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Essay 284 - PCOS

Essay 284 - PCOS Posted by PAUL A.
A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsutism. (a) Justify your clinical assessment. [9 marks] (b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks] (c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks].
Posted by S D.
a) Detailed history about the sites of excessive hair, severity and effects on quality of life should be ascertained. Rapidly progressive hirsutism with abdominal distension suggests androgen secreting ovarian or adrenal tumour. Weight gain, acne, menstrual irregularity, subfertility suggests PCOS; Use of contraceptives such as OC pills or DMPA; Use of medications such as cimetidine, phenytoin might sugest the cause; Family history of hirsutism might suggest congenital adrenal hyperplasia.
Examination should include assessing for the severity of hirsutism using Ferriman Gallway scoring. Abdominal examination to exclude abdominopelvic masses such as ovarian or adrenal tumours. Speculum and bimanual examination to exclude clitoromegaly, assess any adnexal masses.
b) LH, FSH: If LH/FSH ratio is more than 2, might suggest PCOS.
DHEA, DHEA-S: If raised may suggest adrenal tumour as they are exclusively produced in the adrenals and MRI of adrenals is indicated.
Pelvic ultrasound to look for polycystic ovaries
Ultrasound abdomen is indicated if ovarian tumour is suspected.
17-OH Progesterone should be done if there is a family history of CAH.
C) Mild hirsutism with no psychosocial consequences do not require treatment. Psychological support should be provided as hirsutism may be associated with low self esteem. Physical methods such as bleaching, waxing can be tried but they have to done repeatedly and can cause folliculitis and discolouration. Electrolysis is effective but is expensive. Eflornithine (vaniqa) can be used for facial hirsutism but it\'s effects are transient and associated with burning and sometimes discolouration of skin. It should be explained that all medical treatments take about 6-8 months for their effects to be seen and reassurance provided. Dianette is an OC pill containing cyproterone acetate which is licensed for treatmentof hirsutism and should be stopped 3-4 months after hirsutism improves. Finasteride is a nonsteroidal antiandrogen which improves hirsutism but causes emasculation of male fetus and hence effective contraception should be used. Flutamide is an antiandrogen which also causes emasculation of male fetus. Spironolactone is not routinely used as it can cause dangerous hyperkalemia and arrythmias. Ketoconazole can be used but is limited by hepatotoxicity. Information leaflets should be provided on different treatments and woman\'s wishes should be respected.
Posted by dr neelangini G.
A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsutism. (a) Justify your clinical assessment. [9 marks] (b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks] (c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks


a) I would like to take detailed history of hirsutism, regarding sites of hirsutism (hair growth), how frequently she needs to remove excess hair, which will provide the severity of disease . Menstrual history to be taken in detail as she may be having oligomenorrhoea, amenorrhoea, irregular menstruation or menorrhagea which may be associated with polycystic ovarian disease as hirsutism is one of the presenting symptoms . History of subfertility or infertility should be taken as it is also one of the feature of PCOS. In obstetric history , history of early miscarriage in past which is common in PCOS patients. History of Diabetes , hypertension, cardiovascular disease , dyslipidemias, thyroid disorders, history of recent weight gain, any easy bruising or striae as this may be associated with cushing syndrome. Family history of hirsutism also important as it is found in late onset congenital adrenal hyperplasia & PCOS . History of drug intake e.g. Danazol for the treatment of endometriosis,phenytoin for epilepsy,phenothiazine for psychiatric illness or metoclopramide for acid peptic diseases.. Contraception intake like Depot Provera , Combined oral contraceptive pills which may rarely cause hirsutism .
On general examination her weight & height to calculate BMI as high BMI is associated with PCOS & Cushings syndrome.Also frontal balding, acne , oily skin which are associated with high androgens. Thyomegaly and galactorrhoea to be examined to rule out thyroid disease & hyperprolactinemias. Truncal obesity, moon face, buffallow hump (cushings syndrome), acanthosis nigricans(insulin resistance), should be examined. Site& severity of hair growth for grading of hirsutism( by Ferrimen Gallaway score)should be made. On systemic examination abdomen & pelvis should be examined for any abdominopelvic mass for ovarian or adrenal tumours. Any associated signs of virilisation like low voice, clitoromegaly should be looked for as these findings are associated with androgen secreting tumours.

b) Serum testosterone levels to rule out Androgen secreting tumour.Hormonal investigations like FSH & LH Reversal of FSH/LH ratio which is found in PCOS during initial 10 days of cycle. High serum prolactin levels may be associated with PCOS. Fastin Glucose to Fasting insulin ratio, more than 4.5, to confirm insulin resistance as in PCOS. Abdominal – pelvic Ultrasound , CT scan or MRI to diagnose adrenal or ovarian mass. Serum 17 hydroxy progesterone level should be estimated to rule out congenital hyperplasia.

c) Treatment options depend upon patients need like her wish & plan for pregnancy, need for contraception, history of menstrual irregularity or for cosmetic purpose. Exercise & dieting for weight reduction is helpful , Dieticians advice is helpful. She should have medical consultation for obesity , insulin resistance , associated Diabetes, hyperlipidemia & cardiovascular disease. She should be offered cosmetic treatment in the form of shaving, waxing, bleaching or LASER treatment & for this Dermatologist’s advice may be helpful. If she wishes to have pregnancy,Metformin to decrease insulin resistance along with ovulation induction by Clomiphene Citrate for 3 to 6 cycles or option of Laparoscopic ovarian drilling for improved pregnancy rates. If contraception is the need , desogestrel containing Combined OC pills may be helpful. Combined pills will also lead to regular menstruation. If Hirsutism is only an issue & she doesn’t wish to be pregnant in near future then reverse sequential regimen of Cryproterone acetate or Diane 35 containing cryproterone which is a progesterone for atleast 1 year. Spironolactone also has similar efficacy which is androgen antagonist can be given as option. If she does not respond to these medicines or having side effects or intolerance , then drugs like Finasteride, Flutamide can be given along with OCpills.,



Posted by clarice M.
a) Hirsutism can be constitutional or pathological. Certain ethnic groups are more prone to hirsutism and I would enquire if she has any 1st degree female relatives with the same problem.

Pathological hirsutism can be due to increased endogenous or exogenous androgens. Increased androgens may be relative as in the case of polycystic ovarian syndrome (PCOS) or absolute as with an androgen secreting tumour. PCOS is usually associated with oligomenorrhoea or amenorrhoea, hence I would take a detaled menstrual history. Androgen secreting tumours may have virilising effects so I would enquire if she has noticed a deepening in her voice, or clitoromegaly. She may have also noticed increasing abdominal distension, which may suggest mass. Cushing\'s disease can also cause hirsutism, hence I would enquire about the presence of increasing weight gain, sweating, palpitations, and the presence of purple striae on her abdomen.

Exogenous androgens may be unknowingly ingested or conciously taken, hence I would take a detailed drug history.

I would enquire about her plans to conceive as certain treatments for hirsutism may affect her reproductive ability or be teratogenic. I would also enquire about which treatments she has tried and their level of efficacy.

With regards to clinical examination, I would measure her height and weight to calculate her body mass index. Patients with anorexia will have an increase in hair growth but the texture is much finer. I would note the pattern of hair growth and plot it on a Ferriman Gallway chart. I would note the presence of a buffalo-hump, purple striae or moonfaced facies as this would suggest Cushing\'s syndrome. I would perform an abdomino-pelvic examination to exclude a mass.

b) As the clinical examination was normal, investigations should be directed at confirming polycystic ovarian syndrome (PCOS) as this is the most common non-constitutional cause of hirsutism.

However, the diagnosis of PCOS can be made without any further investigations if the patient has clinical signs of hyperandrogenism accompanied by oligo or amenorrhoea. If she does not have any menstrual disturbance, an ultrasound scan demonstrating at least 10 peripheral follicles will support the diagnosis as she already has signs of hyperandrogenism.

A blood test showing a raised androgen index will support the diagnosis of PCOS but can also demonstrate an androgen secreting tumour. This should be suspected if testosterone levels are greater than 7pg/ml.

c) Treatment options are conservative, medical or surgical. Conservative measures include hair removal strategies such as waxing or shaving and bleaching. Bleaching is especially useful on exposed areas of skin. Waxing and shaving are cheap and does not cause long term complications. The patient should be informed that shaving or waxing sould be done in the direction of hairgrowth to prevent the hair follicle from growing inwards and causing an abscess.

Electrolysis of the hair follicles offers a more permanent solution to hirsutism and treatment can often be completed after 3 or 4 visits. Laser treatment is also a useful permanent solution and is particularly effective in patients who are fair skinned. Both electrolysis and laser treatment can be performed on the face. Laser treatment is also faster compared to electrolysis, but still requires more than 1 visit for complete resolution.

Perhaps the most important aspect of conservative management is weight management especially if her BMI is abnormal, or if there has been a sudden weight gain (even in women with a normal BMI). The relative androgen excess will resolve as ovulation is restored. Weight loss should be gradual and the patient should be advised to attend a weight loss group as this has been shown to be more effective than attempting weight loss independently. There are serious long-term health implications for patients with PCOS, and though she presented with hirsutism, the consultation presents an ideal opportunity to discuss these. The emphasis, should again be on optimum weight management.

Medical treatment can be hormonal or non-hormonal. If contraception is required, there are 2 effective preparations available: Yasmin and Dianette. Yasmin contains ethinyl estradiol and drosperinone. Drosperinone is weakly anti-androgenic and can reduce hair growth. It is not known to significantly increase the risk of DVT. Dianette also contains ethinyl oestradiol but has cyproterone acetate instead of drosperinone. Cyproterone acetate is an anti-androgen and has other advantages such as improvement in acne and better weight control. Spironolactone is non-hormonal and is a diuretic. It has weakly anti-androgenic properties that have been shown to be effective for reducing hairgrowth as well as controlling acne.

Finasteride is a 5-alpha reductase inhibitor that is most commonly used in male patients with benign prostatic hypertrophy. It is very effective for hirsutism but must be used with a contraceptive as it will feminise a male fetus.

Finally, I would provide her with literature about PCOS and hirsutism and offer a referral to a nutritionist.
Posted by Neelam A.
a)A detailed history should be taken to know severity, distribution of excessive hair growth and impact of this on her quality of life in addition to symptoms of virilisation in form of deepening of the voice, male baldness and breast atrophy. It is important to know ethinicity as hair growth varies with racial differentiation. Any recent change in weight especially weight gain should also be asked. History of galactorrhoea and acne should also be enquired.
Medications history is important as some drugs such as testosterone, anabolic steroids and danazol use is associated with hirsutism. Use of combined pills with androgenic progesterone such as levonorgestrol and norethisterone may be the contributing factor.
Menstrual history is also important to know menstrual irregularity in form oligo-menorrhoea which points towards the diagnosis of polycystic ovarian syndrome (PCOS). Obstetric history should also be considered as ovulatory infertility may be one of the manifestation of same syndrome. Family history of PCOS should also be taken into account. Medical history of hypothyroidism and Cushing syndrome should be asked.
General examination should include body mass index (BMI) as obesity is the part of PCOS. Distribution and grading of hair should be done according to Ferriman Gallway classification. Abdominal examination should be done to feel any abdomino-pevic mass. External genitalia should be inspected to rule out any cliteromegaly. Vaginal examination should be done to rule out any pelvic mass.
b)FSH and LH should be taken day 2-5 of her cycle.
Prolactin, thyroid function test and cortisol should be checked to rule out other endocrine disorders.
17-OH progesterone should be checked to make diagnosis of late onset of congenital adrenal hyperplasia.
Testosterone, sex hormone binding globulin and dehydroepianrosterone should be checked to know site of excessive androgen production.
c)She should be informed about this diagnosis. Treatment options depend whether fertility is desired or any contraception needed and patient’s wishes.
She should be counselled that all pharmacological agents take 3-6 months before any benefit can be seen.
If she is overweight, she should be asked for lifestyle changes such as weight reduction and excercise.
Physical methods are shaving (associated with pseudofolliculitis), bleaching (skin discolouration), electrolysis and laser treatment (expensive). These can be used for initial 3-6 months before actual effects of any drugs could be seen.
Combined oral contraceptive with non-androgenic progesterone can be used if contraception is required. Dianette is the combination of ethinyl oestridiol with cyproterone acetate which is antiandrogen. It is the best drug for hirsutism. However, its use is associated with increased risk of DVT. Cyproterone can also be used to treat hirsutism but contraception should be recommended as it may emasculate a male foetus. LFT should be monitored as it is hepatotoxic. Medroxyprogesterone should be used in cases where there is contra-indication to oestrogen use.
Spironolactone is an antiandrogen and aldosterone antagonist . Blood pressure and electrolytes should be monitored. Its use is associated with hyperkalaemia and hypotension.
Flutamide is a non-steroidal antiandrogen. LFTs should be monitored.
Finasteride is a 5 alpha reductase inhibitor. Contraception is needed as it results emasculation of a male foetus.
Vanique is used locally. It stops hair growth. Recently, a controlled trial has proved its beneficial effects. Once this drug is stopped, hair starts growing again. Hair growth reaches to pretreatment level within 8 weeks. It causes skin irritation. It should be avoided in pregnancy.
Written information should be provided. Support group contact number should be given.

Posted by Farzana N.
a) Enquiry should be made about the onset and duration of hirsutism,since in cases of adrenal or ovarian tumors with hyperandrogenemia the onset is rapid .associated with acne , changes in voice,muscle bulk and changes in weight, and reduced breast size.
Detailed menstrual history is taken about LMP,menarche, regularity of cycle.Ammenorrhea and oligomenorrhea is found in cases of polycystic ovaries.Contraception history ,COCP containing androgenic progestogens ,norethisterone and levenorgestrel may be cause of her hirsutism.
Obstetric history is taken ,she may have either anovulayory infertility or recurrent abortions in case of PCOS.
Drug history of androgen intake,or drugs associated with hypertrichosis e.g phenytoin,diazoxide and cyclosporineA.Family history of hirsutism may be obtained.
Social impact of hirsurism is obtained to assess severity and decide about mode of treatment.Her needs about contraception or pregnancy should be asked.
Examination should include note of weight and height,high BMI is associated with raised androgens and hirsutism.Semi quantitative assessment of hirsutism is done by ferryman gallway method for severity and also for follow up. BP is measured and other signs of cushings syndromes are noted,such as plethora moon face and striae .Thyroid gland and breasts examined for galactorrhea.Acanthosis nigricans is looked for. Abdominal examination to exclude abdominopelvic mass.Pelvic examination is done to note any clitoral enlargement.
b)Investigations would include LHF,FSH ,prolactin and TFTs , if there is amenorrhea.
Serum testosterone and SHBG is also done.Pelvic USS for PCOS.
c) HIrsutism has a great impact on body image and psychology.Careful and sympathetic counseling forms an important part of treatment.She should be explained that it is a benign condition.The time interval required and the likelihood of successful treatment should be clearly told.
If the woman is obese, she should be advised to reduce weight.This reduces hyperandrogenemia.She should be motivated to achieve this.May need to be referred to dietician for best results.
Other treatment options are physical or pharmacological methods.Medical treatment may take upto 6-9months to be effective,during this period physical methods would be helpful
Physical methods include,Bleaching –it may lead to skin discoloration.Shaving-explain that it does not affect rate of hair growth,but may cause irritation and pseudofolliculitis.These are temporary methods and Electrolysis/laser is the only permanent way of removing hair but it is costly and requires expertise to minimize risk of scarring or infection.
Pharmacological methods include antiandrogens.such as cryproterone acetate(CPA) with estrogen is given in reverse sequential regime.Dianette containing ethynyl estradiol and CPA is effective in 50% of cases and a useful maintenance therapy.Severe cases may require higher doses of CPA .If given alone CPA can cause feminization of male fetus,so it should be combined with OCP to suppress ovulation.Yasmin containing drosperinone –a weak anti androgen,can also reduce hair growth.
Spironolactone -aldosterone antagonist also has androgen receptor blocking activity.It may cause hypotension and hypokalemia,so BP and electrolytes should be monitored.
Flutamide-non steroidal antiandrogen –require LFT monitoring as it can cause hepatotoxicity.
Finasteride – 5-alpha reductase inhibitor-effective contraception required as it can emasculate male fetus.
Topical application of Eflornithine (vaniqua) retards hair growth on face and chin.side effects include skin irritation.
Oral contraceptives are useful in suppressing FSH and LH and hence ovarian androgen production,Progestogens with antiandrogenic property such as, gestodene and and desogestrel are preferred but they are associated with higher risk of VTE.and may be contraindicated if she desires pregnancy.
The woman would need to be referred to PCOS support group.



Posted by Manoj Babu  R.
(a) Justify your clinical assessment. [9 marks]

Clinical assessment should include a detailed history and physical examination. History of rapid onset of hirsutism suggests a cause like adrenal or ovaraian tumor. Presence of other features of hyperandrogenism like any change in voice, severe acne, alopecia, is suggestive of the severity of the underling cause. Symptoms of headache, visual disturbances may suggest intracranial tumors or acromgaly. Abdominal symptoms like loss of appetite, masses, recent onset hypertension may suggest an adrenal tumor or ovarian tumor. Past history of diabetes, chronic skin problems and family history of similar problems is also important. Drug history should exclude medicines like danazole, anabolic steroids or phenothiazines as these can also cause hyperadrogenism.

