Lecture on Hirsutism Management

Introduction

• Distinction between Hirsutism and Hypertrichosis
  • Hypertrichosis: Non-androgenic hair growth, can be due to medical or endocrine reasons.
  • Hirsutism: Androgenic distribution of hair in females, associated with signs like acne, male pattern hair loss, oily skin, menstrual irregularities.

Types of Hair

• Terminal Hair: Long, pigmented, found on eyebrows, scalp, axillary and pubic areas.
• Vellus Hair: Short, fine hair covering most of the body.

Causes of Hirsutism

1. Androgenic Causes
2. Non-androgenic Causes
3. Idiopathic Causes

Clinical Approach

• History Taking: Look for drug intake, weight changes, presence of acne, hair loss, balding, menstrual and reproductive history.
• Physical Examination: Use Ferriman-Gallwey Scoring to assess hair distribution. Score of 8 or more indicates hirsutism.

Importance of Onset and Progression

• Rapid onset may indicate androgen-secreting tumors.
• Gradual onset suggests ovarian causes or non-malignant androgenic causes.

Hormonal Profile

• Key Tests: Total testosterone, Sex Hormone Binding Globulin (SHBG), Free Androgen Index (FAI).
• FAI Calculation: Total Testosterone / SHBG. A high FAI (>5 nmol/L) warrants further investigation for tumors or non-classical congenital adrenal hyperplasia (CAH).

Differential Diagnosis

• Polycystic Ovary Syndrome (PCOS)

  • Rotterdam Criteria: Requires two of three features - oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovaries.
  • Ultrasound not needed if clinical/biochemical hyperandrogenism and irregular cycles are present.

• Androgen-Secreting Tumors

  • Rapid progression, virilizing symptoms.
  • Use MRI/CT if ultrasound/investigations are inconclusive.

• Late-Onset CAH

  • Due to 21-hydroxylase deficiency, results in elevated 17-hydroxyprogesterone.

• Ovarian Hyperthecosis

  • Common post-menopause, associated with rapid hirsutism, virilization, obesity, and insulin resistance.

• Idiopathic Hirsutism

  • Diagnosed after excluding other causes, especially if only hirsutism is present without menstrual irregularities.

Management

• Patient Goals: Determine if the focus is on cosmetic concerns, fertility, or menstrual regulation.
• Treatment Options:
  • Lifestyle changes and cosmetic procedures.
  • For fertility: Delay anti-androgen treatments.
  • For non-fertility cases: Use combined oral contraceptives (COCs) containing anti-androgens or anti-androgens alone if COCs are contraindicated.

Conclusion

• Importance of considering age, onset, and other symptoms in diagnosis.
• Use of diagnostic tests to differentiate between PCOS, CAH, and tumors.
• Consider patient's reproductive goals in management.

Thank you for attending the lecture! Remember to review the flowcharts and guidelines provided for a detailed approach.