Hirsutism

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  • This may be an unrealistic goal for most of my patients but it is fun to think about.
  • Hirsutism

    1. 1. Hirsutism <ul><li>Prepared By : </li></ul><ul><li>Muhammad Aaqib Roll No. 105 </li></ul><ul><li>Batch G </li></ul>JAM
    2. 2. Hirsutism <ul><li>Definition </li></ul><ul><li>APPEARANCE OF EXCESSIVE COARSE (TERMINAL)HAIR IN A PATTERN NOT NORMAL IN THE FEMALE </li></ul><ul><li>Definition highlights the abnormal distribution of excess hair growth ,such as facial ,chest,or upper abdominal hair </li></ul>JAM
    3. 3. JAM
    4. 4. Hirsutism JAM
    5. 5. Hirsutism JAM
    6. 6. Hirsutism JAM
    7. 7. Hirsutism JAM
    8. 8. HYPERTRICHOSIS : <ul><li>GROWTH OF HAIR IN EXCESS OF THE NORMAL WHILE LIMITED TO A NORMAL PATTERN OF DISTRIBUTION </li></ul><ul><li>It is frequently associated with the use of medication such as antiepileptics </li></ul>JAM
    9. 9. VIRILIZATION : <ul><li>VIRILIZATION : REFERS TO CONCURRENT PRESENTATION OF HIRSUTISM WITH A BROAD RANGE OF SIGNS SUGGESTIVE OF ANDROGEN EXCESS , SUCH AS </li></ul><ul><li>ACNE, </li></ul><ul><li>FRONTOTEMPORAL BALDING, </li></ul><ul><li>DEEPENING OF THE VOICE , </li></ul><ul><li>A DECREASE IN BREAST SIZE </li></ul><ul><li>CLITORAL HYPERTROPHY </li></ul>JAM
    10. 10. VIRILIZATION <ul><li>INCREASED MUSCLE MASS </li></ul><ul><li>AMENORREA / OLIGOMENORRHEA </li></ul><ul><li>Virilization is seen less frequently than hirsutism and may reflect a severe underlying pathologic condition ,such as malignancy </li></ul><ul><li>Hirsutism and virilization are closely linked and hirsutism may actually be the first manifestation of a condition that ultimately will lead to virilization in left untreated </li></ul>JAM
    11. 11. VIRILIZATION JAM
    12. 12. BASIC FACTS ABOUT HAIR <ul><li>Three types of Hair : </li></ul><ul><li>Lanugo : Body hair seen in the fetus and newborn </li></ul><ul><li>Vellus : Fine adult hair covering the body </li></ul><ul><li>Terminal hair : Thick pigmented hair of scalp and pubic area </li></ul><ul><li>Thickness of the terminal hair varies form one individual to other depending upon genetic, and possibly nutritional </li></ul>JAM
    13. 13. PRESENTATION OF HIRSUTISM <ul><li>Hirsutism may present in variety of ways </li></ul><ul><li>Hirsutism alone </li></ul><ul><li>Hirsutism and associated pilosebaceous unit overactivity (acne) </li></ul><ul><li>Hirsutism and ovulatory disorders </li></ul><ul><li>Hirsutism and signs of virilization </li></ul>JAM
    14. 14. PRESENTATION OF HIRSUTISM <ul><li>Hirsutism alone is the greatest challenge,patients usually go to dermatologist </li></ul><ul><li>Hirsutism wIth acne is frequently in teenage girls </li></ul><ul><li>Hirsutism with ovulatory disorders comes mostly to gynecologist </li></ul><ul><li>Hirsutism with virilization requires immediate work-up </li></ul>JAM
    15. 15. PATHOGENESIS <ul><li>Androgens are present in the circulation in free and protein bound form </li></ul><ul><li>Binding protein is called is called sex hormone binding protein (SHBG) </li></ul><ul><li>Testosrerone acts after its conversion to dihydrotestosterone </li></ul><ul><li>This conversion is brought about by 5-alpha Reductase enzyme </li></ul>JAM
