Chapter 168 Hirsutism
INTRODUCTION
Description: Hirsutism refers to increased or excessive hair growth only. It may be idiopathic (hypertrichosis) or caused by androgen-stimulated excessive growth. Hypertrichosis involves increased hair on the extremities and tends to be ethnic, racial, or familial in origin. This is not considered hirsutism.
Prevalence: Five percent to twenty-five percent of women, variable within ethnic groups, 60% of women with Cushing’s disease.
ETIOLOGY AND PATHOGENESIS
Causes: Familial, idiopathic, increased hair follicle androgens (5α-reductase). Increased androgen production—ovarian (polycystic ovary syndrome, hilus cell hyperplasia/tumor, arrhenoblastoma, adrenal rest), adrenal (congenital adrenal hyperplasia [10% to 15% of women with hirsutism], Cushing’s disease, virilizing carcinoma or adenoma). Drugs (minoxidil, androgens [including Danocrine], phenytoin, diazoxide). Other (hypothyroidism, hyperprolactinemia).
DIAGNOSTIC APPROACH
Differential Diagnosis
• Cushing’s disease (truncal obesity, facial rounding, cervicodorsal fat deposition [buffalo hump], and red or purple striae are often not fully developed)
• Iatrogenic hirsutism (patients may use steroids for a number of reasons, legal and otherwise, and may not recognize the possibility of virilizing side effects; the use of danazol sodium [e.g., for endometriosis therapy] also may be associated with increased hair growth)
Workup and Evaluation
Laboratory: Evaluation for possible virilizing process (prolactin, dehydroepiandrosterone sulfate [DHEA-s], follicle-stimulating hormone [FSH], thyroid screening). (Patients suspected of having adrenal sources of hyperandrogenicity may be screened by measuring 24-hour urinary-free cortisol, by performing adrenocorticotropic hormone [ACTH] stimulation tests, or by performing an overnight dexamethasone suppression test.) Circulating testosterone is generally normal or only mildly elevated (>1.5 ng/mL). Of patients with idiopathic hirsutism, 80% have elevated levels of 3α-diol-G (metabolite of 5α-reductase).
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