Menstrual history is important to exclude amenorrhoea and oligomenorrhoea which suggests an anovulatory cause like PCOS. Obstetric history should include history of treatment for parity, infertility, and wishes regarding future childbearing.

History should assess the psychological impact of the problem on her and whther it is affecting her social life.

Clinical examination should include BMI and assessment severity and distribution of hirsutism using scoring systems like Ferrimann Gallaway scoring systems. Blood pressure should be measured as it may be elevated in Cushing’s syndrome. Look for features like baldness, breast atrophy or galactorrhoea and thyroid enlargement. Abdominal examination for any adrenal mass, local examination for ciltoromegaly and a pelvic examination to exclude ovarian masses should be done.

Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks]

The most important investigations are a serum total and free testosterone level and a 17-hydroxyprogesterone and and USG of the abdomen and pelvis. If serum testosterone level is more than 5 micromols/L one should initiate further investigations to identify source of androgens. USG will help to identify polycystic ovaries which are the most common cause. It may also reveal rare causes like an adrenal or ovarian tumor. 17-OH progesterone may be elevated in non classical CAH as it is the next common cause after PCOS. Other investigations a Glucose tolerance test diagnose insulin resistance as it common in women with PCOS.


(b) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks].

Any treatment plan should address the psychological aspect of her problem. She should be explained about cause of hirsutism the need for multiple modalities of treatment which includes life style modifications, mechanical methods for hair removal as well as the medical management. She should be told that mechanical measures will be rapid but temporary solution and medical treatment will reduce frequency of further hair removal.

Life style measures include dietary modification and moderate exercises if she obese. Even up to 5 % loss of weight will reduce the insulin resistance in obese women and improve hirsutuism and the menstrual problems.

Mechanical methods like bleaching helps to reduce the pigmentation of the hair, but it can cause changes in the skin color also. Measures like waxing and depilation is also effective. Shaving is also helpful and it does not increase the rate of hair growth, but it can cause psedo-folliculitis and some times folliculitis. Electrolysis is also effective when combined with thermolysis and it can achieve permanent hair loss after repeated treatment.

Laser is also a method of permanent hair removal but it can cause, blistering, pigmentary disturbances and scarring in minority of patients.

Medical treatment includes oral contraceptives (OCPs) which act by suppressing the ovarian androgenesis and increasing SHBG levels. Response will take 3-6 months. It helps in regularizing menstrual cycles and provides contraception. OCPs containg androgen receptor antagonist cyproterone acetone is more effective than standard pills in reducing the hirsutoism while giving good cycle control. But symptoms may reappear after 3-6 months of stopping the treatment and the womwn should be told about it. Oral or intramuscular medroxy progesterone is an alternative if does not wish to take OCPs. Medical treatment should consider her wishes regaring future pregnancy also.

Other antiandrogenic drugs can be considered, if the response to OCPs or progesterones is not adequate. Spironolactone is an oral aldosterone antagonist which has antiandrogenic properties. Serum potassium levels should be monitored while on treatment. Flutamide is a non-steroidal anti-androgen which binds to androgen receptors. It can cause hepatotoxicity and should be reserved for resistant cases. Finastride is 5-alfa reductase inhibitor. It can cause feminsation of a male fetus. Hence reliable contraception should be used along with it.
Posted by Sowmithya B.
A. Onset and its relationship to pregnancy and the rate of progression have to be assessed as rapidly progression could be due to androgen secreting tumours. Severity of the condition has to assessed. History of intake of androgenic drugs like danazole, androgenic progestrogens, and anabolic steroids has to be enquired. History of virilisation like reduction in breast size, deepening of voice, hair loss and Clitromegaly has to be assessed. History of menstrual irregularity has to be enquired. History of infertility has to be asked. Features suggestive of Cushing syndrome has to be asked. History of mass abdomen should be asked. History suggestive of abnormal sexual and gonadal development has to be asked. Family history of late onset congenital adrenal hyperplasia has to be asked. Psychological impact of the condition has to be assessed.
Clinical examination includes assessing severity of the condition by modified Ferriman Gallway scoring. General examination should be directed to look for signs of virilisation, acne, male pattern baldness, acanthosis nigricans, seborrhoea, obesity, and stigmata of Cushing syndrome. Abdominopelvic mass has to be excluded. Clitromegaly has to be assessed.
B. Free androgen index, androstienedione and dehyroepiandrosterone sulphate has to be assessed. If testosterone level is high means androgen secreting tumours has to be excluded. Abdominal CT or MRI can be done to exclude adrenal tumours. Ultrasound abdomen and pelvis to rule out poly cystic ovarian disease and ovarian tumours. I7 alpha hydroxyl progesterone can be checked after ACTH stimulation to exclude late onset congenital adrenal hyperplasia.
C. Weight reduction has to be encouraged. 10% weight loss has been associated with reduction in androgen levels and insulin resistance and hence would facilitate the treatment modality.
Physical methods like bleaching can be recommended but it is associated with skin discolouration. Shaving is associated with skin irritation and folliculitis. Electrolysis and laser therapy can be advised.
Pharmacological methods - Use of oral contraceptive pills with non androgenic progestrogen or cyproterone acetate reduces LH secretion and hence androgen production in ovary and progestrogen also inhibits 5a reductase activity. But side effects include weight gain, breast tenderness, headache, fatigue, and hepatotoxicity. It can emasculate a male fetus and so effective contraception is required.
Progesterone like medroxy progesterone acetate can be used as it reduces LH production. Again weight gain, breast tenderness, irregular bleeding, fluid retention are common side effects
Spironolactone is an effective anti androgen and aldosterone antagonist. Side effects include hypotension and hyperkalemia.
Flutamide, an anti androgen also associated with hepatotoxicity.
Finasteride, a 5a reductase inhibitor is also associated with hepatotoxicity and also can emasculate a male fetus hence contraception is required also with its usage.
Topical usage of eflornithine hydrochloride twice daily only on the face and adjacent area has shown improvement by retarding the hail growth in 4-8 weeks time. The effect lasts only for the duration of treatment. On stopping the pre-treatment condition returns. It is also associated with skin irritation. Treatment has to be avoided during pregnancy and lactation.
Patient should be thoroughly counselled about the various treatment options and improvement can be expected only after 4- 8 weeks time and photos should be used for comparison of treatment results. Patient wishes also should be taken into account.
Posted by Osman A.
a. Severity of her hirsutism should be assessed especially if it is affecting her social life. Detail menstrual history especially irregularity or amount of menstrual loss should be asked. Presence of other hyperandrogenism symptoms like acne or hoarseness of voice should be noted. Medication history like Danazole, Phenytoin or other androgenic drugs is important. Family history of adult onset of congenital adrenal hyperplasia should be explored. Previous form of treatment and responds of treatment for her hirsutism should be asked. Her wishes to conceive or her wish for contraception is important issue to decide the ideal form of treatment. Her BMI should be calculated. Blood pressure should be measured. Presence of acne and oily skin should be noted. The Ferriman and Gallwey score should be done to asses the severity of her hirsutism. Presence of pelvic mass may suggestive of ovarian androgenic secretion tumor. Presence of clitoris enlargement should be noted.
b. FSH and LH on day 2-4 of period to look for inverse ration. Level of testosterone hormone and DHEAS should be sent to differentiate the source of androgen (either from ovary or adrenal glands). 17 OH should be done (hydroxyl progestrerone level) to rule out possibility of adult onset of CAH. Transvaginal ultrasound to look for features of polycystic ovaries and presence of adnexal masses. MRI may be sent if suspicious of adrenal tumor.
c. Life style changes and reduction of bodyweight may improve hirsutism in PCOS patient. Physical method like shaving and bleaching is viable option but unable to control the growth of the hair. Local treatment like VANIQA has been shown to reduce hirsutism significantly. But it is only to be used on the face and chin. Metformine effect on hirsutism is controversial. OCP (oral contraceptive pills) can be given to reduce the LH ration, thus ovarian steridogenesis reduces. Androgenic progestogen component of OCP should be avoided. Medroxyprogesterone acetate can be given to those who are not suitable for OCP. Spironolactone is anti androgen and aldosterone antagonist, blood pressure and potassium should be monitored. Flutamide is steroidal anti androgen, it is effective but has side effect of hepatotoxcicity. Finasteride is alfa reductase inhibitor is another option, but contraception should be given. The patient should be counseled that the treatment effect can be seen after 3 to 6 months.
Posted by S M.
a) I would take a history to determine the sites of the excessive hair such as the face, chest, abdomen and back. I would enquire on the severity of the condition and the effect on her quality of life. The presence of other symptoms such as acne, a deep voice and increasing muscle mass are associated with hyperandrogenaemia which can cause hirsutism. I would take a menstrual history finding out if she had reached menarche, the date of the last menstrual period and the regularity of the cycles. This is important since irregular cycles could point towards polycystic ovaries syndrome. Her fertility wishes are important since they will influence the type of treatment. For example, if she is trying to conceive then the contraceptive pill should not be given or any teratogenic drugs such as danazol. I would enquire whether she is taking any contraceptives since you should not conceive while on some drugs used to treat hirsutism such as Danazol. A drug history is important since some drugs such as steroids can cause excessive hair growth.

I would perform a clinical examination. A body mass index (BMI) will be calculated and a BMI greater or equal to 30 is obesity, an associated factor with PCOS and hirsutism. Obesity on its own can lead to excess production of androgens. The blood pressure should be taken since hypertension can suggest Cushings Syndrome. If there is hypertension, I would look for other characteristics of Cushings Syndrome such as a moon face, striae and truncal obesity. I would look at the different sites of excessive hair and determine the degree of severity using the Ferriman Gallway scoring system. The abdomen will be examined to identify an abdominal mass. Vaginal examination will be done to identify an adnexal or pelvic mass since ovarian tumours can produce androgens and cause hyperandrogenaemia.

b)
I would do luteinizing hormone (LH) and follicular stimulating hormone (FSH). I would do serum prolactin and thyroid function tests to identify other causes of anovulation. Hirsutism can be caused by hyperandrogenemia. I would do serum testosterone, dehydroepiandrosterone(DHEA), DHEA-S and sex hormone binding globulin to confirm hyperandrogenemia. High levels of testosterone would indicate an androgen secreting tumour. A raised level of DHEA-S would suggest an adrenal source of androgen causing the hirsutism. I would do 21-OH-progesterone since this would indicate congenital adrenal hyperplasia. If there are symptoms and signs of Cushings syndrome I would do a dexamethasone suppression test to make the diagnosis.
A pelvic ultrasound scan would be done to identify polycystic ovaries, ovarian cysts or tumours. An abdominal ultrasound would be done to identify an adrenal tumour.


c) The first option is to do nothing which may be acceptable to the patient if it is not affecting her quality of life and the hirsutism is mild. Conservative treatment with counselling and weight loss. Counselling can be useful if she is psychologically affected by the excessive hair. Weight loss can be useful if she has PCOS or is obese to reduce the level of androgens. The treatment may be a mechanical method such as shaving, depilatory creams or laser to remove the excessive hair. It is of good value with the benefit of removal of hair without risk of side effects from medical treatment. The treatment may be medical. The combined oral contraceptive pill (COCP) with cyproterone acetate may be used. This is of good value. The benefit is that it treats the hirsutism as well as provides contraception. It is limited since it can be used only for 3 months, after which the excessive hair may occur again. Danazol is another drug that may be used to treat hirsutism. It is effective in stopping the excessive hair growth but limited by its side effects such as skin reactions, photosensitivity, mood changes and hair loss. It is also important to use contraception simultaneously with Danazol since it can have an emasculating effect on a male fetus. Topical eflornithine is effective but has side effects such as skin reactions and acne. If the diagnosis is congenital adrenal hyperplasia then the woman should be counselled on the diagnosis, referred to an endocrinologist and treated with glucocorticoids. Treatment may be surgical in cases where the cause of the hirsutism is an androgen-secreting tumour.

Posted by Priti T.
Dear Dr Paul,
This new question which u have posted is almost same as question no 182 titalled hirsuitism in the old questions posted.It has previously also been dealt nicely I Think.May be u are trying to check whether the candidates scrutanize your site well or not.Thanks
Dr Priti
Posted by Sandhya P.
A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsutism. (a) Justify your clinical assessment. [9 marks] (b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks] (c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks].
a)I would take a relevant history regarding the onset & rate of progression of hirsutism. The site of excess hair growth like facial , on arms &legs & any hair loss would be asked. Any change in voice ,acne or masculinising features like breast atrophy or mood changes would also be asked as rapid progression of hirsutism with masculinisation would point to an androgen secreting tumour. A detailed menstrual history including LMP ,cycle irregularity suggesting anovulation would be asked as they may point towards a presumptive diagnosis of pcos. A family history of hirsutism should also be asked as quite a few cases are familial and benign. A history of certain drugs like danazol or androgenic progesterone may also cause excess hair growth.She would be asked how this is affecting her body image and social life. Any history of mass abdomen would also be asked .Her need for contraception or pregnancy would be asked as it will affect the management.
A presumptive diagnosis may be reached on good history .
The next step would be a good clinical evaluation . Her BMI, any features of cushings syndrome like striae ,buffalo hump etc would be noted. Any features of virilisation and male pattern baldness would be looked for. A Ferriman-Gallway score of hirsutism is calculated . An abdomino pelvic exam can diagnose any mass or clitoral hypertrophy. This should be supplemented by US study. Any pigmentation or striae are noted.
b) If clinical exam is normal furthur investigations are needed to find out the possible cause.
The aim is to confirm androgen excess and identify its source.
Serum testesterone ,SHBG, Free androgen concentration, DhEA, DHEAS (which is of adrenal origin.
21 OH Progesterone levels- high may imply late onset CAH
Other hormone profile like LH, FSH PROLACTIN USG _ pelvic and abdominal for pcos, ovarian tumor,adrenal neoplasm.
Dexamethasone suppression test is done if cushings is suspected.
Karyotype may be needed in certain cases if AIS Syndrme is suspected
c) She is diagnosed with PCOS, her treatment options would depend on her wishes for contraception and the degree it is affecting her social life.
In mild cases she can be reassured and advised removal of unwanted hair by shaving,waxing or creams all of which are temporary, electrolysis is permanent removal but is costly and can be used only for small areas .Bleaching can help cover facial hair to some extent.. Weight loss should be encouraged as it decreases peripheral conversion of androstenedione to testesterone. It also helps in cycle control.
Pharmacological methods--
1) OCP- supresses LH production& ovarian testesterone production,increases SHBG & lowers free androgen index. It is ideal in women desiring contraception but pills with androgenic progesterones should be avoided.
Newer pills with cyproterone acetate which is antiandrogen is effective but additional contraception is advisable as it can demasculinise a male fetus.Side effects include breast tenderness, fatigue weight gain hepatotoxicity.
2)In patients who cant take OCP, Medroxyprogesterone acetate may be given with effective LH suppression.
3)Spironolactone -aldosterone antagonist& anti androgenmay be given. BP&serum electrolytes should be monitored for hypotension &hyperkalemia.
4)Flutamide-new drug is nonsteroidal antiandrogen- LFT should be monitored due to rare hepatotoxicity.
5)Finasteride is an effective 5alpha reductase inhibitor can decrease furthur progression of hirsutism but additional contraception should be ginven due to risk of demasculinisation of male fetus.
6) Eflornithine skin ornithine decarboxylase is under trial improves acne and facial hair but contraindicated in pregnant women. Risk of skin irritation should be explained