    16. 16. PATHOGENESIS <ul><li>Hair growt is regulated by Androgens and an excessive hair growth may be as a result of one the following </li></ul><ul><li>1. Incresed circulating androgens derived from Ovaries or the Adrenals. </li></ul><ul><li>2. Incresed percentage of free testosterone due to decreased levels of SHBGs </li></ul>JAM
    17. 17. PATHOGENESIS <ul><li>3. Incresed peripheral conversion of testosterone into dihydrotestosterone due to incresed 5-alpha reductase activity. </li></ul><ul><li>4. Genetic or racial predisposition for an increased number of hair follicles per unit skin area </li></ul>JAM
    18. 18. CAUSES OF HIRSUTISM <ul><li>Congenital adrenal hyperplasia </li></ul><ul><li>Testosterone secreting tumors </li></ul><ul><li>Adrenal tumors </li></ul><ul><li>Polycystic ovarian disease </li></ul><ul><li>End organ receptor hypersensitivty </li></ul><ul><li>Medications </li></ul><ul><li>Familial </li></ul><ul><li>Acromegaly </li></ul><ul><li>Idiopathic </li></ul>JAM
    19. 19. DISORDERS OF EXCESS ANDROGEN PRODUCTION <ul><li>Source of androgen : </li></ul><ul><li>Exogenous </li></ul><ul><li>Endogenous (most common) </li></ul><ul><li>Two primary endogenous sources : </li></ul><ul><li>Adrenal glands </li></ul><ul><li>Ovaries </li></ul>JAM
    20. 20. DISORDERS OF EXCESS ANDROGEN PRODUCTION <ul><li>ADRENAL ANDROGEN EXCESS </li></ul><ul><li>May be linked to genetically determined steroid synthesis enzyme deficiency </li></ul><ul><li>Malignant adrenal neoplastic process </li></ul><ul><li>Other conditions like Cushing’s syndrome </li></ul>JAM
    21. 21. DISORDERS OF EXCESS ANDROGEN PRODUCTION <ul><li>Cushing’s syndrome :Hirsutism with weight gain and growth retardation as the primary manifestation,with acne and other cutaneous problems </li></ul>JAM
    22. 22. DISORDERS OF EXCESS ANDROGEN PRODUCTION <ul><li>OVARIAN ORIGIN </li></ul><ul><li>Most common cause is </li></ul><ul><li>POLYCYSTIC OVARIAN SYMDROME </li></ul><ul><li>Other </li></ul><ul><li>Neoplastic ovarian disease </li></ul>JAM
    23. 23. RELATIVE ANDROGEN EXCESS AND SHBG <ul><li><3 % TESTOSTERONE IS FREE </li></ul><ul><li>Mostly bound to Sex hormone binding globuline(SHBG) </li></ul><ul><li>Dcrease in SHBG leads to Excess free Testosterone </li></ul><ul><li>Causes of Reduced SHBG : PCOS(Chronic anovulation) and Obesity </li></ul>JAM
    24. 24. EXCESS REPONSIVITY TO ANDROGEN <ul><li>Excessive response of the receptor to DHT may be due to mutation of the gene of the receptor located on X Chromosome </li></ul><ul><li>Over activity of the 5-alpha-reductase (Type –1 and Type 2] is involved in hirsutism </li></ul>JAM
    25. 25. BASIC APPROACH TO THE DIAGNOSIS OF HIRSUTISM AND VIRILIZATION <ul><li>SYMPTOMS AND HISTORY </li></ul><ul><li>SIGNS </li></ul><ul><li>PHYSICAL EXAMINATION </li></ul><ul><li>INVESTIGATION </li></ul>JAM
    26. 26. APPROACH TO DIAGNOSIS <ul><li>It should be methodical. </li></ul><ul><li>First step : True nature of presentation </li></ul><ul><li>Patient may present with ovulatory problems and hirsutism may not be reported </li></ul><ul><li>There may be normal hair pattern but patient complains about hirsutism </li></ul><ul><li>Evident virilization should investigated at once </li></ul>JAM
