This document discusses the approach to hirsutism, including definitions, causes, clinical assessment, hormonal evaluation, and treatment options. It defines hirsutism as excessive male-pattern hair growth that is androgen dependent. The clinical assessment involves history, physical exam including hirsutism scoring, and lab tests such as testosterone and DHEAS levels. Treatment includes both non-pharmacological options like hair removal as well as pharmacological therapies like combined oral contraceptives, anti-androgens, and 5-alpha reductase inhibitors to suppress androgen production and action. The choice of treatment should be tailored to each individual patient.

1. Approach to
Hirsutism1
P. Krishna Bharadwaj
Moderators
Dr. T. Muneeswar reddy MD
Associate professor
Dr. N. Padmaja MD
Assistant professor

2. Definitions
Hirsutism
Defined as androgen dependent excessive male pattern hair growth
Virilisation
Condition in which androgen levels are sufficiently high to cause
• Deepening of voice
• Breast atrophy
• Increased muscle bulk
• Clitoromegaly
• Increased libido

3. Definitions
Hypertrichosis
refers to hair density or length beyond the
accepted limits of the normal for the particular
age, race or sex.
Androgen independent excess hair growth

4. Hair follicle growth and differentiation
• Vellus : fine, soft, not pigmented
• Terminal : long, coarse, pigmented

5. Differentiation of Pilosebaceous unit
PSU
Sebaceous gland
with vellus hair

6. Cycle of hair growth

7. Hormone regulation in hair growth
cycle
• Androgen insensitive:
• Less sensitive: axillary and pubic hair
• Highly sensitive: chest, upper
abdomen and back

8. Androgens on scalp hair???
Hair loss occurs in scalp
as androgens cause scalp hair
spend less time in the anagen
phase.

9. Correlation between androgens and
hair growth
• Only modest correlation
• Reason: hair growth on follicles depend on
local growth factors and end organ variability
in sensitivity to androgens

10. Genetic and ethnic factors
• Dark haired individuals tend to be more
hirsute than fair skinned.
• Asians and native Americans have less hair in
androgen sensitive regions.
• Mediterranean people have more in the
same.

11. Causes of Hirsutism

12. Clinical assessment
History:
• Age at onset
• Rate of progression
• Associated signs and symptoms like acne and galactorrhea
• Age of onset of menstrual cycles
• Pattern of cycle
• Features of Cushing's syndrome
• Use of any medications
• Family history

13. Physical examination
• BMI
• Blood pressure measurement
• Cutaneous signs like acanthosis nigricans and
skin tags
• Body fat distribution

14. Objective assessment
• Modified scale of FERRIMAN and GALLWEY
• 9 androgen sensitive sites graded from 0 to 4
• Usually 95% of women have score less than 8
• Scores > 8 suggests excessive androgen mediated
hair growth
• Limitations are ethnic considerations where other
features like acne and thinning of scalp hair should
be sought

15. Hirsutism scoring scale of FERRIMAN
AND GALLWEY1

16. Hirsutism scoring scale of FERRIMAN
AND GALLWEY1

17. Hirsutism scoring scale of FERRIMAN
AND GALLWEY1

18. Hormonal evaluation
OVARIE
S
ANDROGENS
LH
ACTH

19. Principal hormones
• Testosterone
• Androstenedione
• Dihydroandrostenedione DHEA
• Sulfated DHEA [DHEA-S]

20. Mechanism
Testosterone Dihydrotestosterone
Isoenzymes of 5 α reductase:
Type 1 sebaceous glands
Type 2 hair follicles and prostate gland
5 α reductase
PSU

21. Lab evaluation
• Testosterone
• DHEAS
• Free testosterone
Plasma testosterone level
>12nmol/l = virilizing tumour
>7nmol/l = suggestive
DHEAS level >18.5µmol/l = adrenal tumour

22. Other investigations
• CT or MRI for localising adrenal mass
• Trans vaginal USG for determing increased
stroma and enlarged ovaries in PCOS
• Measurement of AMH levels
• Dexamethasone suppression test
• Overnight dexamethasone suppresion test
• Measurement of 17(OH) progesterone levels

23. Clinical evaluation of hirsutism

24. Treatment
• Pharmacological
• Non pharmacological
Non pharmacological means must be considered
in all patients either as only treatment or as an
adjunct to drug therapy

25. Non pharmacological treatment
• Bleaching
• Depilatory
• Epilatory
“Shaving does not increase the rate or density of
hair growth”

26. Pharmacological therapy
Interrupting steps in androgen synthesis and action:
• Suppression of adrenal and/or ovarian androgen
production
• Enhancement of androgen binding to plasma proteins
esp. SHBG
• Impairment of peripheral conversion to active
androgen
• Inhibition of androgen action at target tissue level

27. Pharmacological therapy
Combined OCPs are first lie endocrine treatment
for hirsutism and acne, after cosmetic and
dermatologic treatment
• Estrogen component is ethinyl estradiol or
mestranol
• Progestin component predicts the choice of
OCP

28. Effect of OCPs
• May not be evident for 6months
• Maximum effect may require 9-12 month
depending on length of the hair growth cycle

29. Suppression of adrenal androgens
• Adrenal androgens are more sensitive than
cortisol to suppressive effect of
glucocorticoids.
• Dexamethasone or prednisone should be
taken at night time to prevent the nocturnal
surge of ACTH.

30. Anti androgens
• Competitive inhibition of binding of testosterone
and DHT to the androgen receptor.
• Cyproterone acetate is a prototype
• Given on day 1 to day 15 and ethinyl estradiol on
day 5 to day 26 of menstrual cycle.
• Spironolactone is a weak antiandrogen
• As effective as cypro when used at high doses

31. Anti androgens
• Flutamide is a potent non steriodal anti
androgen
• Its hepatocellular toxicity limits use.

32. Enzyme inhibitors
• Finasteride is a 5 α reductase type 2 inhibitor
• Predominance of 5 α reductase type 1 in PSU
limits its efficacy

33. Others
• Eflornithine cream has been approved as
novel treatment for removal of unwanted
facial hair in women
• Overall, choice of any specific agent must be
tailored to the unique needs of the patient
being treated.

34. References
1. Kasper DL et al, Harrison’s principles of
internal medicine. 19th edition. New York:
McGraw-Hill; 2015. p. 331-5.
2. Ehrmann DA et al: Hyperandrogenism,
hirsutism, and polycystic ovary syndrome, in LJ
DeGroot and JL Jameson [eds], Endocrinology,
5th ed. Philadelphia, Saunders, 2006