A detailed history is taken by a provider in search of possible causes for hyperandrogenism or other non-endocrine-related causes. If the distribution of hair growth occurs throughout the body, this is referred to as hypertrichosis, not hirsutism. Endocrine causes
Ovarian cysts such as in polycystic ovary syndrome (PCOS), the most common cause in women. Adrenal gland tumors, adrenocortical adenomas, and adrenocortical carcinoma, as well as adrenal hyperplasia due to pituitary adenomas (as in Cushings disease). Inborn errors of steroid metabolism such as in congenital adrenal hyperplasia, most commonly caused by 21-hydroxylase deficiency. Acromegaly and gigantism (growth hormone and IGF-1 excess), usually due to pituitary tumors. Causes of hirsutism not related to hyperandrogenism include
Familial: Family history of hirsutism with normal androgen levels. Drug-induced: medications were used before the onset of hirsutism. The recommendation is to stop the medication and replace it with another.Minoxidil
Testosterone, danazol, progestins, anabolic steroids, valproic acid, methyldopa
Pregnancy or post-menopause: moderate hirsutism due to prolactin secretion and hyperandrogenism due to decrease estrogen production, respectively. Idiopathic: When no other cause can be attributed to an individuals hirsutism, the cause is considered idiopathic by exclusion. In these cases, mensuration cycles and androgen levels are normal. Diagnosis
Hirsutism is a clinical diagnosis of excessive androgenic, terminal hair growth. A complete physical evaluation should be done prior to initiating more extensive studies, the examiner should differentiate between widespread body hair increase and male pattern virilization. One method of evaluating hirsutism is the Ferriman-Gallwey Score which gives a score based on the amount and location of hair growth.
The Ferriman-Gallwey Score has various cutoffs due to variable expressivity of hair growth based on ethnic background.Diagnosis of patients with even mild hirsutism should include assessment of ovulation and ovarian ultrasound, due to the high prevalence of polycystic ovary syndrome (PCOS), as well as 17α-hydroxyprogesterone (because of the possibility of finding nonclassic 21-hydroxylase deficiency). People with hirsutism may present with an elevated serum dehydroepiandrosterone sulfate (DHEA-S) level, however, additional imaging is required to discriminate between malignant and benign etiologies of adrenal hyperandrogenism. Levels greater than 700 μg/dL are indicative of adrenal gland dysfunction, particularly congenital adrenal hyperplasia due to 21-hydroxylase deficiency. However, PCOS and idiopathic hirsutism make up 90% of cases. Treatment
Treatment of hirsutism is indicated when hair growth causes patient distress. The two main approaches to treatment are pharmacologic therapies targeting androgen production/action, and direct hair removal methods including electrolysis and photoepilaiton. These may be used independently or in combination. Pharmacologic therapies
Common medications consist of antiandrogens, insulin sensitizers, and oral contraceptive pills. All three types of therapy have demonstrated efficacy on their own, however insulin sensitizers are shown to be less effective than antiandrogens and oral contraceptive pills. The therapies may be combined, as directed by a physician, in line with the patients medical goals. Antiandrogens are drugs that block the effects of androgens like testosterone and dihydrotestosterone (DHT) in the body. They are the most effective pharmacologic treatment for patient-important hirsutism, however they have teratogenic potential, and are therefore not recommended in people who are pregnant or desire pregnancy.