    27. 27. APPROACH TO DIAGNOSIS <ul><li>Careful history regarding the timing of onset and chronological progression </li></ul><ul><li>Precocious puberty with androgen excess suggests adrenal enzyme defect </li></ul><ul><li>Family history : androgen excess disorders </li></ul>JAM
    28. 28. APPROACH TO DIAGNOSIS <ul><li>Physical examination </li></ul><ul><li>Establish presence of hirsutism and quantifying it [Ferriman-Gallwey score] </li></ul><ul><li>Presence of acne and virilization and rule out hypertrichosis </li></ul><ul><li>Skin hyperpigmentation,acanthosis nigricans suggests insulin resistance.Often associated with PCO </li></ul>JAM
    29. 29. Ferriman-Gallwey score A total score greater than 8 is considered to be abnormal. JAM
    30. 30. APPROACH TO DIAGNOSIS <ul><li>Measurement of weight and height and blood pressure: defects relates to adrenal enzyme defects </li></ul><ul><li>Galactorrhoea </li></ul><ul><li>Visual genital examination for virilization </li></ul>JAM
    31. 31. APPROACH TO DIAGNOSIS <ul><li>Semiobjective scoring system : Ferriman and Gallwey system ,between 6-12 is the lower limit. </li></ul>JAM
    32. 32. APPROACH TO DIAGNOSIS <ul><li>INVESTIGATION : </li></ul><ul><li>HIRSUTISM: Goal is to rule out serious potential life threatening conditions and gain information that helps in treatment </li></ul><ul><li>Evaluation of Androgen excess: </li></ul><ul><li>Testosterone ,total preferred </li></ul><ul><li>DHEAS </li></ul><ul><li>In selected cases : 17-OHP(fasting morning sample) </li></ul>JAM
    33. 33. APPROACH TO DIAGNOSIS <ul><li>Evaluation of accompanying medical disorder </li></ul><ul><li>Ovulation disorder :FSH,LH </li></ul><ul><li>Thyroid dysfunction:TSH </li></ul><ul><li>Hyperprolactinemia :PRL </li></ul><ul><li>Other investigations ( inselected cases) </li></ul><ul><li>Androgen production :Androstenedione, </li></ul><ul><li>3-alpha Androstenediol glucuronide </li></ul><ul><li>Provocative tests : Corticotropin stimulation tests,Insulin resistance determination </li></ul>JAM
    34. 34. THERAPEUTIC OPTIONS <ul><li>HIRSUTISM </li></ul><ul><li>GOAL: </li></ul><ul><li>The prevention of further stimulation of hair growth </li></ul><ul><li>Cosmetic correction of the problem </li></ul>JAM
    35. 35. THERAPEUTIC OPTIONS <ul><li>BASIC STEPS OF MANAGEMENT OF HIRSUTISM ARE : </li></ul><ul><li>DEFINE THE PROBLEM </li></ul><ul><li>QUANTIFY THE DEGREE OF HIRSUTISM </li></ul><ul><li>INDENTIFY THE PATHOPHYSIOLOGY </li></ul><ul><li>CORRECT THE PROBLEM,WHETHER ACUTE OR CHRONIC </li></ul><ul><li>DEFINE SUCCESS WITH THE PATIENT </li></ul><ul><li>FOLLOW UP </li></ul>JAM
    36. 36. THERAPEUTIC OPTIONS <ul><li>A key element of any therapeutic plan is to define what will ultimately be viewed and successful therapy </li></ul><ul><li>Regular follow up is indicated at appropriate intervals,usually every 3- 6 months </li></ul>JAM
    37. 37. THERAPEUTIC OPTIONS <ul><li>GENERAL MEASURES : </li></ul><ul><li>Eliminating causative factors </li></ul><ul><li>Optimizing weight </li></ul><ul><li>Manage hair </li></ul><ul><li>Bleaching </li></ul><ul><li>Cutting or shaving </li></ul><ul><li>Electrolysis </li></ul><ul><li>Laser epilation </li></ul>JAM
