Hirsutism

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 6 Hirsutism

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

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

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