Hirsutism

Published on 09/03/2015 by admin

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Chapter 6 Hirsutism

Judith Goh

Definition. Hirsutism is the growth of coarse/terminal hair in amounts that are socially unacceptable to a woman. For the woman, this is typically in a male pattern (sexual hair). The Ferriman-Gallwey (see below) hirsutism score is over 8. Under 5% of women (various ethnic origin) in the reproductive age group have scores over 7. Hypertrichosis is generalised excess hair growth that may be hereditary. This is in a non-sexual pattern and is not related to, but may be aggravated by, excess androgens. Virilism is a condition usually secondary to hyperandrogenism and is associated with one or more of clitoral hypertrophy, breast atrophy, male baldness and deepening of the voice.

Prevalence. About 15% of women normally have terminal hair on their faces, and this tends to increase with age. Up to 4% of women seek treatment for hirsutism.

Physiology of hair growth

There are three major groups:

• lanugo: fine, lightly pigmented hair
• vellus hair: short, fine, unpigmented
• terminal hair: longer, thicker and pigmented

Non-sexual hair is present on the scalp, eyebrow and distal extremities. Its growth is not affected by androgens. Ambisexual hair is present in both sexes on the axilla and lower pubic triangle. Small amounts of androgens are required for its growth. Sexual hair is present on the upper pubic triangle, face, chest, ear and nose. It is induced and maintained by androgens.

Hair growth and hirsutism

In the skin, plasma testosterone is converted by 5-alpha-reductase to dihydrotestosterone, which is required for the local stimulation of vellus hair follicles to produce terminal hair. Sensitivity of hair follicles is affected by local metabolism of androgens. Once the hair follicle has been stimulated by androgens to produce terminal hair, the changes persist even in the absence of androgen excess.

Causes of hirsutism

Ovarian

• polycystic ovarian disease, the commonest cause of hirsutism (these women have normal 17-hydroxyprogesterone, raised luteinising hormone (LH) and follicle-stimulating hormone (FSH) ratio (LH:FSH ratio) and elevated prolactin levels)
• tumour: arrhenoblastoma, hilus cell, lipoid, luteoma
• ovotestis

Adrenals

• congenital adrenal hyperplasia, with reduction in the enzyme 21-hydroxylase, an autosomal recessive disease (the women present with ambiguous genitalia and raised levels of 17-hydroxyprogesterone and dehydroepiandrosterone (DHEAS))
• androgen-secreting tumours: over 50% are malignant
• Cushing’s disease with overproduction of adrenocorticotrophic hormone (ACTH)

Others

• endocrinopathies: thyroid dysfunction, acromegaly and hyperprolactinemia
• drugs such as anabolic steroids, danazol and valproic acid

Idiopathic

• normal androgen levels

Investigation and diagnosis

History

• onset, duration, pattern of growth
• weight gain, acne, change in voice
• menstrual changes
• diabetes, Cushing’s syndrome, thyroid disease
• medication, family history

Examination

• general, blood pressure, weight, acne
• Ferriman-Gallwey score for hirsutism
• signs of virilisation
• abdominal and pelvic examination

The diagnosis is a clinical one and the hirsutism score does not necessarily correlate to androgen levels. This is thought be due to the variable response of follicles to androgen.

Investigations

The aim is to exclude serious disease and establish the source of androgens.

• pregnancy test
• ultrasound scan of ovaries for polycystic ovaries or tumour
• early follicular phase tests of serum LH, FSH and prolactin
• glucose tolerance test
• serum levels of free testosterone, DHEAS, androstenedione and 17-hydroxyprogesterone
• assess for Cushing’s syndrome, thyroid function or acromegaly if clinically indicated

Management

Exclude or treat causes (see above).

Principles

• androgen suppression
• peripheral androgen suppression
• removal of unwanted hair
• weight control

Counselling

• reassurance that it is a common condition
• weight loss
• fertility not excluded

Hair therapy

• bleaching to mask hairs
• temporary removal of hair
• epilation, such as plucking or waxing
• depilation, such as shaving, is the removal of hair shaft from the skin surface
• chemicals: may be used to dissolve the hair

Permanent hair reduction

• electrolysis by thermal or chemical methods: causes destruction of hair follicle
• photoepilation using lasers or non-laser light sources: destroys hair follicles

Topical treatment

• eflornithine: an irreversible inhibitor of ornithine decarboxylase, an enzyme necessary for hair growth; reduces hair growth rate but does not remove hair

Pharmacological

Oral contraceptives

• Due to teratogenic potential of antiandrogens (see below), contraception should be used.
• Oral contraceptives also reduce hyperandrogenism by reducing LH (which reduces ovarian androgens), and increase sex hormone-binding globulin (which reduces free serum androgen). Some progesterones (e.g. cyproterone acetate) also act as androgen receptor antagonists.

Spironolactone

• an aldosterone antagonist with dose-dependent inhibition of androgen receptor
• inhibition of 5-alpha-reductase activity
• dose: spironolactone 100–200 mg daily
• contraception required: spironolactone may feminise a male fetus

Cyproterone acetate

• a potent androgen receptor antagonist
• inhibits androgen receptor and inhibits 5-alpha-reductase in the skin
• a potent progesterone that inhibits gonadotrophin and androgen levels
• dose: combined ethinyloestradiol 20–50 μg with cyproterone acetate 50–100 mg
• available as oral contraceptive pill with smaller dose of cyproterone acetate
• side effects include fatigue, reduced libido, weight gain

Finasteride

• inhibition of type 2, 5-alpha reductase activity (types 1 and 2 5-alpha-reductase is involved in hirsutism)
• mixed reports of efficacy compared to spironolactone, with finasteride having either equal or reduced efficacy

Flutamide

• an antiandrogen, inhibiting androgen receptors
• small studies show similar efficacy to spironolactone
• major risk is hepatic toxicity with reported liver failure

Insulin-lowering medications

• The place of these medications (e.g. metformin) in women without menstrual or metabolic dysfunction is controversial.
• Trials have shown reduced efficacy in treating hirsutism compared to spironolactone.

Glucocorticoids

• in small doses, reduce adrenal androgens
• dose is dexamethasone 0.25–0.5 mg/day.
• with antiandrogens, the male fetus may be feminised
• side effects include hypertension, weight gain, skin striae, decrease in bone density

Gonadotropin-releasing hormone agonist (GnRH) agonist

• GnRH analogues: usually combined with oral contraceptive pill and androgen blocker
• rationale: reduce LH and FSH and thus reduce ovarian androgens

Further reading

Martin K.A., Chang R.J., Ehrmann D.A., et al. Evaluation and treatment of hirsutism in premeno-pausal women: an Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism. 2008;93:1105-1120.

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