    38. 38. THERAPEUTIC OPTIONS <ul><li>Management of excess ovarian androgen production : </li></ul><ul><li>Standard therapy is :combined E+P,most commonly OCs </li></ul><ul><li>It reduces ovarian androgen production </li></ul><ul><li>It increases SHBG </li></ul><ul><li>It induces competition at the cellular level for binding to the androgen receptor </li></ul>JAM
    39. 39. THERAPEUTIC OPTIONS <ul><li>Choice of OC </li></ul><ul><li>Some OCs have intrinsic androgens especially progesterone component. So selection should be made accordingly. </li></ul><ul><li>EE + Norgestimarte </li></ul><ul><li>Cyproterone acetate used as progesterone component in Ocs </li></ul>JAM
    40. 40. THERAPEUTIC OPTIONS <ul><li>OVARIAN SUPPRESSION BY LONG ACTING GnRH ANALOGUE </li></ul><ul><li>Can be used for functional ovarian androgen overproduction and even for malignant condition </li></ul><ul><li>But to be used for long with back-up </li></ul>JAM
    41. 41. THERAPEUTIC OPTIONS <ul><li>Long acting GnRH analogues used </li></ul><ul><li>But there is doubt that this therapy will be beneficial over Ocs </li></ul><ul><li>INSULIN SENSITIZING AGENTS: </li></ul><ul><li>For PCO with acanthosis nigicans </li></ul><ul><li>Commonly used agent is : Metformin and Troglitazone,Pioglitazone,Rosiglitazone </li></ul>JAM
    42. 42. THERAPEUTIC OPTIONS <ul><li>MANAGEMENT OF EXCESS ADRENAL ANDROGEN PRODUCTION </li></ul><ul><li>Metabolic correction of the disorder,usually with exogenous steroids </li></ul><ul><li>Dexamethasone,mostly used,But LIMITED ROLE </li></ul>JAM
    43. 43. THERAPEUTIC OPTIONS <ul><li>Management directed to the target organ and cells </li></ul><ul><li>Competition with Androgen receptors:Spironolactone,Flutamide, Ketoconazole,Cyproterone acetate </li></ul><ul><li>5-alpha reductase Inhibitors :Finasteride </li></ul>JAM
    44. 44. THERAPEUTIC OPTIONS androgen receptors competitors <ul><li>SIPRONOLACTONE: </li></ul><ul><li>Best studied and as Gold standard </li></ul><ul><li>Mechanism :Androgen receptors blockade </li></ul><ul><li>Suppression of Androgen biosynthesis </li></ul><ul><li>Increased metabolic clearance of teststerone ( Testosterone  Estrogen ) </li></ul><ul><li>50-200 mg/day in two divided doses </li></ul><ul><li>Spironolactone + OC is well established regimen </li></ul>JAM
    45. 45. THERAPEUTIC OPTIONS androgen receptors competitors <ul><li>FLUTAMIDE : </li></ul><ul><li>Blocks the androgen receptors </li></ul><ul><li>Decreases androgen production </li></ul><ul><li>May have therapeutic value in cases of PCOS </li></ul><ul><li>Usually used with Ocs </li></ul><ul><li>KETOCONAZOLE: </li></ul><ul><li>Equally effective but danger of liver toxicity </li></ul>JAM
    46. 46. THERAPEUTIC OPTIONS <ul><li>SELECTING BEST THERAPY: </li></ul><ul><li>Correct underlying medical problem </li></ul><ul><li>Correct thyroid/hyperprolactinemia </li></ul><ul><li>PCO :oral contraceptives </li></ul><ul><li>Ocs + spironolactone is usually the choice </li></ul><ul><li>75 –80% patients shows response </li></ul><ul><li>Atleast 6 months is needed for evidence of response </li></ul>JAM
    47. 47. THERAPEUTIC OPTIONS <ul><li>If response is seen in 6 months then treatment should be continued for further 6 months and in most cases for number of years </li></ul>JAM
    48. 48. JAM
    49. 49. Hirsutism: Treatment JAM
    50. 50. THANK YOU JAM

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