EXCESSIVE HAIR GROWTH
HIRSUTISM
VIRILIZATION
Hair typeS
• Lanugo : Body hair seen in newborn
• Vellus : Fine adult hair covering body
• Terminal hair : Thick pigmented hair
of scalp and pubic area
Hair cycleS
• Anagen : Growth
influenced by disorders
• Catagen : rapid involution
• Telogen : Quiescent
Eyebrows , eyelashes , vellus hairs
androgen-insensitive
axillary and pubic areas
sensitive to low levels of androgens
scalp region androgens cause
scalp hairs to spend less time in
anagen
HIRSUTISM
EXCESSIVE COARSE (TERMINAL)HAIR.
IN PATTERN NOT NORMAL IN FEMALE .
( facial , chest , upper abdominal hair)
HYPERTRICHOSIS
EXCESS NORMAL
DISTRIBUTION
and
NORMAL
PATTERN OF
medication such as antiepileptics
Hyperthyroidism
anorexia nervosa
VIRILIZATION
IN severe pathologic condition , malignancy
 FRONTOTEMPORAL BALDING
 DEPPENING OF VOICE
 DECREASED BREAST SIZE
 CLITORAL HYPERTROPHY
 INCREASED MUSCLE MASS
 AMENORREA / OLIGOMENORRHEA
androgen levels and quantity of
hair growth is not parrarel
variability in end-organ sensitivity.
Genetic factors
ethnic background
dark-haired individuals
EXCESS REPONSIVITY TO ANDROGEN
TESTOSTERONE
in target receptors
5-ALPHA –REDUCTASE 1
DIHIDROTESTOSTERONE
Excessive response of receptor to DHT
due to mutation in gene
ovaries and adrenal glands
normally contribute equally to
androgen production.
Gonadal hyperandrogenism
Polycystic ovary syndrom
insulin resistance Syndrom
Ovarian neoplasm
Adrenal hyperandrogenism
Congenital adrenal hyperplasia (nonclassic and classic)
Cushing's syndrome
Adrenal neoplasms
Other endocrine disorders
Hyperprolactinemia
Acromegaly
thyroid dis.
Peripheral androgen overproduction
Obesity
Idiopathic
Pregnancy-related hyperandrogenism
Hyperreactio luteinalis
Thecoma of pregnancy
Drugs
Androgens
oral contraceptives containing androgenic progestins
Minoxidil
Phenytoin
Diazoxide
Cyclosporine
ADRENAL ANDROGEN EXCESS
21 alpha Hydroxylase defieiency
11-beta-Hydroxylase deficiency
3-beta-dehydrogenase deficiency
*Classical forms usually presented in
neonatal period as ambiguous genitalia
*Nonclassic forms are linked with
hirsutism.
Drugs & Exogenous Hormones
variety of drugs decrease SHGB, resulting in
increased levels of free T
Androgens
Corticosteroids
Minoxidil
Phenytoin
diazoxide
cyclosporin
APPROACH TO DIAGNOSIS
Careful history
Onset and progression
Family history
medications
Precocious puberty
suggests adrenal enzyme defect
Physical Exam
• Hair pattern type,distribution ,quantity
(F&G)
• acne
• Virilization
• Cushingoid features, galactorrhea ,
acromegal…
• Acanthosis nigricans (in PCOS)
• Wt , ht , BP
• Tanner staging
• Ovarian masses
Evaluation of Hirsutism
1. Total testosterone & or free
2. DHEAS
  DHEAS
adrenal source
CAH or Cushings
  T , DHEA-S normal or minimally elevated
Ovarian source
Pelvice U/S r/o tumor
 Rapid Onset Virilization T>2ng/mL
indicate ovarian neoplasm
A baseline plasma total testosterone level
(>3.5 ng/mL) usually indicates a virilizing
tumor
(>2 ng/mL) is suggestive. nl=1
A basal DHEAS level (>7000 µg/L)
nl=2500suggests an adrenal tumor.
CT or MRI for adrenal mass.
ultrasound may help to identify an ovarian
mass.
treatment
Management
Estrogen
effective 20%
• Reduces LH so ovarian androgen
• increased SHBG
• competition at the cellular level for binding
to androgen receptor
• lower DHEA ( with lower ACTH ?!)
Progestins vary in suppressive effect on SHBG
levels so in androgenic potential.
Ethynodiol diacetate low androgenic potential
Norgestimate nonandrogenic.
Drospirenone
analogue of spironolactone (anti mineralocorticoid)
& antiandrogenic
Ocp
contraindicated
• history of thromboemboli
• increased risk of breast or other
estrogen-dependent cancers .
relative contraindication
smokers
hypertension
history of migraine
SIPRONOLACTONE:
• Androgen receptors
• Androgen biosynthesis
• metabolic clearance of teststerone
( Testosterone  Estrogen )
Spironolactone + OC is well established
regimen
BP low, K low, female feature in male fetus ,
irregular mens
Cyproterone acetate
•Competitive inhibition of binding testosterone
and DHT to androgen receptor.
•Clearance of testosterone by inducing hepatic
enzymes
Cyproterone (50 to 100 mg) is given on days 1 to 15 and ethinyl
estradiol (50 µg) is given on days 5 to 26 of the menstrual cycle.
Side effects: irregular uterine bleeding,
nausea, headache, fatigue, weight gain, and
decreased libido.
FLUTAMIDE :
Blocks the androgen receptors
.liver side effect
KETOCONAZOLE:
• liver toxicity
Eflornithine cream (Vaniqa)
long-term efficacy remains to be
established.