the overall management requires a kind and sympathetic approach . She should be clearly told about the expected improvements and tha she will need to remove unwanted hair till treatment becomes effective. pre & post treatment photographs will help her to notice the change. Good support from family should also be encouraged to decrease her mental anguish.
Posted by Mark D.
Mark d.
a)
I will take a detail history of associated symptoms like weight gain, lethargy,depression, and inactivenes. Such symptoms point towards hypothyroidism. Galactorrea ,headache are suggestive of prolactenemia. Weight gain, rising bp, and striae indicate cushings symdrome.i will take detail menstrual history –regularity,flow,LMP. Associated menstrual disturbances like oligomenorrea,irregular menses are suggestive of polycystic ovaries.family history -particularly history of conginital adrenal hyperplasia in any siblings should be asked .i will check if she has taken any tratements for this in past and review their outcomes.i will asses the impact of hairgrowth on her quality of social and personal life.i will enquire if she is on any medications like antihypertensives,minoxidil, steriods,danazol which may cause hirsuitism. I will review her current method of contraception and her wishes for future fertility.
I will perfork a general examination to note weight, BMI,any truncal striae,thyriodswelling and galactorrea.
I will check the hair growth pattern and texture over 9 sites and calculate the ferriman gallway score. This will asses severity of problem and be useful to moniter effectiveness of treatments.
I will do a per abdominal and bimanual pelvic examination to rule out any adnexal masses like ovarian tumors.adrenal tumors are very small and cannot be diagnosed clinically.
b)i will initially ask for an pelvic ultrasound scan and serum testosterone (sr T) levels. Pelvic scan (TVS) will asses ovarian morphology.10 or more folicles of size 2-8 mm arranged in a peripheral fashion and increased stromal volume is diagnostic of polycystic ovarian disease.
Sr T less than 5 nmol/ml indicate idiopathic hirsuitism or due to polycystic ovaries. Sr T of more than 5 nmol/ml need further investigations to rule out ovarian or adrenal androgen secreting tumors , CAH or cushings disease. It includes Sr DHEAS, 17 OH progeterone levels.these should be done in liason with endocrinologist. Raised Sr dheas indicate adrenal tumor and imaging like CT or MRI is needed to locate the tumor. Raised 17OH P more than 20n mol/ml indicate adult onset CAH .lower levels may be due to cushings or CAH with need to be confirmed with synacthen test for CAH and dexamethasone suppersion tests for cushings.
Sr LH FSH are not recommended with normal menstrual cycles and Sr TSH only if symptoms suggestive of hypothyriodism.
c)
First option is COC pills .They are cheap easily available and effective in 60-70% cases in 6 months .They are contraindicated in presence of conditions like thrombosis,focal migrane and active liver disease.They have side effects like mastalgia,bloating,mood disturbances and nausea. Dianette is a coc pill containing cyproterone acetate as progesterone component is specifically used for it. If gallway score is more than 10 then additional cyproterone acetate can be added to dianette in reverse sequential regimen for better response ,however the side effects are more. Spironolactone can be given with COC pill in low doses ,is more effective than Coc pill alone but is not licenced in UK for this indication.other progesterones like medroxyprogesterone acetate, depot or oral can be used but have not proves to be better than COC pill.Laproscopic ovarain drilling to reduce androgenic milleu is effective for 3-4 months and not recommended for hirsuitism without infertlity. More advanced treatments withn Finesteride and Flutamide are given by specialists under close supervision and monitering of liver function tests as they have significant side effects. Reliable contraception needs to be used with them.
Cosmetic methods like epilation,waxing,threading can be continued although they may interfere with monitering the treatment response.
if the patient wants to conceive then laproscpic drilling or clomiphene or gonadotropins can be given for ovulation induction.
Posted by H H.
The aim of clinical assessment in this case of progressive hirsuitism over a short time is to exclude sinister causes as androgenic tumours or congenital adrenal hyperplasia(CAH) to allow early treatment,in addition to diagnosing other causes of hirsuitism.
I will ask patient of sites of hair growth and effect on her quality of life .I will ask of her menstrual period LMP ,regularity and if there are periods of amenorrhea and if she is using contraception and which type as some hormonal contraceptives have androgenic properties.I will ask of her fertility wishes and if there is difficulty in conceiving.I will go through, her family history of similar condition (CAH) , any gain in weight or increase in her abdomen size(tumours).Will ask of symptoms of hypothyroidism(cold intolerance ad weight gain) and of any previous treatment of her hirsuitism.
On examination , will do BP , BMI ( increased in PCOD and Cushing), look for abdominal stria and distribution of hair detecting its severity using the Ferriman Gallway score(eleven areas on body with a score 1 to 4 for each), examin abdomen for abdominal masses , do local examination detecting clitromegaly.

Will do serum testosterone which would be markedly elevated in androgenic tumours and CAH.Measuring dehydroepiandrosterone acetate which is elevated in adrenal tumours. Measure 17 alpha hydroxy progesterone (CAH). LH may be elevated in PCOD. TSH elevated in hypothyroidism .Do ultrasound to detect polycystic ovaries and tumours. CT scan for androgenic tumours.Karyotype in case of clitromegaly.

I wil tell her that treatment can take time to have an effect and if she is worried of cosmotic appearance specially on face , she can use methods like shaving,waxing,epilation, electrolysis or laser in special centers. Combined pills can be used to increase serum hormne binding globulins which bind to androgens and lower its level in blood, and will regulate period if irregular. Cyproterne acetate will bind to androgen receptors and used as pills dianette can regulate cycles also.Flutamide bind to androgen receptors lowering androgen level and useful in treatment . Finasteride inhibit 5 alpha reductase enzyme and prevent testosterone changing to the active dihydrotestosterone.Topical eflornithine cream (vaiqa) can be used locally to suppress new hair formation
Posted by J P.
a.Hirsutism onset and the speed of progression should be enquired.The social impact should be sensitively enquired.Site of hirsutism whether restricted to face or all over should be enquired as this influences treatment.Any symptoms of virilisation like deepening of voice,breast atrophy,male type scalp baldness should be enquired.Detailed menstrual history including its regularity, any episodes of amenorrhea and last menstrual period should be asked. Any mode of contraception if used and contraindications to contraceptive pills if any present will be enquired.Her fertility wishes will be enquired. since treatment medications may be teratogenic.Any history of recent increase in weight,deepening of voice,increased pigmentation suggestive of cushings syndrome will be enquired.Any swelling in abdomen suggestive of ovarian or adrenal tumour will be asked.Any androgenic drugs intake and the treatment history for hirsutism will be enquired.Family history of hirsutism may suggest late onset adrenal hyperplasia.
General examination to be done to look for BP,BMI which if increased along with abdominal striae is suggestive of cushings syndrome. Hirsutism is graded by Ferriman –Gallway Abdominal and pelvic examination to be done for detection of abdomino pelvic mass.[ovarian or adrenal].Examination of external genitalia for clitoromegaly to be done.
b.Investigations include to find out the source of hyperandrogenism.Serum testosterone ,SHBG,FAI should be done.Teststerone more than 4.8 nmol/l is suggestive of ovarian or adrenal mass,in case CT or MRI is indicated.DHEAS elevated is of adrenal origin. 17 hydroxy progesterone elevation is indicative of late onset adrenal hyperplasia.USS will be done to look of polycystic ovaries.
c.Treatment options depend on her fertility wishes.Non pharmacological methods like 10 % weight reduction in obese PCOS may decrease peripheral conversion of androstenedione to androgens.Cosmetic methods like waxing,bleeching depilation may be tried but this is temporary and may cause irritation and folliculitis.
Medications like oral contraceptive pills [using progestogens of non androgenic ]can be used,which decrease LH and raise SHBG, thusdecreasing free androgen levels.Cyproterone acetate which is anti androgenic can be used but should be combined with ethinyl estradiol as this emasculate male fetus.Flutamide and finasteride can be tried but the possibility of emasculation of male fetus if conception occurs should be borne in mind,hence adequate contracetion used.Spiranolactone can also be used for hirsutism but its use is limted by dangerous side effects like hyperkalemia and arrythmias.All medications may have a latent period of 3-6 months before its full effects occur which should be explained to the patient.For facial hair topical eflornithine can be used but hair may regrow once treatment is stopped.Laproscopic ovarian drilling may be used in PCOS since this normalizes LH,SHBG in more than 60 % of women.But this has the inherent risks due to laproscopy and the long term effect on ovarian function is not known.Written information will be given and patient wishes respected.







Posted by Arun J.
a -Hirsuitism is a distressing situation and is associated with considerable patient anxiety.So patient needs sympathetic approach. So i would first ask her history( like its impact on quality of life and her social status,regularity of menses and LMPas hyperandrogenic states can be associated with menstrual irregularities,previous conceptions and its outcome,or if she has subfertility,previous treatment history and its outcome,history of drug intake like androgenic steroids/ progestogens, danazol, phynetoin,etc,family history of similar problems in sisters as PCOS has genetic inheritance,any change in voice as it is a sign of virilisation,weight gain as it occurs in PCOS and cushings disease or syndrome,constipation and cold intolerance to R/O hypothyroidism,and breast milk secretion) and then examine her.I would check her B.Pas it may be raised in cushings , look for the pattern of hair growth amd map it (Ferriman galleway score),look for breast milk secretion(20% PCOS patients have it) ,breast atrophy, clitoromegaly, labial fusion as they are signs of defeminisation /virilisation,hyperpimentation in flexural areas(acanthosis nigricans-a sign of insulin resistence),and also look for striae in skin (in cushings ). I would also look for any abdominal masses and do bimanual pelvic examination to find out ovarian masses.

b -I would do srerum free testosterone( though it may show considerable variation),DHEA, DHEAS,SHBG,17 alpha hydroxy progesterone and ultrasound pelvis to look for ovarian morphology,and CT abdomen and pelvis to rule out adrenal masses.
c- I would explain, that her hair growth is due to PCOS, reassure her and give her additional psychotherapy as hirsuitism is associated with considerable anxiety.Treatment options are either physical and pharmacological methods.Epilation, depilatory
creams ,waxing and shaving offer good cosmetic results,has no side effects and does not increase hair growth.Electrolysis is a permanent method except that it is costly and may cause scarring.
Combined oral contraceptive pills increase SHBG,and inhibit gonadotropins and help decrease hair growth and it has added benefit as a contraceptive.Dianette is very effective in treating hirsuitism but needs additional contraception as it may cause feminisation of a male fetus, and it cant be used for long . Spironolactone ,flutamide, and finasteride are useful but needs electrolyte monitoring ,LFT monitoring and additional contraceptive use respectively when they are used.Eflornithine hydrochloride can be applied topically over face and chin, but it is not safe to use if the patient becomes pregnant.
Posted by S M.
SM reply.
a)
A thorough history of onset and distribution of hirsutism must be elicited .A rapid onset is seen with ovarian/adrenal tumors secreting androgens. A slow onset is associated with idiopathic hirsutism and polycystic ovarian syndrome (PCOS). Family history of hirsutism must be asked for which may indicate congenital adrenal hyperplasia .Any increase in weight gain must be looked for ,which is commomnly seen with PCOS and cushing’s syndrome . History of drug intake like danazol , steroids must be asked for as they cause hirsutism . I will ask about her menarche , LMP and menstrual cycle regularity as PCOS is associated with oligomenorrhoea. I will ascertain her plans for pregnancy and whether she is using any contraception. Associated alopecia , breast atrophy and change in voice indicates high androgen levels from ovarian /adrenal source.Effects on quality of life must be enquired into.
On examination , I will check for BMI as obesity leads to excessive peripheral conversion of androstenedione to testosterone. I will look for buffalo hump , purple sriae , moon- face indicative of cushing’s syndrome . I will check for thyroid swelling as hypothyroidism is associated with hirsutism.Breasts will be checked for atrophy/ galactorrhoea .Abdomen will be examined for any mass suggestive of adrenal/ovarian tumour . Truncal obesity, acanthosis nigicans ,alopecia are usually associated with PCOS .
Vaginal examination will be carried out to look for pelvic tumours .

b)
The investigations I would like to carry out are LH , FSH , TSH, Prolactin, DHEAS ,testosterone, 17 hydroxy progesterone ,Blood sugar fasting and post prandial and pelvic ultrasound for PCOS / ovarian tumours.

c)
If hirsutism is mild, reassurance alone may suffice. Counselling will help develop self-esteem. Multi-disciplinary team including the dietician , dermatologist and psychologist may be essential.
Weight reduction prevents excessive conversion of androstenidione to testosterone. Physical methods like shaving, bleaching , waxing can be tried.Side-effects are skin irritation and pseudo-folliculitis.
Dermatological referral is required for laser or electrolysis treatment. If contraception is required , combined oral contraceptive ( COC) pills can be used for contraception and hirsutism . It increases SHBG and reduces LH levels . Gestodene has anti-androgenic activity.Medroxy progesterone acetate contraception also helps in reducing hirsutism . Cyproterene acetate has anti-androgenic properties , must be used with other contraception to avoid feminization of a male fetus . Spirinolactone has anti-androgenic activity but can cause hypotension and hyperkalemia . Eflornithine hydrochloride is effective when used locally .Side-effect of adverse skin reaction must be explained. Oral Finastride is a 5 alpha redutase inhibitor which is effective too .Additional contraception must be ensured .Flutamide , anti androgen, can be tried. Adverse reaction of hepatotoxicity must be borne in mind. Written information and address
of support groups must be offered.

Posted by Manoj M.
A) A rapid onset of hirsutism in the last 3-6 months may suggest underlying androgen producing tumour.
A family history of hirsutism may suggest familial conditions with hirsutism like non classical adrenal hyperplasia / polycystic ovarian syndrome(PCOS)
Additonal history of headache, visual disturbance, galactorrhoea may suggest prolactinoma.
Her fertility wishes and contraceptive choices should be ascertained as will help in her treatment options.
Her menstrual history should be obtained as changes in pattern may suggest underlying ovarian pathology.
History of any treatment done so far may suggest further treatment option for her.
History of quality of life affected may necissitate need for psychological input.
Examination including pattern of hirsutism and external visibility of hair may suggest severity of condition.
Round facies , buffalo hump, central obesity, proximal weakness of muscles may suggest cushings syndrome.
Pulse and BP assessment as hypertension may suggest alternative treatment options.
Body mass index(BMI) assessment as raised BMI is associated with PCOS related hirsutism.

B) A high testosterone level may suggest PCOS but a very high level may suggest underlying subclinical androgen tumors.
A free androgen index should be obtained with levels of sex hormone binding globulin(SHBG) and testosterone levels to suggest PCOS.
In absence of other clinical signs a baseline screening of thyroid function and prolactin levels should be done to exclude subclinical thyroid disease and prolactinomas.
pelvic ultrasound scan for ovarian morphology may suggest polycystic ovaries and also to exclude ovarian tumors.
CT scan may be necessary to exclude adrenal tumors but this is unlikely without clinical signs.

C) Supportive treatment for PCOS with obesity may need dietician for weight loss and exercise will help reduce hyperandrogen state and hirsutism.
Pharmacological treatment with combined oral contraceptive pill is helpful for hirsutism, this will also depend on her contraceptive choice and fertility wishes.
Combined pill with low androgenic / anti androgenic effects progestins is desirable for treatment of hirsutism. preparations which include cyproterone acetate and drospirenone act againt ovarian androgen production and helpful for treatment of hirsutism.
If oestrogen is contraindicated progestins like medoxyprogesterone acetate as depot injections or oral tablets is helpful in decreasing androgen levels.
High dose oestrogen preparation is also helpful in increasing SHBG levels and treating hirsutism but should be used with progestin to prevent proliferative effect of oestrogens.
Gonadotropin releasing hormone agonist is not commonly used to treat hirsutism unless associated with hyperinsulinemia.
Anti androgens like spironolactone, finasteride and flutamide is used to treat hirsutism but will need adequate contraceptive measures as associated with fetal adverse effects.
Eflornithine cream is used as local application to reduce facial hair in the treatment of hirsutism.
Non pharmacological treatment with mechanical removal of hair and laser treatment is used but need repeated treatments and may not be compliant with cost issues.
She may need psychological support and she as she may need long term treatment for hirsutism.
She should be provided with written information.
Posted by Priti T.
prt

a]A full detailed history is taken regarding increasing facial hair and the speed of progression.Aslow progression indicates PCOS or late onset congenital adrenal hyperplasia[CAH].A fast progression suggests ovarian/adrenal tumour secreting androgens.Other Hx suggestive of virilisation is taken.Hx of amenorroea or oligomenorroea and its duration is to be noted.Hx of breast atrophy and voice change suggests associated virilisation.Obstetric history or the Hx of infertility and the desire for further children should be elicited.Hx of drug intake like danazol,anabolic steroids is taken as they can cause hirsuitism.The effect of hirsuitism on the quality of life of patient is important.Any previos hx of thyroid dysfunction/hyperprolactinemia can be accompanied by increased adrenal androgens.Family hx of hirsuitism or CAH may be positive.
Detailed clinical examination includes BMI for obesity,and B.P. with pletora ,moon facies to rule out Cushing\'s Syndrome.Severity of hirsuitism is assessed by Ferriman and Gallway semi quantitative scale.Photography can be a useful adjunct.Abdominal and pelvic examination is done to rule out masses and vulval examination is done to detect clitoromegaly.

b]Serum Testosterone and SHBG are done for detecting free androgen index.Testosterone levels more tham 6nmol/l suggests androgen secreting tumour.DHEA and DHEAS levels are done.Raised DHEAS levels suggests adrenal cause of androgens,while normal level implies ovarian source.Elevated 17OH Progesterone levels suggests late onset CAH.
Serum TSH/Prolactin are done especially if the patient is amenorroeic.Serum LH,FSH done on 3rd day which are elevated or altered diagnose PCOS.TVS can be done to confirm PCOS additionallly.Urinary cortisol and overnight dexamethasone suppression tests are done to exclude Cushing\'s syndrome.According to the results of these investigation a small group may require CT/MRI of adrenal gland to rule out adrenal tumour.In case of excessive virilisation Karotype may be done.

c]MDT approach shoul be taken for the treatment especially if ther is associated virilisation.95% of the cases of hirsuitism are due to idiopathic reasons or PCOS.Mild cases need only ressurance and the mechanical methods.Topical Vaniqua[eflornithine]is licensed in U.K for facial applications.Various mechanical methods used for hirsuitism are cheap and effective but require repeated application.Laser treatmaent and electrolysis are expensive but give good cosmetic result.
Medical treatment for hirsuitism includes COCP prescription.The first choice is DIANETTE ,a combination of cyproterone 2mg and ethinyl estradiol.It should be used for a period of 6-9months to be effective.The other good choice is Yasmin which contains drospirenone having one third the potency of cyperoterone acetate.COCPs are cost effective and offer contraception and menstrual regulation.Also they suppress LH and ovarian androgen synthesis and increase SHBG.Cyproterone acetate is limited by the adverse effects like depression,weight gain,breast tenderness and VTE.
Medroxy Progesterone Acetate can be used if patient wants long acting contraception.Other antiandrogens like Flutamide can be used.It is hepatotoxic and hence LFT should be checked.Finasteride is 5alpha reductase inhibitor and should be used with effective contraception as it can emasculate the male foetus.
Metformin can reduce the hirsuitism associated with PCOS,but it is not licensed for it.Informed consent can be taken from the patient and properly documented for its use.
Patient should be reassured and be given the name and contact no of support group like VERITY [pcos].She should be encouraged to have positive body image of herself.

