Hirsutism

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Chapter 18 HIRSUTISM

Theodore O’Connell

Hirsutism is defined as the presence of excessive coarse terminal hair in a pattern not normal in women in areas such as the face, chest, or upper abdomen. This disorder is a sign of increased androgen action on hair follicles, which may result from increased levels of endogenous or exogenous androgens or from increased sensitivity of hair follicles to normal levels of circulating androgens.

In evaluating hirsutism, it is important to determine whether hirsutism exists alone or whether virilization is also present. This distinction is important because virilization may reflect a serious underlying pathologic condition, such as malignancy. Virilization manifests with a wide range of signs of androgen excess in addition to hirsutism, such as acne, frontotemporal balding, amenorrhea, oligomenorrhea, deepening of the voice, and clitoromegaly.

The most common triggering mechanism for hirsutism is excess androgen production. Although androgens may come from an exogenous source, androgen excess is most commonly endogenous. The two primary sources of endogenous androgens are the adrenal glands and the ovaries. Adrenal gland–related causes include congenital adrenal hyperplasia, Cushing syndrome, or tumor. Ovarian causes include polycystic ovary syndrome and tumors.

Medications Linked to Hirsutism

Anabolic steroids

Progestins (especially levonorgestrel, norethindrone, and norgestrel)

Suggested Work-Up

Measurement of serum testosterone, serum 17α-hydroxyprogesterone, and dehydroepiandrosterone sulfate (DHEAS)	To evaluate for ovarian and adrenal tumors and adult-onset adrenal hyperplasia
Serum prolactin measurement	To evaluate for pituitary tumors
Thyroid-stimulating hormone (TSH) measurement	To evaluate for thyroid dysfunction
Fasting serum glucose measurement	To evaluate for insulin resistance in patients suspected of having polycystic ovary syndrome

Additional Work-Up

Adrenocorticotropic hormone (ACTH) stimulation test	When Cushing syndrome or adult-onset congenital adrenal hyperplasia is suspected
Glucose tolerance test	In patients with suspected polycystic ovary syndrome with elevated fasting serum glucose levels
CT scanning of the abdomen and pelvis	To assess the adrenal glands and ovaries in patients whose history, physical examination findings, or laboratory evaluation results are suggestive of the presence of a virilizing tumor

FURTHER READING

Gilchrist VJ, Hecht BR. A practical approach to hirsutism. Am Fam Physician. 1995;52:1837-1846.

Hunter MH, Carek PJ. Evaluation and treatment of women with hirsutism. Am Fam Physician. 2003;67:2565-2572.

Leung AK, Robson WL. Hirsutism. Int J Dermatol. 1993;32:773-777.

Plouffe L. Disorders of excessive hair growth in the adolescent. Obstet Gynecol Clin. 2000;27:79-99.

Redmond GP, Bergfeld WF. Diagnostic approach to androgen disorders in women: acne, hirsutism, and alopecia. Cleve Clin J Med. 1990;57:423-427.

Speroff L, Glass RH, Kase NG, editors. Clinical Gynecologic Endocrinology and Infertility, 6th. Baltimore: Lippincott Williams & Wilkins. 1999:529-556.

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