Q3.

What further information would

you seek on clinical examination?
1. Measure height, weight, and blood pressure
May suggest conditions of androgen excess

Documentation of hair amount, distribution, and characteristics in androgen

dependent areas (Modified FerrimanGallway score for grading hirsutism)
Terminal hair Vellus hair
Areas: Face, Inter-mammary
Dark region, gluteal area and anterior
Softthighs
Important to differentiate
Thick Fine
between terminal hair and vellus hair (vellus hair is
not hirsutism) Coarse Unpigmented
 3. Look for clinical features of related causes of hirsutism
Causes Features
PCOS (polycystic Hirsutism
ovarian Acne
syndrome) Male pattern baldness
Androgen Sudden onset or rapid progression of hair growth
secreting tumor Severe hirsutism
Signs of virilization (severe form of androgen excess)
Deepening of voice
Temporal balding
Breast atrophy
Clitoromegaly
Pelvic or abdominal mass
Cushings Increased fat distribution in the face , neck region, upper back and
syndrome torso
Striae ( purple or red)
Easy bruising
Proximal muscle weakness
Congenital Hirsutism
Adrenal Clitoral hypertrophy
Hyperplasia Urogenital abnormalities (penile urethra or hypospadius)
(CAH) Labioscrotal fusion
Ferriman-Gallway scoring system

Cleveland Clinic Journal of Medicine June 2010 vol. 77 no. 6 388-398

Q4. What investigations should be
arranged?
 General Investigations
Blood investigations (specific markers)
Urine dipstick (TRO Diabetes Mellitus)
Urea and Electrolytes (low potassium in CAH)
Pelvic ultrasonography to detect an ovarian
neoplasm or a polycystic ovary.
Magnetic resonance imaging (MRI) or
computed tomography (CT) of the adrenal
region is useful for diagnosis.
 Specific markers
Testosterone
raised (>200 ng/ml) in case of malignant tumor of the adrenal or ovary

Dehydroepiandrosterone sulfate (DHEAS)

Raised DHEAS (>700 g/dl) indicates an adrenal cause, benign or malignant.

17 Hydroxy progesterone
Unique for CAH. <200 ng/dl excludes the disease. Mildly increased levels
between 300-1,000 ng/dl require an ACTH stimulation test.

24H urine free cortisol

measured in women with signs and symptoms of Cushing's syndrome.

LH/FSH greater than 3 is indicative of PCOS

Prolactin raised in hyperprolactinemia due to hypothalamic disease or a

pituitary tumor.
 Q5. What treatment options are
available for this woman, how long
would they need to be taken for, and
how effective they are?

Principles of management of hirsutism:

1. To remove the source of excess
androgen.
2. To suppress or neutralize the action
of androgen.
3. To remove the excess hair.
 1. Removal of source
W
eight reduction reduce hyperinsulinaemia &
androgen excess
Adrenal or ovarian tumor should be surgically
treated.

Cushings disease can be treated by
adrenalectomy, radiation to the pituitary or
removal of ACTH producing tumor by
transsphenoidal surgery.
In iatrogenic cases, the offending drugs should
be stopped.
 2. Suppress/neutralize excess
Androgen
Hormone profile Drugs
Elevated T (Ovary) Combined oral contraceptives (COC s containing
drospirenone or desogestrel)

Normal T and DHEA-S Anti-androgens

3-AG (idiopathic) i.e: Cyproterone acetate (Dianette)

DHEA-S ,normal T Dexamethasone

Women intolerant of other GnRH analogues with low-dose HRT

therapies
Hyperinsulinaemia Metformin

Duration of therapy: Response of all the drugs are slow.

Drugs should be continued for at least 6 months.
 3. Remove excess hair
Ways Explanation (effectiveness)
Shaving Does not increase the rate of hair growth or thicken hair
Useful technique and yields instant results.
Leave stubble that is unpleasant, unsightly, and sharp, and may irritate
the skin.
Waxing and Effective
plucking Can be painful and may cause scarring, folliculitis, and
hyperpigmentation.
Bleaching Improve the appearance of dark hair in the short term
May lead to skin irritation.
Skin irritation is problematic as it is itchy, unsightly, and paradoxically
can lead to increased hair growth.
Electrolysis Uses a localized electric charge to destroy hair cells at the bulb.
Effective
Time-consuming, painful, and may leave scars or pigmentation changes.
Lasers Used selectively in the process of photothermolysis, a recent technique
that generally yields better results than electrolysis.
Only affects hair in the growing phase, thus must be repeated over
several months.
More effective if used with Eflornithine cream (Vaniqua),applied topically