Posted by shree D.
sttas

A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsutism. (a) Justify your clinical assessment. [9 marks]
I would measure this patient\'s BMI, as this is often elevated in patients with a diagnosis of PCOS. I would check blood pressure, as she may have an adrenal tumour leading to elevated BP. I would examine the distribution and hair type (course, fine, location of male hair distribution-eg. facial hair). I would also loof for acne, often seen in those with PCOS. I would perform an abdominal examination to exclude abdominal or pelvic masses. A vaginal examination must be performed to exclude adnexal masses. I would also look at the patietn\'s ethnicity.

In the history, I would exclude medications which may lead to hirsutism. I would look for a history of headaches or change in vision, as this may indicate a pituitary tumour. I would also ask about weight gain, change in skin and voice.
(b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks]
I would request a hormonal profile, including FSH, LH (day 2-6 in cycle), Testosterone and Sex hormone binding globulin. I would arrange a pelvic ultrasound and abdominal CT

(c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks].
Cosmetic treatments (eg. waxing) are easily accessible over the counter, but are not permanent and may be time consuming.

Laser treatment may be effective but is costly and rarely available on the NHS.

Vaniqua is a topical treatment which can be prescribed. It is effective, but only for the duration of use.

Dianette is an androgenic contraceptive pill which can be used to treat hirsutism. However, it requires patient compliance and may have unpleasant side effects such as breast tenderness, irregular bleeding. Again, it is only effective for the duration of use

Spironolactone is a very effective treatment, but has an anti-diuretic effect.
Posted by Ashwinibilagi25 B.
A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsuitism. (. [9 marks]]
a) Justify your clinical assessment

I would like to take a detailed history including the onset and the progression of hirsuitism.
Affect on quality of life has to be assessed in a sensitive matter any negative body image should be explored. How does patient cope with it? Does it have any impact on her social, personal and professional life?
Was the problem there since teens? Or is it a new problem? Is it progressively getting worse? Development female secondary characteristics should be confirmed and previous medical problems would be elicited.
Any abdominal mass suggests androgen secreting tumour
History of oligomenorrhea / secondary amenorrhea indicates polycystic ovarian syndrome.
Recent history of increase in weight, change of voice is important in light of any new medications like danazol, steroids (Cushing’s disease) or other androgens like testosterone.
Body image issues like history of anorexia nervosa, bulimia nervosa recent history of weight loss might be useful to rule out the secondary hair growth secondary to mal nourishment.
Plans of conception should be noted as it might have an impact on the management of the patients
Any history of migraine, active liver disease, and thromboembolism should be noted along with any drug allergies.

(b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks

I would like to perform hormone profile including estrogens progesterone, testosterone and androgens also FSH & LH .

Ultrasound pelvis will be useful to rule out abdominal mass/polycystic ovarian syndrome

c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsuitism [7 marks].

Her treatment options will depend on the affect on the quality of life and plans of getting pregnant in the near future.

I f hirsuitism is not affecting her quality of life than conservatory management can be ensued.

If patient is keen on conceiving in near future, then cosmetic methods like shaving and waxing should be advised permanent solutions like electrolysis can be advised.
If patient is not planning to get pregnant in near future then, combined oral contraceptive pills along with low dose cyproterone acetate could be prescribed ,or cocs on their own can be prescribed. Vaniqua has also shown to be of benefit but is temperorary.

Othe less used medications are spironolactone,flutamide,finestride are less popular due to their notorious side effects profile

Posted by A H.
In the history I will enquire about the rate of hair growth the frequency of hair removal. This can give an idea of the probable cause. Benign pathology, for example, polycystic ovary syndrome (PCOS) will cause a lesser degree of hirsutism than androgen producing tumours or exogenous androgens.Also this can be used as a baseline to monitor response to treatment.
A history of oligomenorrhoea will be elicited as this is a feature of PCOS. There is usually a history of recent weight gain. Hirsute women with PCOS are often obese
A drug history will be taken to exclude an iatrogenic cause, for example the use of androgenic progestogens or danazol.
features of virilisation will be asked. These include increased muscle mass. deepening of the voice decreased libido and breast atrophy.
On examination, I will measure blood pressure because hypertension is found in patients with Cushing\'s syndrome or late onset congenital adrenal hyperplasia.
Body habitus will be examined for a cushingoig truncal obesity or male muscle distribution fopund in hyperandrogenism.
Weight and height will be measured and body mass index (BMI) calculated for a baseline to monitor treatment.
The breasts will be examined for atrophy which can be found in hyperandrogenism or galactorrhoea foun in a small percentage of PCOS patients.
An abdominal and pelvic exam will be done to exclude an ovarian mass and cliteromegaly.

b) I wll do serum testosterone levels, and a pelvic ultrasound scan to identify an ovarian mass or polycystic ovaries Fasting serum insulin and an oral glucose tolerance test will also be done.

c)Treatment of hirsutism involves counselling the patient about the diagnosis and modes of treatment. It will be emphasised that althouh pharmacotreatment, if desired will cause a fall in serum testosterone levels, but decreasd hair growth will only be evident after three to six months.
Shaving is effective and cheap but can cause irritation or pseudofolliculitis. Bleaching may lead to skin discolourationbut can be used in milder hirsutism.
Permanent hair removal can be achieved by electrolysis or laser treatment. However these are epensiveand need well triaed personnel to reduce chance of scarring or shock in the case of electrolysis.
Pharmcological methds include ovarian suppressin using the combined oral contraceptive pill(COCP). COCPs with androgenic progectogens should be avoided as these mayworsen hirsutism. Dianette, containing the anti-androgen cyproterone acetate may be more suitable. Cyproterone acetate may be used alone but reliable contraception must be used as it can emasculate a male foetus.
If COCP is contraindicated, medroxyprogesterone can be used. Topical treatment with eflormiththine hydrochloride (Vaniqa) is effective for use on the face and chin. Improvement is evident by eight weeks after start of use and is maintained throughout treatment but hair growth is same as pretreatment, by eight weeks after stopping. Skin irritation is the major side-effect.
Other systemic therapy include the anti-androgen flutamide, which can cause hepatotoxicity; spironolactone, but can cause hyperkalaemia and hypertension or the finasteride.
Posted by Ron C.
A.
History taking should focus on cycle problems, especially oligo-amenorrhea being common in PCOS. Any changes in weight related to the complaints or cycle. I will ask regarding contraception, current method, recent changes, and use of COCP (as it would reduce hirsutism and risk for endometrial hyperplasia). I’ll enquire regarding obstetric history and whether keen to conceive as many treatments will interefer with the latter. I’ll ask for changes in voice and baldness as well as family history for ovarian tumours, to assess whether there may be an androgen producing tumour (very rare).
I’ll assess weight and height to calculate BMI and assess whether obese to determine likelihood of PCOS. Blood pressure as it is often found together with PCOS. I’ll examine breasts for atrophy and abdominal for palpable mass (ie androgen producing tumour). I’ll look at distribution of the hair pattern to see whether it is typically male. On inspection of the vulva I look for enlarged clitoris suggestive of hormone producing tumour (or late onset AGS).
I will also ask her about any medication that may affect hairgrowth.

B.
Blood investigations include testosterone levels (although readings variable), DHEA-S, Prolactine, TSH & fT4, FSH & LH and Renal function test with electrolytes. An abdominal or – if difficult to assess, transvaginal ultrasound to assess the ovaries is needed.

C.
Treatment of the PCOS will mostly also resolve the problems of hirsutism.
Weight loss combined with exercise in those obese must be encouraged, as it will restore cycle and hormonal balance as well as reduce overweight related health risks. Motivation is difficult though and it takes time and good compliance. Metformine 500 mg 3 times daily can be used as adjunct, will often favourably improve lipid profile, but can often cause gastro-intestinal complaints.
COCP will regulate cycle, increase SHBG and thus reduce circulating testosterone, but would be problematic if she is keen to conceive. Dianette as contraceptive has the additional benefit of the anti-androgenic action of the crypteronacetate component. Anti-androgens are all problematic if she is keen to conceive as they affect the fetus (teratogenic, e-masculanisation). Symptomatic treatment would be in the form of bleaching, epilation (with or without small electric current), foam for hair removal, or even shaving.
Posted by PAUL A.
a) Detailed history about the sites of excessive hair, severity and effects on quality of life (1) should be ascertained. Rapidly progressive hirsutism with abdominal distension suggests androgen secreting ovarian or adrenal tumour. Weight gain, acne, menstrual irregularity (1) , subfertility suggests PCOS; Use of contraceptives such as OC pills or DMPA how is this useful? ; Use of medications such as cimetidine, phenytoin might sugest the cause does phenytoin cause hirsutism? Causes hypertrichosis ; Family history of hirsutism might suggest congenital adrenal hyperplasia (1) .
Examination should include assessing for the severity of hirsutism using Ferriman Gallway scoring (1) . Abdominal examination to exclude abdominopelvic masses such as ovarian or adrenal tumours. Speculum and bimanual examination to exclude clitoromegaly, assess any adnexal masses (1) ? BMI, BP, features of Cushing’s .
b) LH, FSH: If LH/FSH ratio is more than 2, might suggest PCOS not criterion for diagnosis .
DHEA, DHEA-S incorrect – DHEA-S is almost exclusively adrenal but the ovaries produce DHEA : If raised may suggest adrenal tumour as they are exclusively produced in the adrenals and MRI of adrenals is indicated.
Pelvic ultrasound to look for polycystic ovaries
Ultrasound abdomen is indicated if ovarian tumour is suspected (1) .
17-OH Progesterone should be done if there is a family history of CAH should be done even if family Hx is negative .
C) Mild hirsutism with no psychosocial consequences do not require treatment. Psychological support should be provided as hirsutism may be associated with low self esteem (1) . Physical methods such as bleaching, waxing can be tried but they have to done repeatedly and can cause folliculitis and discolouration. Electrolysis is effective but is expensive (1) . Eflornithine (vaniqa) (1) can be used for facial hirsutism but it\'s effects are transient and associated with burning and sometimes discolouration of skin. It should be explained that all medical treatments take about 6-8 months for their effects to be seen and reassurance provided. Dianette is an OC pill containing cyproterone acetate (1) can you use any other COCP?which is licensed for treatmentof hirsutism and should be stopped 3-4 months after hirsutism improves. Finasteride is a nonsteroidal antiandrogen 5-alpha-reductase inhibitor which improves hirsutism but causes emasculation of male fetus and hence effective contraception should be used. Flutamide is an antiandrogen which also causes emasculation of male fetus. Spironolactone is not routinely used as it can cause dangerous hyperkalemia and arrythmias. Ketoconazole can be used but is limited by hepatotoxicity (1) . Information leaflets should be provided on different treatments and woman\'s wishes should be respected.
Posted by PAUL A.
A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsutism. (a) Justify your clinical assessment. [9 marks] (b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks] (c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks


a) I would like to take detailed history of hirsutism, regarding sites of hirsutism (hair growth), how frequently she needs to remove excess hair, which will provide the severity of disease not a measure of severity – it may be a measure of impact on the woman . Menstrual history (1) to be taken in detail as she may be having oligomenorrhoea, amenorrhoea, irregular menstruation or menorrhagea which may be associated with polycystic ovarian disease as hirsutism is one of the presenting symptoms . History of subfertility or infertility should be taken as it is also one of the feature of PCOS. In obstetric history , history of early miscarriage in past which is common in PCOS patients. History of Diabetes , hypertension, cardiovascular disease , dyslipidemias, thyroid disorders, history of recent weight gain, any easy bruising or striae as this may be associated with cushing syndrome. Family history of hirsutism also important as it is found in late onset congenital adrenal hyperplasia (1) & PCOS . History of drug intake e.g. Danazol for the treatment of endometriosis, phenytoin causes hypertrichosis for epilepsy, phenothiazine for psychiatric illness or metoclopramide for acid peptic diseases do these cause hirsutism? Do you use metoclopramide for peptic ulcer disease? .. Contraception intake like Depot Provera , Combined oral contraceptive pills which may rarely cause hirsutism ?? recognised cause?? .
On general examination her weight & height to calculate BMI as high BMI is associated with PCOS & Cushings syndrome.Also frontal balding, acne , oily skin which are associated with high androgens . Thyomegaly and galactorrhoea to be examined to rule out thyroid disease & hyperprolactinemias. Truncal obesity, moon face, buffallow hump (cushings syndrome), acanthosis nigricans(insulin resistance), should be examined (1) . Site& severity of hair growth for grading of hirsutism( by Ferrimen Gallaway score (1) )should be made. On systemic examination abdomen & pelvis should be examined for any abdominopelvic mass for ovarian or adrenal tumours. Any associated signs of virilisation like low voice, clitoromegaly should be looked for as these findings are associated with androgen secreting tumours (1) .

b) Serum testosterone levels to rule out Androgen secreting tumour will you measure any other androgens? DHEA, DHEA-S; SHBG .Hormonal investigations like FSH & LH Reversal of FSH/LH ratio not diagnostic criterion which is found in PCOS during initial 10 days of cycle. High serum prolactin levels may be associated with PCOS. Fastin Glucose to Fasting insulin ratio, more than 4.5, to confirm insulin resistance as in PCOS. Abdominal – pelvic Ultrasound , CT scan or MRI to diagnose adrenal or ovarian mass ? polycystic ovaries . Serum 17 hydroxy progesterone level should be estimated to rule out congenital hyperplasia (1) .

c) Treatment options depend upon patients need like her wish & plan for pregnancy, need for contraception, history of menstrual irregularity or for cosmetic purpose. Exercise & dieting for weight reduction is helpful , Dieticians advice is helpful. She should have medical consultation for obesity , insulin resistance , associated Diabetes, hyperlipidemia & cardiovascular disease. She should be offered cosmetic treatment in the form of shaving might make hair coarser and worsen the situation , waxing, bleaching or LASER treatment & for this Dermatologist’s advice may be helpful (1) . If she wishes to have pregnancy did the question say anything about pregnancy? ,Metformin to decrease insulin resistance along with ovulation induction by Clomiphene Citrate for 3 to 6 cycles or option of Laparoscopic ovarian drilling for improved pregnancy rates. If contraception is the need , desogestrel why desogestrel? containing Combined OC pills may be helpful. Combined pills will also lead to regular menstruation. If Hirsutism is only an issue & she doesn’t wish to be pregnant in near future then reverse sequential regimen of Cryproterone acetate or Diane 35 containing cryproterone which is a progesterone (1) progestogen for atleast 1 year. Spironolactone also has similar efficacy which is androgen antagonist can be given as option. If she does not respond to these medicines or having side effects or intolerance , then drugs like Finasteride, Flutamide (1) ? eflornithine hydrochloride??can be given along with OCpills.,
Posted by PAUL A.
a) Hirsutism can be constitutional or pathological. Certain ethnic groups are more prone to hirsutism is this hirsutism or just variations in hair density / distribution? and I would enquire if she has any 1st degree female relatives with the same problem.

Pathological hirsutism can be due to increased endogenous or exogenous androgens. Increased androgens may be relative as in the case of polycystic ovarian syndrome (PCOS) or absolute as with an androgen secreting tumour. PCOS is usually associated with oligomenorrhoea or amenorrhoea, hence I would take a detaled menstrual history (1) . Androgen secreting tumours may have virilising effects so I would enquire if she has noticed a deepening in her voice, or clitoromegaly. She may have also noticed increasing abdominal distension, which may suggest mass. Cushing\'s disease can also cause hirsutism, hence I would enquire about the presence of increasing weight gain, sweating, palpitations, and the presence of purple striae on her abdomen (1) .

Exogenous androgens may be unknowingly ingested or conciously taken, hence I would take a detailed drug history which drugs specifically? .

I would enquire about her plans to conceive obstetric Hx as certain treatments for hirsutism may affect her reproductive ability or be teratogenic. I would also enquire about which treatments she has tried and their level of efficacy impact on quality of life .

