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Hirsutism or frazonism is the excessive hairiness on women in those parts of the body where terminal hair does not normally occur or is minimal - for example, ...
HIRSUTISM DEFINITION Hirsutism: Excessive growth of androgen dependent sexual hair. It is present on the upper lip, chin, tip of the nose, lobes of ears, limbs, chest, abdomen & upper pubic triangle. Hypertricosis: Excessive growth of non sexual hair as in nevoid hypertricosis, anorexia nervosa, nerve injuries, and hypothyroidism. CLASSIFICATION OF HIRSUTISM Mild: Fine pigmented hair affecting the face (incomplete beard), chest, abdomen & perineum. Moderate: Coarse pigmented hair affecting same areas as in mild cases. Severe: Coarse pigmented hair affecting the face (complete beard), tip of nose, ear lobes, temporal recession, chest, abdomen, perineum & proximal interphalangeal joints. CAUSES OF HIRSUTISM 1. Adrenal gland: Congenital adrenal hyperplasia (partial or complete 21 hydroxylase deficiency, 11 hydroxylase deficiency, 3 B ol dehydrogenase deficiency). Adrenal tumors: usually develop before the age of puberty or after the age of menopause. These tumors secrete DHA, DHA-S & rarely testosterone. 2. Ovarian causes: Androgenic ovarian tumors as sertoli lyedig cell tumor, adrenal rest tumor, hilar cell tumor, and gonadoblastoma. These tumors secrete mainly testosterone & rarely DHA. Ovarian hyperandrogenism: as PCOD, hyperthecosis, stromal cell hyperplasia in post menopausal woman & hilar cell hyperplasia. 3. Mixed ovarian & adrenal hyperandrogenism: 30-40% of cases of hirsutism are due to combined ovarian & adrenal hyperandrogenism. Increase adrenal production of androgen leads to inhibition of follicular maturation & induction of premature atresia and consequent increase in the production of ovarian androgen. 4. Thyroid gland: Hypothyroidism due to decrease of SHBG may be associated with hirutism. 5. Pituitary gland: Cushing’s syndrome due to increase production of ACTH. Acromegaly due to increased production of GH. Hyperprolactinemia; (prolactin stimulates the production of DHAS by adrenal gland). Increase production of adrenal androgen through corticotropin androgen stimulating hormone (CASH). 6. Iatrogenic drugs: Danazol is a 17 alpha ethinyl testosterone derivative. Progestogen of the 19 nor-testosterone derivative. Androgen is sometimes used for treatment of postmenopausal osteoporosis. 7. Idiopathic: Many cases of hirsutism are not associated with increased androgen production, but may be due to increase sensitivity of hair follicles to normal female androgen levels, either due to increased receptor activity or due to increased activity of the enzyme 5 alpha reductase, which is responsible for conversion of testosterone (T) into DHT which has a more potent action. INVESTIGATIONS for a case of HIRSUTISM 1. Hormonal assays Plasma T level (n= 0.2-0.8 ng/ml), levels > 2 ng/ml suggest androgen secreting tumor. Free T level (n= 1-3% of total T) it is a good index for androgenicity. DHAS is secreted by the adrenal glands only, (n= 1500-2500 ng/ml), levels > 9000 ng/ml suggests adrenal tumor. Thyroid function test. 2. Ovarian & Renal vein catheterization; may point to the source of excess androgen Other investigations: X ray skull lateral view on sella turcica. CT scanning on the pituitary. Visual field examination. IVP for adrenal tumor. Abdominal & pelvic ultrasonography. Laparoscopy to visualize the ovaries. TREATMENT OF A CASE OF HIRSUTISM: Treatment of the cause. Oral Contraceptive Pills (OCP): they are indicated in cases of ovarian & combined hyperandrogenism, or severe DUB irrespective to the cause of hyperandrogenism. Progestogen content suppresses the production of ovarian androgen & estrogenic content increases the level of SHBG and decreases the level of free T. Progestogen: either depot provera 300 mg/3 months IM or provera tablets 30 mg/day. They suppress LH & decrease ovarian production of androgen + increase the metabolic clearance rate of androgen. Dexamethasone: 0.5-1 mg at bed time. It is indicated in cases of adrenal hyperandrogenism. Plasma cortisol level should be done frequently as the dose of dexamethasone should be high enough to suppress androgen but not high enough to suppress cortisol. Cyproterone acetate: It is powerful antiandrogen that competes with androgen at the receptor site. Dose: 100mg/day for 10 days (day 5-14) + ethinyl estradiol 0.05mg/day for 21 days (day 5-25) to minimize menstrual irregularities. Diane (an OCP containing 2mg cyproterone acetate + 0.05mg ethinyl estradiol) is given from day 5-25 of the cycle. Side effects include headache, nausea & vomiting, weight gain and menstrual irregularities. 6. Spironolactone: in a dose of 100-200 mg/day, is a powerful antihypertensive drug. It competes with androgen at the receptor site as well as it increases the metabolic clearance rate of androgen. 7. Cimetidine: it competes with androgen at the receptor site. Dose: 300mg 5 times daily. 8. Removal of already formed hair by depilatories, electrolysis, or laser therapy
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