperinolactone is a diuretic with anti androgenic effects but it causes electrolyte imbalance and hypotension. Flutamide is a non steroidal anti androgen but it might cause hepatotoxicity. Finasteride is a 5 alpha reductase inhibitor is affective but might feminise a male foetus. All medical treatments need to be taken for over 6 months to give an effect. Physical methods are bleaching might cause skin discolouration, waxing (painful), shaving (follicullitis) and laser electrolysis (expensive and not available in NHS). |
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Posted by Aroosha B. |
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| Dear Dr paul U CHECKED ALL QUESTIONS REGARDING HIRSUTISM EXCEPT MINE MAY BE BY MISTAKE KINDLY RECONSIDER THANKS DR AROOSHA |
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