With regards to clinical examination, I would measure her height and weight to calculate her body mass index. Patients with anorexia will have an increase in hair growth this is not hirsutism but the texture is much finer. I would note the pattern of hair growth and plot it on a Ferriman Gallway chart (1) . I would note the presence of a buffalo-hump, purple striae or moonfaced facies as this would suggest Cushing\'s syndrome. I would perform an abdomino-pelvic examination to exclude a mass (1) BP, signs of virilisation.

b) As the clinical examination was normal, investigations should be directed at confirming polycystic ovarian syndrome (PCOS) as this is the most common non-constitutional cause of hirsutism it might be the most common cause but there are other potentially serious causes like androgen producing tumours. Clinical examination may still be normal .

However, the diagnosis of PCOS can be made without any further investigations if the patient has clinical signs of hyperandrogenism accompanied by oligo or amenorrhoea. If she does not have any menstrual disturbance, an ultrasound scan demonstrating at least 10 peripheral follicles will support the diagnosis as she already has signs of hyperandrogenism.

A blood test showing a raised androgen index will support the diagnosis of PCOS but can also demonstrate an androgen secreting tumour. This should be suspected if testosterone levels are greater than 7pg/ml. will you measure any other androgens? 21-OH-progesterone

c) Treatment options are conservative, medical or surgical. Conservative measures include hair removal strategies such as waxing or shaving and bleaching. Bleaching is especially useful on exposed areas of skin. Waxing and shaving are cheap and does not cause long term complications ? folliculitis, coarser hair . The patient should be informed that shaving or waxing sould be done in the direction of hairgrowth to prevent the hair follicle from growing inwards and causing an abscess.

Electrolysis (1) of the hair follicles offers a more permanent solution to hirsutism and treatment can often be completed after 3 or 4 visits. Laser treatment is also a useful permanent solution and is particularly effective in patients who are fair skinned. Both electrolysis and laser treatment can be performed on the face. Laser treatment is also faster compared to electrolysis, but still requires more than 1 visit for complete resolution.

Perhaps the most important aspect of conservative management is weight management (1) especially if her BMI is abnormal increased , or if there has been a sudden weight gain (even in women with a normal BMI). The relative androgen excess will resolve as ovulation is restored. Weight loss should be gradual and the patient should be advised to attend a weight loss group as this has been shown to be more effective than attempting weight loss independently. There are serious long-term health implications for patients with PCOS, and though she presented with hirsutism, the consultation presents an ideal opportunity to discuss these. The emphasis, should again be on optimum weight management.

Medical treatment can be hormonal or non-hormonal. If contraception is required, there are 2 effective preparations available: Yasmin and Dianette (1) . Yasmin contains ethinyl estradiol and drosperinone. Drosperinone is weakly anti-androgenic and can reduce hair growth. It is not known to significantly increase the risk of DVT. Dianette also contains ethinyl oestradiol but has cyproterone acetate instead of drosperinone. Cyproterone acetate is an anti-androgen and has other advantages such as improvement in acne and better weight control. Spironolactone is non-hormonal and is a diuretic. It has weakly anti-androgenic properties that have been shown to be effective for reducing hairgrowth as well as controlling acne.

Finasteride is a 5-alpha reductase inhibitor (1) that is most commonly used in male patients with benign prostatic hypertrophy. It is very effective for hirsutism but must be used with a contraceptive as it will feminise a male fetus.

Finally, I would provide her with literature you were asked to evaluate treatment options about PCOS and hirsutism and offer a referral to a nutritionist.
Posted by PAUL A.
a)A detailed history should be taken to know severity, distribution of excessive hair growth and impact of this on her quality of life (1) in addition to symptoms of virilisation in form of deepening of the voice, male baldness and breast atrophy. It is important to know ethinicity as hair growth varies with racial differentiation. Any recent change in weight especially weight gain should also be asked (1) . History of galactorrhoea and acne should also be enquired.
Medications history is important as some drugs (1) such as testosterone, anabolic steroids and danazol use is associated with hirsutism. Use of combined pills with androgenic progesterone such as levonorgestrol and norethisterone may be the contributing factor.
Menstrual history is also important to know menstrual irregularity in form oligo-menorrhoea which points towards the diagnosis of polycystic ovarian syndrome (PCOS) no – will occur with conditions like androgen-secreting tumours / Cushing’s . Obstetric history should also be considered as ovulatory infertility may be one of the manifestation of same syndrome. Family history of PCOS should also be taken into account. Medical history of hypothyroidism and Cushing syndrome should be asked.
General examination should include body mass index (BMI) as obesity is the part of PCOS. Distribution and grading of hair should be done according to Ferriman Gallway classification (1) . Abdominal examination should be done to feel any abdomino-pevic mass. External genitalia should be inspected to rule out any cliteromegaly. Vaginal examination should be done to rule out any pelvic mass (1) BP, signs of Cushing’s.
b)FSH and LH should be taken day 2-5 of her cycle.
Prolactin, thyroid function test and cortisol should be checked to rule out other endocrine disorders.
17-OH progesterone (1) should be checked to make diagnosis of late onset of congenital adrenal hyperplasia.
Testosterone, sex hormone binding globulin and dehydroepianrosterone should be checked to know site of excessive androgen production (1) ? ultrasound scan abdomen / pelvis + MRI if markedly elevated androgens .
c) She should be informed about this diagnosis. Treatment options depend whether fertility is desired or any contraception needed and patient’s wishes.
She should be counselled that all pharmacological agents take 3-6 months before any benefit can be seen.
If she is overweight, she should be asked for lifestyle changes such as weight reduction and exercise
you are not answering the question. You were not asked about what should be done. You are expected to present the treatment options and their value .
Physical methods (1) are shaving (associated with pseudofolliculitis), bleaching (skin discolouration), electrolysis and laser treatment (expensive). These can be used for initial 3-6 months before actual effects of any drugs could be seen.
Combined oral contraceptive with non-androgenic progesterone can be used if contraception is required. Dianette is the combination of ethinyl oestridiol with cyproterone acetate which is antiandrogen. It is the best drug for hirsutism ? evidence . However, its use is associated with increased risk of DVT. Cyproterone can also be used to treat hirsutism but contraception should be recommended as it may emasculate a male foetus. LFT should be monitored as it is hepatotoxic. Medroxyprogesterone should be used in cases where there is contra-indication to oestrogen use (1) .
Spironolactone is an antiandrogen and aldosterone antagonist . Blood pressure and electrolytes should be monitored. Its use is associated with hyperkalaemia and hypotension.
Flutamide is a non-steroidal antiandrogen. LFTs should be monitored.
Finasteride is a 5 alpha reductase inhibitor. Contraception is needed as it results emasculation of a male foetus (1) .
Vanique (1) eflornithine hydrochloride is used locally. It stops hair growth. Recently, a controlled trial has proved its beneficial effects. Once this drug is stopped, hair starts growing again. Hair growth reaches to pretreatment level within 8 weeks. It causes skin irritation. It should be avoided in pregnancy.
Written information should be provided. Support group contact number should be given not answering the question .
Posted by PAUL A.
a) Enquiry should be made about the onset and duration of hirsutism,since in cases of adrenal or ovarian tumors with hyperandrogenemia the onset is rapid .associated with acne , changes in voice,muscle bulk and changes in weight, and reduced breast size (1) .
Detailed menstrual history is taken about LMP,menarche, regularity of cycle.Ammenorrhea and oligomenorrhea is found in cases of polycystic ovaries.Contraception history ,COCP containing androgenic progestogens ,norethisterone and levenorgestrel may be cause of her hirsutism.
Obstetric history (1) is taken ,she may have either anovulayory infertility or recurrent abortions in case of PCOS.
Drug history of androgen intake,or drugs associated with hypertrichosis e.g phenytoin,diazoxide and cyclosporineA.Family history of hirsutism may be obtained (1) .
Social impact of hirsurism (1) is obtained to assess severity and decide about mode of treatment.Her needs about contraception or pregnancy should be asked.
Examination should include note of weight and height,high BMI is associated with raised androgens and hirsutism.Semi quantitative assessment of hirsutism is done by ferryman gallway (1) method for severity and also for follow up. BP is measured and other signs of cushings syndromes are noted,such as plethora moon face and striae (1) .Thyroid gland and breasts examined for galactorrhea.Acanthosis nigricans is looked for. Abdominal examination to exclude abdominopelvic mass.Pelvic examination is done to note any clitoral enlargement (1) .
b)Investigations would include LHF,FSH ,prolactin and TFTs , if there is amenorrhea.
Serum testosterone and SHBG is also done.Pelvic USS for PCOS (1) DHEA, DHEA-S, 21-OH-Progesterone, MRI abdomen / pelvis if markedly elevated androgens .
c) HIrsutism has a great impact on body image and psychology.Careful and sympathetic counseling forms an important part of treatment.She should be explained that it is a benign condition.The time interval required what is it? and the likelihood of successful treatment should be clearly told.
If the woman is obese, she should be advised to reduce weight.This reduces hyperandrogenemia.She should be motivated to achieve this.May need to be referred to dietician for best results weight reduction is the treatment option. You were not asked about what should be done .
Other treatment options are physical or pharmacological methods.Medical treatment may take upto 6-9months to be effective,during this period physical methods would be helpful
Physical methods include,Bleaching –it may lead to skin discoloration.Shaving-explain that it does not affect rate of hair growth,but may cause irritation and pseudofolliculitis.These are temporary methods and Electrolysis/laser (1) is the only permanent way of removing hair but it is costly and requires expertise to minimize risk of scarring or infection.
Pharmacological methods include antiandrogens.such as cryproterone acetate(CPA) with estrogen is given in reverse sequential regime.Dianette containing ethynyl estradiol and CPA is effective in 50% of cases and a useful maintenance therapy.Severe cases may require higher doses of CPA .If given alone CPA can cause feminization of male fetus,so it should be combined with OCP to suppress ovulation.Yasmin containing drosperinone –a weak anti androgen,can also reduce hair growth (1) .
Spironolactone -aldosterone antagonist also has androgen receptor blocking activity.It may cause hypotension and hypokalemia,so BP and electrolytes should be monitored.
Flutamide-non steroidal antiandrogen –require LFT monitoring as it can cause hepatotoxicity.
Finasteride – 5-alpha reductase inhibitor-effective contraception required as it can emasculate male fetus (1) .
Topical application of Eflornithine (vaniqua) retards hair growth on face and chin.side effects include skin irritation (1) .
Oral contraceptives are useful in suppressing FSH and LH and hence ovarian androgen production,Progestogens with antiandrogenic property such as, gestodene and and desogestrel are preferred but they are associated with higher risk of VTE.and may be contraindicated if she desires pregnancy.
The woman would need to be referred to PCOS support group.

Posted by PAUL A.
(a) Justify your clinical assessment. [9 marks]

Clinical assessment should include a detailed history and physical examination. History of rapid onset of hirsutism suggests a cause like adrenal or ovaraian tumor. Presence of other features of hyperandrogenism like any change in voice, severe acne, alopecia (1) , is suggestive of the severity of the underling cause. Symptoms of headache, visual disturbances may suggest intracranial tumors or acromgaly. Abdominal symptoms like loss of appetite, masses, recent onset hypertension ? abdominal symptom?? may suggest an adrenal tumor or ovarian tumor. Past history of diabetes, chronic skin problems and family history of similar problems is also important. Drug history should exclude medicines like danazole, anabolic steroids (1) or phenothiazines as these can also cause hyperadrogenism.

Menstrual history is important to exclude amenorrhoea and oligomenorrhoea which suggests an anovulatory cause like PCOS. Obstetric history should include history of treatment for parity ?? , infertility, and wishes regarding future childbearing (1) .

History should assess the psychological impact of the problem on her and whther it is affecting her social life.

Clinical examination should include BMI and assessment severity and distribution of hirsutism using scoring systems like Ferrimann Gallaway scoring systems (1) . Blood pressure should be measured as it may be elevated in Cushing’s syndrome (1) . Look for features like baldness, breast atrophy or galactorrhoea and thyroid enlargement. Abdominal examination for any adrenal mass, local examination for ciltoromegaly and a pelvic examination to exclude ovarian masses should be done (1) .

Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks]

The most important investigations are a serum total and free testosterone level and a 17-hydroxyprogesterone (1) and and USG of the abdomen and pelvis. If serum testosterone level is more than 5 micromols/L one should initiate further investigations to identify source of androgens. USG will help to identify polycystic ovaries which are the most common cause. It may also reveal rare causes like an adrenal or ovarian tumor (1) ? MRI . 17-OH progesterone may be elevated in non classical CAH as it is the next common cause after PCOS. Other investigations a Glucose tolerance test diagnose insulin resistance as it common in women with PCOS.


(b) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks].

Any treatment plan should address the psychological aspect of her problem. She should be explained about cause of hirsutism the need for multiple modalities of treatment which includes life style modifications, mechanical methods for hair removal as well as the medical management. She should be told that mechanical measures will be rapid but temporary solution and medical treatment will reduce frequency of further hair removal.

Life style measures include dietary modification and moderate exercises if she obese (1) . Even up to 5 % loss of weight will reduce the insulin resistance in obese women and improve hirsutuism and the menstrual problems.

Mechanical methods (1) like bleaching helps to reduce the pigmentation of the hair, but it can cause changes in the skin color also. Measures like waxing and depilation is also effective. Shaving is also helpful and it does not increase the rate of hair growth, but it can cause psedo-folliculitis and some times folliculitis. Electrolysis is also effective when combined with thermolysis and it can achieve permanent hair loss after repeated treatment.

Laser is also a method of permanent hair removal but it can cause, blistering, pigmentary disturbances and scarring in minority of patients.

Medical treatment includes oral contraceptives (OCPs) which act by suppressing the ovarian androgenesis and increasing SHBG levels (1) . Response will take 3-6 months. It helps in regularizing menstrual cycles and provides contraception. OCPs containg androgen receptor antagonist cyproterone acetone is more effective than standard pills in reducing the hirsutoism while giving good cycle control. But symptoms may reappear after 3-6 months of stopping the treatment and the womwn should be told about it. Oral or intramuscular medroxy progesterone is an alternative if does not wish to take OCPs (1) . Medical treatment should consider her wishes regaring future pregnancy also.

Other antiandrogenic drugs can be considered, if the response to OCPs or progesterones is not adequate. Spironolactone is an oral aldosterone antagonist which has antiandrogenic properties. Serum potassium levels should be monitored while on treatment. Flutamide is a non-steroidal anti-androgen which binds to androgen receptors. It can cause hepatotoxicity and should be reserved for resistant cases. Finastride is 5-alfa reductase inhibitor. It can cause feminsation of a male fetus (1) . Hence reliable contraception should be used along with it.
Posted by PAUL A.
A. Onset and its relationship to pregnancy and the rate of progression have to be assessed as rapidly progression could be due to androgen secreting tumours (1) . Severity of the condition has to assessed how do you assess severity?. History of intake of androgenic drugs like danazole, androgenic progestrogens, and anabolic steroids has to be enquired. History of virilisation like reduction in breast size, deepening of voice, hair loss and Clitromegaly has to be assessed (1) . History of menstrual irregularity has to be enquired. History of infertility has to be asked. Features suggestive of Cushing syndrome has to be asked how does the examiner know that you know these features? . History of mass abdomen should be asked. History suggestive of abnormal sexual and gonadal development has to be asked how do you ask this? . Family history of late onset congenital adrenal hyperplasia has to be asked. Psychological impact of the condition has to be assessed (1) .
Clinical examination includes assessing severity of the condition by modified Ferriman Gallway scoring (1) . General examination should be directed to look for signs of virilisation, acne, male pattern baldness, acanthosis nigricans, seborrhoea, obesity, and stigmata of Cushing syndrome. Abdominopelvic mass has to be excluded. Clitromegaly has to be assessed (1) .
B. Free androgen index, androstienedione and dehyroepiandrosterone sulphate has to be assessed (1) . If testosterone level is high means androgen secreting tumours has to be excluded. Abdominal CT or MRI can be done to exclude adrenal tumours. Ultrasound abdomen and pelvis to rule out poly cystic ovarian disease and ovarian tumours (1) . I7 alpha hydroxyl progesterone can be checked after ACTH stimulation to exclude late onset congenital adrenal hyperplasia (1) .
C. Weight reduction has to be encouraged (1) . 10% weight loss has been associated with reduction in androgen levels and insulin resistance and hence would facilitate the treatment modality.
Physical methods (1) like bleaching can be recommended but it is associated with skin discolouration. Shaving is associated with skin irritation and folliculitis. Electrolysis and laser therapy can be advised.
Pharmacological methods - Use of oral contraceptive pills (1) with non androgenic progestrogen or cyproterone acetate reduces LH secretion and hence androgen production in ovary and progestrogen also inhibits 5a reductase activity. But side effects include weight gain, breast tenderness, headache, fatigue, and hepatotoxicity. It can emasculate a male fetus and so effective contraception is required.
Progesterone progestogen like medroxy progesterone acetate (1) can be used as it reduces LH production. Again weight gain, breast tenderness, irregular bleeding, fluid retention are common side effects
Spironolactone is an effective anti androgen and aldosterone antagonist. Side effects include hypotension and hyperkalemia.
Flutamide, an anti androgen also associated with hepatotoxicity.
Finasteride (1) , a 5a reductase inhibitor is also associated with hepatotoxicity and also can emasculate a male fetus hence contraception is required also with its usage.
Topical usage of eflornithine hydrochloride (1) twice daily only on the face and adjacent area has shown improvement by retarding the hail growth in 4-8 weeks time. The effect lasts only for the duration of treatment. On stopping the pre-treatment condition returns. It is also associated with skin irritation. Treatment has to be avoided during pregnancy and lactation.
Patient should be thoroughly counselled about the various treatment options and improvement can be expected only after 4- 8 weeks time and photos should be used for comparison of treatment results. Patient wishes also should be taken into account.

