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Hirsutism , Virilism, Gynaecomastia, Impotence


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Published in: Health & Medicine

Hirsutism , Virilism, Gynaecomastia, Impotence

  1. 1. Hirsutism , Virilism, gynaecomastia, impotence
  2. 2. <ul><li>Hirsutism is common (10% of women)and usually benign . </li></ul><ul><li>It implies increased hair growth in women , in the male pattern . </li></ul><ul><li>If menstruation is normal there is almost certainly no increased testosterone production. </li></ul><ul><li>If menstruation is abdominal the cause is usually polycystic ovary syndrome. </li></ul><ul><li>(stein – Levelthl syndrome): bilateral polycystic ovaries; secondary oligomenorrhoea; infertility ; obesity, Hirsutism . </li></ul><ul><li>The cause is androgen hypersecretion. </li></ul>
  3. 3. Tests : <ul><li>Ultrasound ↑plasma LH:FSH ratio, </li></ul><ul><li>and less consistently, </li></ul><ul><li>↑ testosterone and ↑ oestradiol. </li></ul><ul><li>Another cause of Hirsutism with irregular menses is late-onset congenital adrenal hyperplasia – deficiency of 21-hydroxylase enzyme in the adrenal gland. Ovarian tumours are a rare cause. </li></ul>
  4. 4. Management : <ul><li>operative . Explain that she is not turning into a man </li></ul><ul><li>Depilation with wax or creams, or electrolysis (which is expensive , and time-consuming, but does work). </li></ul><ul><li>1:10 hydrogens help by increasing serum sex hormone-binding globulin – but always combine with a progesterone (= the Pill) to prevent excess risk of uterine neoplasia or cyproterone acetate ( an anti-androgen and progestogen ), eg up to 00 mg on days 1–11, with oestrogen on days 1–21. </li></ul><ul><li>Clomifene (= clomiphene) or infertility. </li></ul>
  5. 5. <ul><li>Virilism is rare . </li></ul><ul><li>It is characterized by amenorrhoea: </li></ul><ul><li>climoromegaly; </li></ul><ul><li>deep voice; </li></ul><ul><li>temporal hair recession; Hirsutism. </li></ul><ul><li>This condition needs further investigations for androgen secreating adrenal and ovarian tumours. </li></ul>
  6. 6. Gynaecomastia : <ul><li>implies an abnormal amount of breast tissue in males (it may occur in normal puberty). </li></ul><ul><li>It is due to an increase in the oesterogen/androgen ration. </li></ul><ul><li>It is seen in syndromes of androgen deficiency (eg Klinefleter’s, Kallman’s). </li></ul><ul><li>It may result from liver disease or testicular tumours (oestrogens ↑), </li></ul><ul><li>or accompany hyperthyroidism . </li></ul>
  7. 7. <ul><li>The commonest causes are drugs: </li></ul><ul><li>oestrogens, especially stiboestrol </li></ul><ul><li>(= diethylistible-strol); </li></ul><ul><li>spironolactone; </li></ul><ul><li>cimetidine ; </li></ul><ul><li>digoxin; </li></ul><ul><li>testosterone; </li></ul><ul><li>marijuana </li></ul>
  8. 8. Impotence: <ul><li>Failure in adult male to sustain adequate erection for viginal penetration . </li></ul><ul><li>It is common in old age. </li></ul><ul><li>Psychological causes are common and are more likely if impotence occurs only in some situations; </li></ul><ul><li>if there is a clear stress to account for the onset of the impotence, and if early morning erections occur (although these may persist at the onset of organic disease) . </li></ul><ul><li>Psychological causes may exacerbate organic causes. </li></ul><ul><li>The major organic cause is diabetes. </li></ul>
  9. 9. Other organic causes are: <ul><li>Drug causes: </li></ul><ul><li>Antihypertensives including diuretics and B –blockers), </li></ul><ul><li>major transquillizers, </li></ul><ul><li>alcohol , </li></ul><ul><li>Oestrogens , </li></ul><ul><li>antidepressants, </li></ul><ul><li>cimetidine. </li></ul>
  10. 10. Pathological causes: <ul><li>Hyperthyroidism, </li></ul><ul><li>hypepgonadism, </li></ul><ul><li>MS, </li></ul><ul><li>autonomic neuropahy, </li></ul><ul><li>atheoma, </li></ul><ul><li>bladder-neck surgery, </li></ul><ul><li>prolactin ↑, </li></ul><ul><li>cirrhosis, </li></ul><ul><li>cancer. </li></ul>
  11. 11. <ul><li>Tests: </li></ul><ul><ul><ul><ul><li>UCEs, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>LFT, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Glucose, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>TFT; </li></ul></ul></ul></ul><ul><ul><ul><ul><li>LH; </li></ul></ul></ul></ul><ul><ul><ul><ul><li>FSH; </li></ul></ul></ul></ul><ul><ul><ul><ul><li>cholestrol; </li></ul></ul></ul></ul>
  12. 12. <ul><li>testosterone (eg if libido ↓) Nocturnal tumescence studies are not usually needed if alprostadial does not induced erection, the cause is probably vasscular. </li></ul><ul><li>Doppler may show ↓ blood flow, </li></ul><ul><li>but is rarely needed as vascular reconstruction is difficult. </li></ul>
  13. 13. Treatment: <ul><li>Mange underlying causes. </li></ul><ul><li>Offer counseling + vacuum aids; </li></ul><ul><li>implants; </li></ul><ul><li>alprostadil, ie prostaglandin E1 (Injection or via urethra); </li></ul><ul><li>or sildenafil (Viagra), a phosphodiesterase inhibitor – increases GMP levels. </li></ul><ul><li>It is effective and administrated orally, SE; headache (16%); flushing (10%); </li></ul><ul><li>dyspepsia (7%); </li></ul><ul><li>nasal congestion (40%); </li></ul><ul><li>mild, transient. </li></ul><ul><li>Predominantly blue/green tingeing of vision (due to inhibition of isoenzyme of PDE6 in the retina or increased pulsatile choroidal flow) </li></ul>
  14. 14. Contraindications to sildenafil (Viagra) <ul><li>Concurrent use of nitrates </li></ul><ul><li>Hepatic impairment </li></ul><ul><li>BP > 90/50 mmHG </li></ul><ul><li>Recent stroke </li></ul><ul><li>Recent myocardial infraction </li></ul><ul><li>Bleeding disorders </li></ul><ul><li>Degenerative retinal disorders </li></ul><ul><li>Active peptic ulceration </li></ul>
  15. 15. Other causations: <ul><li>Peyronie’s disease </li></ul><ul><li>Risk of priapmism (sickle cell anaemia, myeloma , leukemia) </li></ul><ul><li>Concurrent complex antihypertensive régiments </li></ul><ul><li>Dyspnoea on minimal effort (sexual activity may be unsupportable) </li></ul><ul><li>There is a theoretical risk of interactions with inhibitors of cytochrome, </li></ul><ul><li>such as cimetidine. </li></ul><ul><li>Use in men with severe coronary disease has been a question, but in one careful study, </li></ul><ul><li>no adverse cardiovascular effects of were detected in men with severe coronary artery disease. </li></ul>