Hirsutism resident survival guide

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Hirsutism Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: S.Mojdeh Mirmomen, M.D.

Synonyms and Keywords: Approach to hirsutism, Hirsutism workup, Excessive hair growth management

Overview

Hirsutism is a common endocrinological and dermatological complaint that is defined as a condition that results in the presence of excessive amounts of dark coarse hair (terminal hair) in a male-like pattern distribution in females. It usually appears in the chin, upper lip, chest, back, and anterior thighs. Hirsutism presents in 5-10% of females in reproductive age [1]. Hirsutism is different from hypertrichosis that defined as excessive hair growth all over the body with no sexual distribution and it is not an androgen-dependent condition. Underlying androgen disorders are the most common causes of hirsutism and polycystic ovary syndrome (PCOS) accounts for nearly 70-80% of these conditions. Pharmacological therapy or direct hair removal methods is considered as initial therapy for women with mild hirsutism without underlying endocrine disorders. Lifestyle modifications are also recommended in obese patients with PCOS.

Causes

Common Causes

Hyperandrogenic hirsutism

Non-hyperandrogenic hirsutism

Diagnosis

Shown below is an algorithm summarizing the diagnosis of hirsutism according the Endocrine Society Clinical Practice guideline. [2][3]

 
 
 
 
Initial evaluation & diagnosis of hirsutism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History & physical examination including pelvic examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medication use?
Ask for anabolic or androgenic steroids (in athletes, patients who are using dietary supplements, patients with sexual dysfunction, or in patients with a partner who uses testosterone gel) and valproic acid (in patient with neurologic disorders)
 
 
 
Discontinue medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Isolated local hair growth
 
 
 
Direct hair removal methods
 
 
 
Improvement or stable
 
 
 
Normal variant
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal hirsutism score or local hair growth with symptoms* suggesting hyperandrogenic endocrine disorder?
*Symptoms include menstrual irregularity, infertility, galactorrhea, signs or symptoms of hypothyroidism, Cushing syndrome, acromegaly, central obesity, acanthosis nigricans, clitoromegaly, or sudden-onset or rapid-progression hirsutism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Early morning total testosterone blood level
 
 
 
Progression or unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
 
 
 
 
 
 
 
 
 
Elevated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild isolated hirsutism
 
 
 
 
 
 
Moderate to severe hirsutism or presence of hyperandrogenic endocrine disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct hair removal methods or oral contraceptive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement or stable
 
Progression or unstable
 
 
 
Free testosterone blood level
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Elevated
 
Hyperandrogenemia
 
 
 
Full hormonal workup^
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Idiopathic hirsutism
 
Reevaluate if hirsutism progresses
 
  • The most important hyperandrogenic endocrine disorders that need to be evaluated include PCOS, nonclassic congenital adrenal hyperplasia, Cushing syndrome, androgen-secreting tumors and hyperprolactinemia.


  • Ferriman–Gallwey hirsutism scoring system.
  • Each of the nine sensitive to androgen body parts (upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, arm and thigh) is assigned a score from 0-4 for absent to severe hirsutism.
  • The total hirsutism score is calculated by adding separate scores from each body part. In the US, generalized hirsutism that defined as a score equal or greater than 8, is abnormal, but regionally excessive hair growth with score less than 8 considered as a common normal variant [4]. The normal score is lower and higher in Asian and Mediterranean populations, respectively.[2]

Treatment

The below algorithm summarizes the treatment of hirsutism according the Endocrine Society Clinical Practice guideline.[2]

 
 
 
 
 
 
 
 
 
 
Initial therapy for patient with hirsutism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild hirsutism and no evidence of an endocrine disorder
 
 
 
 
 
 
Moderate or patient-important hirsutism
 
 
 
 
Severe hirsutism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Direct hair removal methods
 
Pharmacological therapy
 
 
 
Pharmacological therapy (add direct hair removal if needed)
 
 
 
 
Combined pharmacological therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Photoepilation for women with auburn, brown, or black unwanted hair
Electrolysis for women with white or blonde hair
 
 
 
 
• Start oral contraceptives in women who are not seeking fertility
** Use oral contraceptives containing the lowest effective dose of ethinyl estradiol and a low-risk progestin for women at higher risk for venous thromboembolism (e.g., obese or >39 years old)
• Start either oral contraceptives or anti-androgens in women who are not sexually active, have undergone permanent sterilization, or who are using long-acting reversible contraception
 
 
 
 
 
 
 
Oral contraceptives and antiandrogens
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Add an antiandrogen if hirsutism remains despite 6 months of monotherapy with an oral contraceptive
 
 
 
 
 
 
 
 
 
 

Do's

  • A trial of at least 6 months is required before making any changes in dose or type of the drug.[2]

Don'ts

  • Combination therapy of an oral contraceptive and antiandrogen is not recommended as an initial therapy unless the patient is suffering from severe hirsutism.[2] [4]

References

  1. Barrionuevo P, Nabhan M, Altayar O, Wang Z, Erwin PJ, Asi N; et al. (2018). "Treatment Options for Hirsutism: A Systematic Review and Network Meta-Analysis". J Clin Endocrinol Metab. 103 (4): 1258–1264. doi:10.1210/jc.2017-02052. PMID Review 29522176 Review Check |pmid= value (help).
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Martin KA, Anderson RR, Chang RJ, Ehrmann DA, Lobo RA, Murad MH; et al. (2018). "Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 103 (4): 1233–1257. doi:10.1210/jc.2018-00241. PMID 29522147.
  3. Bode D, Seehusen DA, Baird D (2012). "Hirsutism in women". Am Fam Physician. 85 (4): 373–80. PMID 22335316.
  4. 4.0 4.1 Mihailidis J, Dermesropian R, Taxel P, Luthra P, Grant-Kels JM (2017). "Endocrine evaluation of hirsutism". Int J Womens Dermatol. 3 (1 Suppl): S6–S10. doi:10.1016/j.ijwd.2017.02.007. PMC 5419053. PMID 28492032.