GOOD ANSWER
Posted by PAUL A.
a. Severity of her hirsutism should be assessed especially if it is affecting her social life (1) Quality of life. Detail menstrual history especially irregularity or amount of menstrual loss should be asked why? JUSTIFY . Presence of other hyperandrogenism symptoms like acne or hoarseness of voice should be noted WHY? . Medication history like Danazole, Phenytoin or other androgenic drugs is important WHY? Does phenytoin cause hirsutism?? . Family history of adult onset of congenital adrenal hyperplasia should be explored. Previous form of treatment and responds of treatment for her hirsutism should be asked. Her wishes to conceive or her wish for contraception is important issue to decide the ideal form of treatment (1) . Her BMI should be calculated. Blood pressure should be measured. Presence of acne and oily skin should be noted. The Ferriman and Gallwey score (1) should be done to asses the severity of her hirsutism. Presence of pelvic mass may suggestive of ovarian androgenic secretion tumor. Presence of clitoris enlargement should be noted (1) WHY?.
b. FSH and LH on day 2-4 of period to look for inverse ration not relevant to the diagnosis of PCOS . Level of testosterone hormone and DHEAS should be sent to differentiate the source of androgen (either from ovary or adrenal glands). 17 OH should be done (hydroxyl progestrerone level) to rule out possibility of adult onset of CAH (1) . Transvaginal ultrasound to look for features of polycystic ovaries and presence of adnexal masses. MRI may be sent if suspicious of adrenal tumor (1) .
c. Life style changes and reduction of bodyweight (1) may improve hirsutism in PCOS patient. Physical method like shaving and bleaching is viable option but unable to control the growth of the hair. Local treatment like VANIQA (1) eflornithine hydrochloride has been shown to reduce hirsutism significantly. But it is only to be used on the face and chin. Metformine effect on hirsutism is controversial. OCP (oral contraceptive pills) (1) can be given to reduce the LH ration, thus ovarian steridogenesis reduces. Androgenic progestogen component of OCP should be avoided. Medroxyprogesterone acetate can be given to those who are not suitable for OCP (1) . Spironolactone is anti androgen and aldosterone antagonist, blood pressure and potassium should be monitored. Flutamide is steroidal anti androgen, it is effective but has side effect of hepatotoxcicity. Finasteride is alfa reductase inhibitor is another option, but contraception should be given (1) . The patient should be counseled that the treatment effect can be seen after 3 to 6 months.
Posted by PAUL A.
a) I would take a history to determine the sites of the excessive hair such as the face, chest, abdomen and back. I would enquire on the severity of the condition and the effect on her quality of life (1) . The presence of other symptoms such as acne, a deep voice and increasing muscle mass are associated with hyperandrogenaemia which can cause hirsutism. I would take a menstrual history finding out if she had reached menarche, the date of the last menstrual period and the regularity of the cycles. This is important since irregular cycles could point towards polycystic ovaries syndrome not necessarily – you get irregular menses with almost any endocrine disorder . Her fertility wishes are important since they will influence the type of treatment (1) . For example, if she is trying to conceive then the contraceptive pill should not be given or any teratogenic drugs such as danazol. I would enquire whether she is taking any contraceptives since you should not conceive while on some drugs used to treat hirsutism such as Danazol do you use danazol to TREAT hirsutism? . A drug history is important since some drugs such as steroids can cause excessive hair growth.

I would perform a clinical examination. A body mass index (BMI) will be calculated and a BMI greater or equal to 30 is obesity, an associated factor with PCOS and hirsutism. Obesity on its own can lead to excess production of androgens. The blood pressure (1) should be taken since hypertension can suggest Cushings Syndrome. If there is hypertension, I would look for other characteristics of Cushings Syndrome such as a moon face, striae and truncal obesity. I would look at the different sites of excessive hair and determine the degree of severity using the Ferriman Gallway scoring system (1) . The abdomen will be examined to identify an abdominal mass. Vaginal examination will be done to identify an adnexal or pelvic mass since ovarian tumours can produce androgens and cause hyperandrogenaemia ? cliteromegaly .

b)
I would do luteinizing hormone (LH) and follicular stimulating hormone (FSH). I would do serum prolactin and thyroid function tests to identify other causes of anovulation. Hirsutism can be caused by hyperandrogenemia. I would do serum testosterone, dehydroepiandrosterone(DHEA), DHEA-S and sex hormone binding globulin to confirm hyperandrogenemia (1) . High levels of testosterone would indicate an androgen secreting tumour. A raised level of DHEA-S would suggest an adrenal source of androgen causing the hirsutism. I would do 21-OH-progesterone since this would indicate congenital adrenal hyperplasia (1) . If there are symptoms and signs of Cushings syndrome I would do a dexamethasone suppression test to make the diagnosis.
A pelvic ultrasound scan would be done to identify polycystic ovaries, ovarian cysts or tumours. An abdominal ultrasound would be done to identify an adrenal tumour (1) ? MRI .


c) The first option is to do nothing which may be acceptable to the patient if it is not affecting her quality of life and the hirsutism is mild. Conservative treatment with counselling and weight loss (1) . Counselling can be useful if she is psychologically affected by the excessive hair. Weight loss can be useful if she has PCOS or is obese to reduce the level of androgens. The treatment may be a mechanical method (1) such as shaving, depilatory creams or laser to remove the excessive hair. It is of good value with the benefit of removal of hair without risk of side effects from medical treatment. The treatment may be medical. The combined oral contraceptive pill (COCP) (1) with cyproterone acetate may be used. This is of good value. The benefit is that it treats the hirsutism as well as provides contraception. It is limited since it can be used only for 3 months this is incorrect (-1) , after which the excessive hair may occur again. Danazol is another drug that may be used to treat hirsutism second time you have written this – does it CAUSE hirsutism or is it a treatment? Danazol is androgenic . It is effective in stopping the excessive hair growth but limited by its side effects such as skin reactions, photosensitivity, mood changes and hair loss hair loss in danazol (scalp hair) is a consequence of its androgenic effects (-1) . It is also important to use contraception simultaneously with Danazol since it can have an emasculating effect on a male fetus no – it is androgenic and will virilise a female fetus . Topical eflornithine (1) is effective but has side effects such as skin reactions and acne. If the diagnosis is congenital adrenal hyperplasia READ THE QUESTION!!! then the woman should be counselled on the diagnosis, referred to an endocrinologist and treated with glucocorticoids. Treatment may be surgical in cases where the cause of the hirsutism is an androgen-secreting tumour.
Posted by PAUL A.
Dear Dr Paul,
This new question which u have posted is almost same as question no 182 titalled hirsuitism in the old questions posted.It has previously also been dealt nicely I Think.May be u are trying to check whether the candidates scrutanize your site well or not.Thanks
Dr Priti


Given the number of essays on the website, it is very likely that you will come across two questions that are similar. However, these questions have been set and answered independently and if you simply write the answer in essay 182, it will probably fail. The current question requires more careful reading. If you come across a question that you recognise in the exam, do not be tempted to reproduce an answer you have seen here or anywhere else. You should approach the question as if it is an entirely new question, reading and taking account of every word.
Posted by Ahmad A.
Detailed history may determine the aetiology of hirsutism. As, secondary or oligomenorrhoea, progressive gain weight and inability to conceive may be a cause of polycystic ovarian syndrome (PCOS) and Cushing\'s syndrome. Voice change may indicate a virilism of androgenic adrenal or ovarian tumour. Also, history of drug intake may be a cause of hirsutism like, Danazol for Endometriosis, psychotropic drugs and Diasoxide for hypertension.
Examination of the patient may indicate the cause of hirsutism. General examination with hypertension may be a sign of Cushing\'s syndrome. Cushinoid features of increase body mass index, broad chest, deposition of fat in abdominal area and thin leg with week muscles. Virilization distribution of hair, boldness of the head and atrophy of the breast may indicate an androgenic tumour. Freidman Gallway classification can estimate the severity of condition, a score out of total 44. Abdominal examination and palpation of any abdomino-pelvic masses.

Investigation required should includes, LH, FSH of the second to third day of the period(PCOS), free testosterone, Androstendion (Ovarian tumour) and dehydroepiandrostendrione (adrenal tumour). Ultrasound examination as pelvic (abdominal or trans vaginal) for ovarian mass, and upper abdominal for adrenal mass.

Treatment of PCOS can be as following, Cyproterone acetate (2mg/day) in combination with ethinyl estradiol may be used as cyclic forms. It may be used as a contraceptive method. Cyproterone acetate (50 mg/day in the first 10 days of the cycle), however contraception should be used while using such regimen. Third generation progestogen (Desogetryl and gestoden) in combination with ethinyl estradiol as combined oral contraceptive pills (COCP) Other COCP containing Desporinon (Yasmine) may be used. Spirinolactone, antiandrogenic drug may be used, however electrolyte imbalance in form of hyponatremia as a drawback of spirnolactone. Flutamide is another antiandrogenic medication can be used however it may cause liver toxicity, so, liver function may be evaluated before medication started. Cosmotic treatment in form laser ablation and bleaching can be used as it may improve the psychological condition. Psychological referral can be offered in case of resistant cases.
Posted by clarice M.
RE: Late onset congenital adrenal hyperplasia

I\'ve tried to look online and in textbooks, but can\'t find out how late is \"late\" onset

Does anyone know?

Thanks
Posted by PAUL A.
A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsutism. (a) Justify your clinical assessment. [9 marks] (b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks] (c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks].
a)I would take a relevant history regarding the onset & rate of progression of hirsutism. The site of excess hair growth like facial , on arms &legs & any hair loss would be asked. Any change in voice ,acne or masculinising features like breast atrophy or mood changes would also be asked as rapid progression of hirsutism with masculinisation would point to an androgen secreting tumour (1) . A detailed menstrual history including LMP ,cycle irregularity suggesting anovulation would be asked as they may point towards a presumptive diagnosis of pcos this is incorrect – any endocrine disorder will cause oligo / amenorrhoea if severe . A family history of hirsutism should also be asked as quite a few cases are familial and benign (1) . A history of certain drugs like danazol or androgenic progesterone may also cause excess hair growth (1) .She would be asked how this is affecting her body image and social life (1) . Any history of mass abdomen would also be asked .Her need for contraception or pregnancy would be asked as it will affect the management (1) .
A presumptive diagnosis may be reached on good history .
The next step would be a good clinical evaluation . Her BMI, any features of cushings syndrome like striae ,buffalo hump etc would be noted. Any features of virilisation and male pattern baldness would be looked for (1) ? BP. A Ferriman-Gallway score (1) of hirsutism is calculated . An abdomino pelvic exam can diagnose any mass or clitoral hypertrophy (1) . This should be supplemented by US study. Any pigmentation or striae are noted.
b) If clinical exam is normal furthur investigations are needed to find out the possible cause.
The aim is to confirm androgen excess and identify its source.
Serum testesterone ,SHBG, Free androgen concentration, DhEA, DHEAS (which is of adrenal origin (1) .
21 OH Progesterone levels- high may imply late onset CAH (1)
Other hormone profile like LH, FSH PROLACTIN
USG _ pelvic and abdominal for pcos, ovarian tumor,adrenal neoplasm (1) ? MRI.
Dexamethasone suppression test is done if cushings is suspected.
Karyotype (1) may be needed in certain cases if AIS Syndrme what is this?? is suspected
c) She is diagnosed with PCOS, her treatment options would depend on her wishes for contraception and the degree it is affecting her social life.
In mild cases she can be reassured and advised you are not answering the question – you were not asked about what you would do removal of unwanted hair by shaving,waxing or creams all of which are temporary, electrolysis is permanent removal but is costly and can be used only for small areas .Bleaching can help cover facial hair to some extent.. Weight loss should be encouraged as it decreases peripheral conversion of androstenedione to testesterone. It also helps in cycle control.
Pharmacological methods--
1) OCP- supresses LH production& ovarian testesterone production,increases SHBG & lowers free androgen index. It is ideal in women desiring contraception but pills with androgenic progesterones should be avoided.
Newer pills with cyproterone acetate which is antiandrogen is effective but additional contraception is advisable as it can demasculinise a male fetus.Side effects include breast tenderness, fatigue weight gain hepatotoxicity.
2)In patients who cant take OCP, Medroxyprogesterone acetate may be given with effective LH suppression.
3)Spironolactone -aldosterone antagonist& anti androgenmay be given. BP&serum electrolytes should be monitored for hypotension &hyperkalemia.
4)Flutamide-new drug is nonsteroidal antiandrogen- LFT should be monitored due to rare hepatotoxicity.
5)Finasteride is an effective 5alpha reductase inhibitor can decrease furthur progression of hirsutism but additional contraception should be ginven due to risk of demasculinisation of male fetus.
6) Eflornithine skin ornithine decarboxylase is under trial improves acne and facial hair but contraindicated in pregnant women. Risk of skin irritation should be explained
why did you decide to number your answer? What is it in the question that makes numbering appropriate here but not in (a) or (b)?

the overall management requires a kind and sympathetic approach . She should be clearly told about the expected improvements and tha she will need to remove unwanted hair till treatment becomes effective. pre & post treatment photographs will help her to notice the change. Good support from family should also be encouraged to decrease her mental anguish You were asked to evaluate treatment options – what are the options and what is their value. You were not asked to describe / outline your treatment .
Posted by PAUL A.
Mark d.
a)
I will take a detail history of associated symptoms like weight gain, lethargy,depression, and inactivenes. Such symptoms point towards hypothyroidism. Galactorrea ,headache are suggestive of prolactenemia If a woman presents with hirsutism, will hypothyroidism or hyperprolactinaemia be the first two conditions on your list? . Weight gain, rising bp, and striae will you get these from Hx? indicate cushings symdrome.i will take detail menstrual history –regularity,flow,LMP. Associated menstrual disturbances like oligomenorrea, irregular menses are suggestive of polycystic ovaries you get irregular menses with any endocrine disorder if severe .family history (1) -particularly history of conginital adrenal hyperplasia in any siblings should be asked .i will check if she has taken any tratements for this in past and review their outcomes.i will asses the impact of hairgrowth on her quality of social and personal life (1) .i will enquire if she is on any medications like antihypertensives,minoxidil, steriods,danazol which may cause hirsuitism. I will review her current method of contraception and her wishes for future fertility (1) .
I will perfork a general examination to note weight, BMI,any truncal striae,thyriodswelling and galactorrea ? BP .
I will check the hair growth pattern and texture over 9 sites and calculate the ferriman gallway score (1) . This will asses severity of problem and be useful to moniter effectiveness of treatments.
I will do a per abdominal and bimanual pelvic examination to rule out any adnexal masses like ovarian tumors.adrenal tumors are very small and cannot be diagnosed clinically (1) Cliteromegaly .
b)i will initially ask for an pelvic ultrasound scan and serum testosterone (sr T) levels (1) . Pelvic scan (TVS) will asses ovarian morphology.10 or more folicles of size 2-8 mm arranged in a peripheral fashion and increased stromal volume is diagnostic of polycystic ovarian disease.
Sr T less than 5 nmol/ml indicate idiopathic hirsuitism or due to polycystic ovaries. Sr T of more than 5 nmol/ml need further investigations to rule out ovarian or adrenal androgen secreting tumors , CAH or cushings disease. It includes Sr DHEAS, 17 OH progeterone levels.these should be done in liason with endocrinologist. Raised Sr dheas indicate adrenal tumor and imaging like CT or MRI (1) is needed to locate the tumor. Raised 17OH P more than 20n mol/ml indicate adult onset CAH (1) .lower levels may be due to cushings or CAH with need to be confirmed with synacthen test for CAH and dexamethasone suppersion tests for cushings.
Sr LH FSH are not recommended with normal menstrual cycles and Sr TSH only if symptoms suggestive of hypothyriodism.
c)
First option ? weight reduction is COC pills .They are cheap easily available and effective in 60-70% cases in 6 months (1) .They are contraindicated in presence of conditions like thrombosis,focal migrane and active liver disease.They have side effects like mastalgia,bloating,mood disturbances and nausea. Dianette is a coc pill containing cyproterone acetate as progesterone component is specifically used for it. If gallway score is more than 10 then additional cyproterone acetate can be added to dianette in reverse sequential regimen for better response ,however the side effects are more. Spironolactone can be given with COC pill in low doses ,is more effective than Coc pill alone but is not licenced in UK for this indication.other progesterones like medroxyprogesterone acetate (1) , depot or oral can be used but have not proves to be better than COC pill.Laproscopic ovarain drilling to reduce androgenic milleu is effective for 3-4 months and not recommended for hirsuitism without infertlity. More advanced treatments withn Finesteride and Flutamide (1) are given by specialists under close supervision and monitering of liver function tests as they have significant side effects. Reliable contraception needs to be used with them.
Cosmetic methods (1) like epilation,waxing,threading can be continued although they may interfere with monitering the treatment response.
if the patient wants to conceive then laproscpic drilling or clomiphene or gonadotropins can be given for ovulation induction.
Posted by PAUL A.
The aim of clinical assessment in this case of progressive hirsuitism over a short time is to exclude sinister causes as androgenic tumours (1) or congenital adrenal hyperplasia(CAH) to allow early treatment,in addition to diagnosing other causes of hirsuitism.
I will ask patient of sites of hair growth and effect on her quality of life (1) .I will ask of her menstrual period (1) LMP ,regularity and if there are periods of amenorrhea and if she is using contraception and which type as some hormonal contraceptives have androgenic properties.I will ask of her fertility wishes (1) and if there is difficulty in conceiving.I will go through, her family history of similar condition (CAH) , any gain in weight or increase in her abdomen size(tumours).Will ask of symptoms of hypothyroidism(cold intolerance ad weight gain) and of any previous treatment of her hirsuitism.
On examination , will do BP , BMI (1) ( increased in PCOD and Cushing), look for abdominal stria and distribution of hair detecting its severity using the Ferriman Gallway score (1) (eleven areas on body with a score 1 to 4 for each), examin abdomen for abdominal masses , do local examination detecting clitromegaly ? pelvic mass .

