Hirsutism for undergraduate

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undergraduate course lectures in Obstetrics&Gynecology prepared by DR Manal Behery Professor of OB &Gyne Faculty of medicine ,Zagazig University

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Hirsutism for undergraduate

  1. 1. Dr Manal Behery Prof OB&GYNE ZAGAZIG UNIV 2014
  2. 2. Source of androgens in women • 1-Ovarian theca and stromal cells <LH control 2-Adrenal cortex 3- Peripheral (< pre cursors)  Skin  Adipose tissue  Liver  Placenta
  3. 3. Function of androgen in women ?  Estradiol production (aromatisation in granulosa cells <FSH control)  Sex drive  Muscular mass, etc…
  4. 4. The production rate of testosterone in the normal female is 0.2 to 0.3 mg/day Normal total testosterone concentration in serum is below 0.8ng/ml 6
  5. 5. Androgen in circulation 7 Normal women Hirsute women 80% SHBG 79% SHBG 19% Albumin 19% Albumin 1% Free 2% Free
  6. 6. Types of hair Lanugo Fetal hair Vellus Short, fine, Unpigmented Before puberty Terminal Long, coarse, pigmented arises from vellus hair
  7. 7. Androgen increase in the transformation of the vellus to terminal hair & increase sebaceous Follicle activity
  8. 8. Hirsutism: Excessive growth of terminal hair in male sexual sites.
  9. 9. Hypertrichosis Excessive growth of thin vellus hair at any body site Drug-induced hypertrichosis
  10. 10. Causes
  11. 11. . Hirsutism is a consequence of several factors 1.Androgen production 2. The sensitivity of the androgen receptors at the level of the hair follicle. 3.The activity of 5œ-reductase
  12. 12. Role of 5-Reductase  Converts Testosterone to Dihydrotestostero ne in hair follicles  Is increased in both idiopathic and other forms of hirsutism
  13. 13. •the commonest cause (90%). • •More in African, Mediterranian population. •Positive family history. •* No menstrual abnormalities. * due to increased sensitivity of hair follicle 1) Constitutional (idiopathic):
  14. 14. (2) Ovarian cause: 1. PCO “→ the commonest cause. 2. . Stromal hyperthecosis. 3-Pregnancy luteoma 3. Androgen secreting tumors: - Sertoli-lyedig tumors.- Gynandroblastoma.
  15. 15. Ovarian causes
  16. 16. Reproductive cycle regulated by HPO axis
  17. 17. LH, FSH androgen Estrogen GnRH Anovulation H-P-O axis Dysfunction in PCOS
  18. 18. (3) Adrenal cause: 1.Congenital adrenal hyperplasia. 2. Cushing syndrome. 3. Androgen secreting tumors. Congenital adrenal hyperplasia
  19. 19. 4) Pituitary cause: * Pituitary adenoma "Prolactinoma".  * Growth H. secreting tumor.acromegaly
  20. 20. Anabolic steroids Danazol Metoclopramide Methyldopa Phenothiazines Progestins Reserpine Testosterone 5) Iatrogenic:
  21. 21. (6) Obesity
  22. 22. hirsute alone hirsute with pilosebaceous unit overactivity (acne) hirsutism and ovulatory disorders hirsutism and signs of virilization Presentation of hirsutism
  23. 23. The clinical evaluation of hirsutism  When and where is the hair?  Weight and menstrual history  Family history  Drugs  Acne  Symptoms or signs of virilisation • Temporal hair loss • Voice change • Clitoral enlargement
  24. 24. Ferriman-Gallwey hirsutism scoring system
  25. 25. CLASSIFICATION
  26. 26.  Hirsutism:Ferriman- Gallwey Scoring System Acne: 50% Mild  moderate severe
  27. 27. General examination . Thyroid disease, Cushing syndrome, Signs of virilization, Signs of insulin resistance e.g. acanthosis nigricans.
  28. 28. Acanthosis Nigricans • Velvety plaques on nape of neck and intertriginous areas • Associated with insulin resistance
  29. 29. .Breast: Galactorrhea {Hyperprolactinaemia can be accompanied by increase in adrenal androgen} Breast atropy
  30. 30. Pelvic exam for ovarian mass
  31. 31. Investigations  Investigations are needed if:  Hirsutism occurs in childhood  There are features of virilization   Hirsutism is of sudden or recent onset  There is menstrual irregularity or cessation
  32. 32. Testosterone ng dl) >200 <200 U/S of the ovary Anovulation (PRL, TSH) Adenxal mass Nothing Laparotomy CT of the adrenala & ovaries Laparotomy
  33. 33. Total Testosterone (T) DHEA-S (DS) 17-hyroxyprogesterone (17-OHP) T > 200 ng/dl DS > 700 μg/dl Suspect Tumor 17-OHP > 2 ng/ml Suspect CAH T Elevated ± DS Elevated DS Elevated T & DS Normal PCOS Adrenal Idiopathic Laboratory Evaluation
  34. 34.  PCOS  T LH/FSH  usually inc 2/1  Late-onset CAH 17-OH-P >200 ng/dL  Androgen-secreting ov tumor Total T >200 ng/dL  Androgen-secreting ad tumor DHEAS  >700 g/dL  Cushing syndrome Cortisol Increased  Exogenous androgen use Toxicology  screen Increased
  35. 35. TREATMENT
  36. 36. OCPs: first option when fertility is not desired  Decrease in LH secretion and decrease in androgen production  Increase in hepatic production of (SHBG)  Decreased adrenal androgen secretion
  37. 37. Cyproterone acetate: A progestin with strong antiandrogenic action. Inhibits gonadotrophin secretion and compet efor androgen receptors on target organs Dosage- 100mg from D5-D14 with ethinyloestradiol 30µg, from D 5 to D25
  38. 38.  Androgen receptors blockade  Suppression of Androgen biosynthesis  Increased metabolic clearance of teststerone ( Testosterone  Estrogen )  50-200 mg/day pd  Spironolactone + OC is well established regimen Spironolactone, 50-200 mg per day
  39. 39. Insulin-Sensitizing Agents  Induction of ovulation  Some reduced hair growth  Improved glucose utilization  Lowered serum insulin  Lipid lowering properties
  40. 40. 47 FLUTAMIDE :  Blocks the androgen receptors  Decreases androgen production  Usually used with Ocs KETOCONAZOLE:  Equally effective but danger of liver toxicity  Last resort of treatment.
  41. 41. Electrolysis: . Needle is inserted into the hair follicle •a current is used to destroy the dermal papilla. •All areas, usually the face •May give permanent removal •Pain, scarring, painful, repeat treatments needed, time consuming, expensive, pigmentation
  42. 42. b. Laser & intense pulsed light • A light source sufficient to penetrate to the follicular bulge & the papillae is directed at the hair by probe. •All areas •May give permanent hair reduction, efficient, painless •Dark hair required, expensive, scarring, skin pigmentation, repeated treatments usually necessary
  43. 43. Treatment options for hirsutism  Counselling  Cosmesis  Combined Oral Contraceptive  Cyproterone acetate • With or without COC e.g. Diane  Spironolactone • Causes irregular periods  Topical Eflornithine
  44. 44. Questions?

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