Will do serum testosterone which would be markedly elevated in androgenic tumours and CAH.Measuring dehydroepiandrosterone acetate which is elevated in adrenal tumours DHEA-S . Measure 17 alpha hydroxy progesterone (1) (CAH). LH may be elevated in PCOD. TSH elevated in hypothyroidism .Do ultrasound to detect polycystic ovaries and tumours. CT scan for androgenic tumours (1) .Karyotype (1) in case of clitromegaly.

I wil tell her that not answering the question. You were not asked to tell her… Evaluate – what are the options and what is their value? treatment can take time to have an effect and if she is worried of cosmotic appearance specially on face , she can use methods like shaving,waxing,epilation, electrolysis or laser in special centers. Combined pills can be used to increase serum hormne binding globulins which bind to androgens and lower its level in blood (1) , and will regulate period if irregular. Cyproterne acetate will bind to androgen receptors and used as pills dianette can regulate cycles also.Flutamide bind to androgen receptors lowering androgen level does it lower levels? and useful in treatment . Finasteride inhibit 5 alpha reductase enzyme and prevent testosterone changing to the active dihydrotestosterone (1) .Topical eflornithine cream (vaiqa) can be used locally to suppress new hair formation ? value – how useful is it?
Posted by PAUL A.
a.Hirsutism onset and the speed of progression should be enquired.The social impact (1) should be sensitively enquired.Site of hirsutism whether restricted to face or all over should be enquired as this influences treatment.Any symptoms of virilisation like deepening of voice,breast atrophy,male type scalp baldness should be enquired (1) why? Justify .Detailed menstrual history including its regularity, any episodes of amenorrhea and last menstrual period should be asked. Any mode of contraception if used and contraindications to contraceptive pills if any present will be enquired.Her fertility wishes will be enquired. since treatment medications may be teratogenic (1) .Any history of recent increase in weight,deepening of voice,increased pigmentation suggestive of cushings syndrome will be enquired.Any swelling in abdomen suggestive of ovarian or adrenal tumour will be asked (1) .Any androgenic drugs intake ? examples and the treatment history for hirsutism will be enquired.Family history of hirsutism may suggest late onset adrenal hyperplasia.
General examination to be done to look for BP,BMI (1) which if increased along with abdominal striae is suggestive of cushings syndrome. Hirsutism is graded by Ferriman –Gallway (1) Abdominal and pelvic examination to be done for detection of abdomino pelvic mass.[ovarian or adrenal].Examination of external genitalia for clitoromegaly to be done (1) .
b.Investigations include to find out the source of hyperandrogenism.Serum testosterone ,SHBG,FAI should be done (1) what is FIA??.Teststerone more than 4.8 nmol/l is suggestive of ovarian or adrenal mass,in case CT or MRI is indicated.DHEAS elevated is of adrenal origin. 17 hydroxy progesterone elevation is indicative of late onset adrenal hyperplasia (1) .USS will be done to look of polycystic ovaries (1) .
c.Treatment options depend on her fertility wishes.Non pharmacological methods like 10 % weight reduction (1) in obese PCOS may decrease peripheral conversion of androstenedione to androgens.Cosmetic methods (1) like waxing,bleeching depilation may be tried but this is temporary and may cause irritation and folliculitis.
Medications like oral contraceptive pills (1) [using progestogens of non androgenic ]can be used,which decrease LH and raise SHBG, thusdecreasing free androgen levels.Cyproterone acetate which is anti androgenic can be used but should be combined with ethinyl estradiol as this emasculate male fetus.Flutamide and finasteride (1) can be tried but the possibility of emasculation of male fetus if conception occurs should be borne in mind,hence adequate contracetion used.Spiranolactone can also be used for hirsutism but its use is limted by dangerous side effects like hyperkalemia and arrythmias.All medications may have a latent period of 3-6 months before its full effects occur (1) which should be explained to the patient.For facial hair topical eflornithine (1) can be used but hair may regrow once treatment is stopped.Laproscopic ovarian drilling may be used in PCOS since this normalizes LH,SHBG in more than 60 % of women.But this has the inherent risks due to laproscopy and the long term effect on ovarian function is not known. Written information will be given and patient wishes respected not relevant to the question .
Posted by PAUL A.
a -Hirsuitism is a distressing situation and is associated with considerable patient anxiety.So patient needs sympathetic approach. So i would first ask her history( like its impact on quality of life (1) and her social status what do you mean by social status? Does this mean social class? What is its relevance? , regularity of menses and LMPas hyperandrogenic states can be associated with menstrual irregularities,previous conceptions and its outcome,or if she has subfertility,previous treatment history and its outcome,history of drug intake like androgenic steroids/ progestogens, danazol, phynetoin (1) why? You were asked to JUSTIFY ,etc no marks for this ,family history of similar problems in sisters as PCOS has genetic inheritance,any change in voice as it is a sign of virilisation,weight gain as it occurs in PCOS and cushings disease or syndrome,constipation and cold intolerance to R/O hypothyroidism,and breast milk secretion) and then examine her this is all one sentence! To gain marks, you should address every point in a separate sentence .I would check her B.P ? BMI as it may be raised in cushings , look for the pattern of hair growth amd map it (Ferriman galleway score (1) ),look for breast milk secretion(20% PCOS patients have it) ,breast atrophy, clitoromegaly, labial fusion as they are signs of defeminisation /virilisation,hyperpimentation in flexural areas(acanthosis nigricans-a sign of insulin resistence),and also look for striae in skin (in cushings ). I would also look for any abdominal masses and do bimanual pelvic examination to find out ovarian masses (1) .

b -I would do srerum free testosterone( though it may show considerable variation),DHEA, DHEAS,SHBG (1) ,17 alpha hydroxy progesterone and ultrasound pelvis to look for ovarian morphology,and CT abdomen and pelvis to rule out adrenal masses (1) address blood tests and scans in separate sentences .
c- I would explain, that her hair growth is due to PCOS, reassure her and give her additional psychotherapy as hirsuitism is associated with considerable anxiety NOT ANSWERING THE QUESTION. WHAT ARE THE OPTIONS AND WHAT IS THEIR VALUE? .Treatment options are either physical and pharmacological methods.Epilation, depilatory
creams ,waxing and shaving (1) offer good cosmetic results, has no side effects ? folliculitis, coarser hair with shaving and does not increase hair growth.Electrolysis is a permanent method except that it is costly and may cause scarring.
Combined oral contraceptive pills (1) increase SHBG,and inhibit gonadotropins and help decrease hair growth and it has added benefit as a contraceptive.Dianette is very effective in treating hirsuitism but needs additional contraception as it may cause feminisation of a male fetus, and it cant be used for long . Spironolactone ,flutamide, and finasteride are useful but needs electrolyte monitoring ,LFT monitoring and additional contraceptive use respectively this is the problem with writing long sentences – this sentence means that electrolyte monitoring needed with spironolactone (correct), LFT monitoring needed with flutamide and additional contraceptive needed with finasteride (but not with flutamide or spironolactone). Will that be correct? when they are used.Eflornithine hydrochloride can be applied topically over face and chin ? value , but it is not safe to use if the patient becomes pregnant.
Posted by Maayka ..
nellie

a) A history of menstrual irregularity such as oligomenorrhoea or amenorrhoea, together with infertility may suggest PCOS as a cause. A history of abdominal distention may suggest an ovarian or adrenal tumour. It is also important to find out about her reproductive ambitions as it may have an impact on her treatment. Any exogenous causes like drugs used e.g. steroids, testosterone for muscle bulking especially esp. in athletes may be responsible. It is necessary to inquire about any methods previously tried for hair removal and how often it was done. The woman should also be asked about her self image issues and if the hirsutism has had a negative impact on her social life.

Examination is done generally – BP if elevated may suggest Cushing’s syndrome, especially if there are other features like moon facies, truncal obesity, hump on back and thinning skin. The abdomen is palpated for any obvious masses, which is suggestive of either an adrenal or ovarian tumour. The external genitalia should be examined to rule out causes of hyperandrogenism like late onset congenital adrenal hyperplasia or virilization – clitoromegaly will be present here. The distribution of the hair should be scored by the Ferriman Gallwey scoring system so that it can be recorded for comparison in the future for treatment effects. With the patient’s permission, pictures can also be taken.

b) Hormone levels of testosterone, DHEAS – which is produced only by the adrenals, 17 hydroxyprogesterone will aid in differentiating an adrenal from ovarian cause for the increased androgen levels, which is likely present. Also, sex hormone binding globulin, LH, FSH and fasting insulin will assist in determining if PCOS is a likely cause. Other investigations include ultrasound of the pelvis and abdomen to look at the adrenals and if latter suggested, CT abdomen can be done.

c) Physical methods have some drawbacks, each one different. Waxing – painful, requires frequent visits and associated with redness, folliculitis following procedure. Bleaching - does not reduce the hair follicles but aids in camouflaging the hirsutism. Shaving – results in coarser hair but is a cheap, inexpensive method, can be done by the patient herself, but results in folliculitis. Electrolysis - is permanent hair removal following several visits, will be tedious and is painful.
Medical options include the COCP which do not contain androgenic progestogens or an OCP with antiandrogen like Cyproterone acetate (Diane 35). Also for those who are unable to use the COCP, Medroxyprogesterone acetate can be used because it also reduces LH production and thus ovarian androgen production. Finasteride is a 5 alpha reductase inhibitor and acts at the level of the pilosebaceous unit in reducing the androgen levels. Flutamide is a non- steroidal antiandrogen with side effect of hepatotoxicity so its use must be monitored with LFTs. Ketoconazole also has limited use because of hepatotoxicity.
Another option is a topical cream, Eflonithine hydrochloride, which reduces hair growth after 4- 8 weeks of use but it regrows once it stops to pretreatment state.
She should also be provided with written information to aid her in making the best choice.
Posted by PAUL A.

SM reply.
a)
A thorough history of onset and distribution of hirsutism must be elicited .A rapid onset is seen with ovarian/adrenal tumors secreting androgens (1) . A slow onset is associated with idiopathic hirsutism and polycystic ovarian syndrome (PCOS). Family history of hirsutism must be asked for which may indicate congenital adrenal hyperplasia .Any increase in weight gain must be looked for ,which is commomnly seen with PCOS and cushing’s syndrome . History of drug intake like danazol (1) , steroids must be asked for as they cause hirsutism . I will ask about her menarche , LMP and menstrual cycle regularity as PCOS is associated with oligomenorrhoea so are other endocrine disorders . I will ascertain her plans for pregnancy and whether she is using any contraception. Associated alopecia , breast atrophy and change in voice (1) indicates high androgen levels from ovarian /adrenal source.Effects on quality of life (1) must be enquired into.
On examination , I will check for BMI ? BP as obesity leads to excessive peripheral conversion of androstenedione to testosterone. I will look for buffalo hump , purple sriae , moon- face indicative of cushing’s syndrome (1) . I will check for thyroid swelling as hypothyroidism is associated with hirsutism.Breasts will be checked for atrophy/ galactorrhoea .Abdomen will be examined for any mass suggestive of adrenal/ovarian tumour . Truncal obesity, acanthosis nigicans ,alopecia are usually associated with PCOS .
Vaginal examination will be carried out to look for pelvic tumours ? cliteromegaly .

b)
The investigations I would like to carry out are LH , FSH , TSH, Prolactin, DHEAS ,testosterone, 17 hydroxy progesterone ,Blood sugar fasting and post prandial and pelvic ultrasound for PCOS / ovarian tumours (1) you were not asked to list the investigations .

c)
If hirsutism is mild, reassurance alone may suffice. Counselling will help develop self-esteem. Multi-disciplinary team including the dietician , dermatologist and psychologist may be essential.
Weight reduction (1) prevents excessive conversion of androstenidione to testosterone. Physical methods like shaving, bleaching , waxing can be tried.Side-effects are skin irritation and pseudo-folliculitis (1) .
Dermatological referral is required for laser or electrolysis treatment. If contraception is required , combined oral contraceptive ( COC) pills (1) can be used for contraception and hirsutism . It increases SHBG and reduces LH levels . Gestodene has anti-androgenic activity.Medroxy progesterone acetate contraception also helps in reducing hirsutism . Cyproterene acetate has anti-androgenic properties , must be used with other contraception to avoid feminization of a male fetus (1) . Spirinolactone has anti-androgenic activity but can cause hypotension and hyperkalemia . Eflornithine hydrochloride is effective when used locally .Side-effect of adverse skin reaction must be explained (1) . Oral Finastride is a 5 alpha redutase inhibitor which is effective too .Additional contraception must be ensured .Flutamide (1) , anti androgen, can be tried. Adverse reaction of hepatotoxicity must be borne in mind. Written information and address
of support groups must be offered.
Posted by PAUL A.
A) A rapid onset progression of hirsutism in the last 3-6 months may suggest underlying androgen producing tumour (1) .
A family history of hirsutism may suggest familial conditions with hirsutism like non classical adrenal hyperplasia / polycystic ovarian syndrome(PCOS)
Additonal history of headache, visual disturbance, galactorrhoea may suggest prolactinoma.
Her fertility wishes (1) and contraceptive choices should be ascertained as will help in her treatment options.
Her menstrual history should be obtained as changes in pattern may suggest underlying ovarian pathology.
History of any treatment done so far may suggest further treatment option for her ? use of androgenic drugs .
History of quality of life (1) affected may necissitate need for psychological input.
Examination including pattern of hirsutism and external visibility of hair may suggest severity of condition.
Round facies , buffalo hump, central obesity, proximal weakness of muscles may suggest cushings syndrome.
Pulse and BP assessment as hypertension may suggest alternative treatment options.
Body mass index(BMI) assessment as raised BMI (1) is associated with PCOS related hirsutism presence of abdominal / pelvic mass, cliteromegaly; Ferriman-Gallway scoring .

B) A high testosterone level may suggest PCOS but a very high level may suggest underlying subclinical androgen tumors.
A free androgen index should be obtained with levels of sex hormone binding globulin(SHBG) and testosterone levels to suggest PCOS (1) DHEA, DHEA-S .
In absence of other clinical signs a baseline screening of thyroid function and prolactin levels should be done to exclude subclinical thyroid disease and prolactinomas.
pelvic ultrasound scan for ovarian morphology may suggest polycystic ovaries and also to exclude ovarian tumors.
CT scan may be necessary to exclude adrenal tumors but this is unlikely without clinical signs Which clinical signs will you expect? (1) .

C) Supportive treatment for PCOS with obesity may need dietician for weight loss (1) and exercise will help reduce hyperandrogen state and hirsutism.
Pharmacological treatment with combined oral contraceptive pill (1) is helpful for hirsutism, this will also depend on her contraceptive choice and fertility wishes.
Combined pill with low androgenic / anti androgenic effects progestins is desirable for treatment of hirsutism. preparations which include cyproterone acetate and drospirenone act againt ovarian androgen production and helpful for treatment of hirsutism.
If oestrogen is contraindicated progestins like medoxyprogesterone acetate (1) as depot injections or oral tablets is helpful in decreasing androgen levels.
High dose oestrogen preparation is also helpful in increasing SHBG levels and treating hirsutism but should be used with progestin to prevent proliferative effect of oestrogens.
Gonadotropin releasing hormone agonist is not commonly used to treat hirsutism unless associated with hyperinsulinemia.
Anti androgens (1) like spironolactone, finasteride and flutamide is used to treat hirsutism but will need adequate contraceptive measures as associated with fetal adverse effects.
Eflornithine cream how useful is it? is used as local application to reduce facial hair in the treatment of hirsutism.
Non pharmacological treatment with mechanical removal (1) of hair and laser treatment is used but need repeated treatments and may not be compliant with cost issues.
She may need psychological support and she as she may need long term treatment for hirsutism.
She should be provided with written information not answering the question .
Posted by PAUL A.
prt

a]A full detailed history is taken regarding increasing facial hair and the speed of progression.Aslow progression indicates PCOS or late onset congenital adrenal hyperplasia[CAH].A fast progression suggests ovarian/adrenal tumour secreting androgens (1) .Other Hx suggestive of virilisation is taken how does the examiner know that you know the other Hx? . Hx of amenorroea or oligomenorroea and its duration is to be noted.Hx of breast atrophy and voice change suggests associated virilisation.Obstetric history or the Hx of infertility and the desire for further children (1) should be elicited.Hx of drug intake like danazol (1) ,anabolic steroids is taken as they can cause hirsuitism.The effect of hirsuitism on the quality of life (1) of patient is important.Any previos hx of thyroid dysfunction/hyperprolactinemia can be accompanied by increased adrenal androgens.Family hx of hirsuitism or CAH may be positive.
Detailed clinical examination includes BMI for obesity,and B.P (1) . with pletora ,moon facies to rule out Cushing\'s Syndrome.Severity of hirsuitism is assessed by Ferriman and Gallway (1) semi quantitative scale.Photography can be a useful adjunct.Abdominal and pelvic examination is done to rule out masses and vulval examination is done to detect clitoromegaly (1) .

b]Serum Testosterone and SHBG are done for detecting free androgen index.Testosterone levels more tham 6nmol/l suggests androgen secreting tumour.DHEA and DHEAS levels are done.Raised DHEAS levels suggests adrenal cause of androgens (1) ,while normal level implies ovarian source.Elevated 17OH Progesterone levels suggests late onset CAH (1) .
Serum TSH/Prolactin are done especially if the patient is amenorroeic.Serum LH,FSH done on 3rd day which are elevated or altered diagnose PCOS not criterion for diagnosing PCOS .TVS can be done to confirm PCOS additionallly.Urinary cortisol and overnight dexamethasone suppression tests are done to exclude Cushing\'s syndrome.According to the results of these investigation a small group may require CT/MRI of adrenal gland to rule out adrenal tumour (1) .In case of excessive virilisation Karotype (1) may be done.

c] MDT approach shoul be taken not answering the question. What are the options and what is their value? for the treatment especially if ther is associated virilisation.95% of the cases of hirsuitism are due to idiopathic reasons you are told that she has PCOS or PCOS.Mild cases need only ressurance and the mechanical methods.Topical Vaniqua[eflornithine]is licensed in U.K for facial applications.Various mechanical methods used for hirsuitism are cheap and effective but require repeated application.Laser treatmaent and electrolysis are expensive but give good cosmetic result (1) .
Medical treatment for hirsuitism includes COCP (1) prescription.The first choice is DIANETTE ,a combination of cyproterone 2mg and ethinyl estradiol.It should be used for a period of 6-9months to be effective.The other good choice is Yasmin which contains drospirenone having one third the potency of cyperoterone acetate.COCPs are cost effective and offer contraception and menstrual regulation.Also they suppress LH and ovarian androgen synthesis and increase SHBG.Cyproterone acetate is limited by the adverse effects like depression,weight gain,breast tenderness and VTE.
Medroxy Progesterone Acetate (1) can be used if patient wants long acting contraception.Other antiandrogens like Flutamide can be used.It is hepatotoxic and hence LFT should be checked.Finasteride is 5alpha reductase inhibitor and should be used with effective contraception as it can emasculate the male foetus (1) .
Metformin can reduce the hirsuitism associated with PCOS,but it is not licensed for it.Informed consent can be taken from the patient and properly documented for its use.
Patient should be reassured and be given the name and contact no of support group like VERITY [pcos].She should be encouraged to have positive body image of herself not necessary for this question .
Posted by PAUL A.
sttas

A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsutism. (a) Justify your clinical assessment. [9 marks]
DO YOU EXAMINE PATIENTS BEFORE YOU TAKE A HISTORY? I would measure this patient\'s BMI, as this is often elevated in patients with a diagnosis of PCOS. I would check blood pressure, as she may have an adrenal tumour leading to elevated BP (1) . I would examine the distribution and hair type (course, fine, location of male hair distribution-eg. facial hair). I would also loof for acne, often seen in those with PCOS. I would perform an abdominal examination to exclude abdominal or pelvic masses. A vaginal examination must be performed to exclude adnexal masses cliteromegaly . I would also look at the patietn\'s ethnicity can you always tell ethnicity just by looking? .

In the history, I would exclude medications which may lead to hirsutism. I would look for a history of headaches or change in vision, as this may indicate a pituitary tumour. I would also ask about weight gain, change in skin and voice.
(b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks]
I would request a hormonal profile, including FSH, LH (day 2-6 in cycle), Testosterone and Sex hormone binding globulin. I would arrange a pelvic ultrasound and abdominal CT (1)

(c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsutism [7 marks].
Cosmetic treatments (1) (eg. waxing) are easily accessible over the counter, but are not permanent and may be time consuming.

Laser treatment may be effective but is costly and rarely available on the NHS.

Vaniqua (1) eflornithine HCl is a topical treatment which can be prescribed. It is effective, but only for the duration of use.

Dianette is an androgenic is it? Why will you want to prescribe androgens? contraceptive pill which can be used to treat hirsutism. However, it requires patient compliance is there any drug treatment which does not require compliance? and may have unpleasant side effects such as breast tenderness, irregular bleeding. Again, it is only effective for the duration of use

Spironolactone is a very effective treatment, but has an anti-diuretic effect. Your answer lacks detail – see notes on hirsutism
Posted by PAUL A.
A 33 year old woman has been referred to the gynaecology clinic because of a 6 months history of progressive hirsuitism. (. [9 marks]]
a) Justify your clinical assessment

I would like to take a detailed history including the onset and the progression of hirsuitism.
Affect effect on quality of life (1) has to be assessed in a sensitive matter any negative body image should be explored. How does patient cope with it? do not ask questions Does it have any impact on her social, personal and professional life?
Was the problem there since teens? Or is it a new problem? Is it progressively getting worse? the examiner asks the questions and you provide the answer Development female secondary characteristics should be confirmed how? and previous medical problems like what? would be elicited.
Any abdominal mass suggests androgen secreting tumour
History of oligomenorrhea / secondary amenorrhea indicates polycystic ovarian syndrome no, it does not. You can get this with any severe endocrine disorder .
Recent history of increase in weight, change of voice is important in light of any new medications like danazol, steroids (Cushing’s disease) will exogenous steroids cause Cushing’s disease? or other androgens like testosterone.
Body image issues like history of anorexia nervosa, bulimia nervosa recent history of weight loss might be useful to rule out the secondary hair growth secondary to mal nourishment.
Plans of conception should be noted as it might have an impact on the management of the patients (1)
Any history of migraine, active liver disease, and thromboembolism should be noted along with any drug allergies.

(b) Which investigations would you undertake given that no other abnormalities were identified on clinical assessment? [4 marks

I would like to perform hormone profile including estrogens progesterone ? value , testosterone and androgens is testosterone not an androgen? also FSH & LH .

Ultrasound pelvis will be useful to rule out abdominal mass/polycystic ovarian syndrome (1) ? MRI

c) She is found to have the polycystic ovary syndrome. Evaluate the treatment options for her hirsuitism [7 marks].

Her treatment options will depend on the affect on the quality of life and plans of getting pregnant in the near future.

I f hirsuitism is not affecting her quality of life than conservatory management can be ensued.

If patient is keen on conceiving in near future, then cosmetic methods (1) like shaving and waxing should be advised permanent solutions like electrolysis can be advised.
If patient is not planning to get pregnant in near future then, combined oral contraceptive pills (1) along with low dose cyproterone acetate could be prescribed ,or cocs on their own can be prescribed. Vaniqua (1) eflornithine HCl has also shown to be of benefit but is temperorary.

Othe less used medications are spironolactone,flutamide,finestride are less popular are they effective? You were asked to evaluate due to their notorious side effects profile
Posted by PAUL A.
In the history I will enquire about the rate of hair growth the frequency of hair removal. This can give an idea of the probable cause. Benign pathology, for example, polycystic ovary syndrome (PCOS) will cause a lesser degree of hirsutism than androgen producing tumours or exogenous androgens (1) .Also this can be used as a baseline to monitor response to treatment.
A history of oligomenorrhoea will be elicited as this is a feature of PCOS will occur in any endocrine disorder if severe . There is usually a history of recent weight gain. Hirsute women with PCOS are often obese
A drug history will be taken to exclude an iatrogenic cause, for example the use of androgenic progestogens or danazol (1) .
features of virilisation will be asked. These include increased muscle mass. deepening of the voice decreased libido and breast atrophy (1) .
On examination, I will measure blood pressure because hypertension is found in patients with Cushing\'s syndrome or late onset congenital adrenal hyperplasia.
Body habitus will be examined for a cushingoig truncal obesity or male muscle distribution fopund in hyperandrogenism.
Weight and height will be measured and body mass index (BMI) (1) calculated for a baseline to monitor treatment.
The breasts will be examined for atrophy which can be found in hyperandrogenism or galactorrhoea foun in a small percentage of PCOS patients.
An abdominal and pelvic exam will be done to exclude an ovarian mass and cliteromegaly (1) ? Ferriman-Gallway score .

b) I wll do serum testosterone levels DHEA, DHES-S, 21-OH-progesterone , and a pelvic ultrasound scan to identify an ovarian mass or polycystic ovaries (1) Fasting serum insulin and an oral glucose tolerance test will also be done.

c)Treatment of hirsutism involves counselling the patient about the diagnosis and modes of treatment. It will be emphasised that althouh pharmacotreatment, if desired will cause a fall in serum testosterone levels, but decreasd hair growth will only be evident after three to six months.
Shaving (1) is effective and cheap but can cause irritation or pseudofolliculitis. Bleaching may lead to skin discolourationbut can be used in milder hirsutism.
Permanent hair removal can be achieved by electrolysis or laser treatment. However these are epensiveand need well triaed personnel to reduce chance of scarring or shock in the case of electrolysis.
Pharmcological methds include ovarian suppressin using the combined oral contraceptive pill(COCP) (1) . COCPs with androgenic progectogens should be avoided as these mayworsen hirsutism. Dianette, containing the anti-androgen cyproterone acetate may be more suitable. Cyproterone acetate may be used alone but reliable contraception must be used as it can emasculate a male foetus.
If COCP is contraindicated, medroxyprogesterone can be used (1) . Topical treatment with eflormiththine hydrochloride (Vaniqa) is effective for use on the face and chin. Improvement is evident by eight weeks after start of use and is maintained throughout treatment but hair growth is same as pretreatment, by eight weeks after stopping (1) . Skin irritation is the major side-effect.
Other systemic therapy include the anti-androgen flutamide (1) , which can cause hepatotoxicity; spironolactone, but can cause hyperkalaemia and hypertension or the finasteride.
Posted by PAUL A.
A.
History taking should focus on cycle problems, especially oligo-amenorrhea being common in PCOS. Any changes in weight related to the complaints or cycle ? meaning?? . I will ask regarding contraception, current method, recent changes, and use of COCP (as it would reduce hirsutism and risk for endometrial hyperplasia). I’ll enquire regarding obstetric history and whether keen to conceive as many treatments will interefer with the latter (1) . I’ll ask for changes in voice and baldness as well as family history for ovarian tumours are these familial? , to assess whether there may be an androgen producing tumour (1) (very rare).
I’ll assess weight and height to calculate BMI and assess whether obese to determine likelihood of PCOS. Blood pressure (1) as it is often found together with PCOS. I’ll examine breasts for atrophy and abdominal for palpable mass (ie androgen producing tumour). I’ll look at distribution of the hair pattern to see whether it is typically male. On inspection of the vulva I look for enlarged clitoris suggestive of hormone producing tumour (or late onset AGS) (1) Ferriman-Gallway score .
I will also ask her about any medication that may affect hairgrowth.

B.
Blood investigations include testosterone levels (although readings variable), DHEA-S, Prolactine, TSH & fT4, FSH & LH and Renal function test with electrolytes. An abdominal or – if difficult to assess, transvaginal ultrasound to assess the ovaries is needed (1) 21-OH-progesterone, MRI FOR ADRENAL MASS; Karyotype .

C.
Treatment of the PCOS will mostly also resolve the problems of hirsutism.
Weight loss (1) combined with exercise in those obese must be encouraged, as it will restore cycle and hormonal balance as well as reduce overweight related health risks. Motivation is difficult though and it takes time and good compliance. Metformine 500 mg 3 times daily can be used as adjunct, will often favourably improve lipid profile, but can often cause gastro-intestinal complaints.
COCP (1) will regulate cycle, increase SHBG and thus reduce circulating testosterone, but would be problematic if she is keen to conceive. Dianette as contraceptive has the additional benefit of the anti-androgenic action of the crypteronacetate component. Anti-androgens are all problematic if she is keen to conceive what if she does not want a pregnancy? Which drugs are available and what is their value? as they affect the fetus (teratogenic, e-masculanisation). Symptomatic treatment would be in the form of bleaching, epilation (with or without small electric current), foam for hair removal, or even shaving (1) .
Posted by Atashi S.
(a) Detailed history regarding duration , site of excessive hair growth and its effect on quality of life should be taken. Her desire for treatment should be ascertained. Menstrual history including LMP, H/O irregular bleeding, oligomenorrhoea, amenorrhoea should be taken, which is associated with PCOS. Obstetric history including H/O recurrent miscarriage, H/O sub fertility which are also associated with PCOS. Contraceptive history including H/O taking injectable depot preparation or use of hormonal IUCD which may be the cause. Drug history should be taken regarding H/O taking danazole, anabolic steroid, testosterone, androgenic progestogen which may be the cause. On examination presence of striae in the skin should be looked for .BMI should be assessed and BP should be measured. P/A examination is to be done for to exclude any suspected ovarian or adrenal tumour. P/V examination is to be done to detect any cliteromegaly. Bimanual examination is to be done to exclude any ovarian tumour.
(b) Blood for androstenedion, sex hormone binding globulin, fasting glucose and insulin ratio, serum FSH and LH ratio and oestradiol and oestrone ratio is to be done to detect PCOS. Serum testosterone and DHEA level to be tested which is markedly elevated in case of androgen producing ovarian or adrenal tumour. Serum 17 hydroxy progesterone is to be tested as it is elevated in case of late onset congenital adrenal hyperplasia .USG is to be done to detect polycystic ovary.
( c) Explanation of the condition to the patient. She should be advised for weight reduction and achieve BMI <25. Oral contraceptive pill will remove excess androgen and will reduce sex hormone binding globulin. Pill containing 3rd generation progesterone is suitable. Cyproterone acetate can be given which can be act as an anti androgen and improve hirsutism. But it can be used with barrier contraception as it emasculate female foetus Other anti androgen like flutamide can be used .All the pharmacological agent will take longer time to be effective of at least 3to 6 month .Use of Metformin is shown to be moderately effective in case of hirsutism in PCO. Cosmetic method like shaving, electrolysis will remove hair temporarily but it do not prevent terminal hair growth.
Posted by PAUL A.
Detailed history may determine the aetiology of hirsutism. As, secondary or oligomenorrhoea, progressive gain weight and inability to conceive may be a cause of polycystic ovarian syndrome (PCOS) and Cushing\'s syndrome (1) . Voice change may indicate a virilism of androgenic adrenal or ovarian tumour (1) . Also, history of drug intake may be a cause of hirsutism like, Danazol (1) for Endometriosis, psychotropic drugs and Diasoxide for hypertension.
Examination of the patient may indicate the cause of hirsutism. General examination with hypertension may be a sign of Cushing\'s syndrome. Cushinoid features of increase body mass index (1) , broad chest, deposition of fat in abdominal area and thin leg with week muscles. Virilization distribution of hair, boldness of the head and atrophy of the breast may indicate an androgenic tumour. Freidman Gallway (1) classification can estimate the severity of condition, a score out of total 44. Abdominal examination and palpation of any abdomino-pelvic masses cliteromegaly .

Investigation required should includes, LH, FSH of the second to third day of the period(PCOS) not criterion for diagnosis , free testosterone, Androstendion (Ovarian tumour) and dehydroepiandrostendrione (adrenal tumour) (1) DHEA-S. Ultrasound examination as pelvic (abdominal or trans vaginal) for ovarian mass, and upper abdominal for adrenal mass ? MRI .

Treatment of PCOS can be as following, Cyproterone acetate (2mg/day) in combination with ethinyl estradiol may be used as cyclic forms. It may be used as a contraceptive method. Cyproterone acetate (50 mg/day in the first 10 days of the cycle), however contraception should be used while using such regimen. Third generation progestogen (Desogetryl and gestoden) in combination with ethinyl estradiol as combined oral contraceptive pills (COCP) (1) Other COCP containing Desporinon (Yasmine) may be used. Spirinolactone, antiandrogenic drug may be used, however electrolyte imbalance in form of hyponatremia as a drawback of spirnolactone. Flutamide is another antiandrogenic medication can be used however it may cause liver toxicity, so, liver function may be evaluated before medication started ARE THESE DRUGS EFFECTIVE? . Cosmotic treatment (1) in form laser ablation and bleaching can be used as it may improve the psychological condition. Psychological referral can be offered in case of resistant cases.