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
Hypertricosis: Excessive growth of non
sexual hair as in nevoid hypertricosis,
anorexia nervosa, nerve injuries, and
CLASSIFICATION OF HIRSUTISM
Mild: Fine pigmented hair affecting the
face (incomplete beard), chest, abdomen
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
CAUSES OF HIRSUTISM
1. Adrenal gland:
Congenital adrenal hyperplasia (partial or
complete 21 hydroxylase deficiency, 11
hydroxylase deficiency, 3 B ol
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 &
Ovarian hyperandrogenism: as PCOD,
hyperthecosis, stromal cell hyperplasia in
post menopausal woman & hilar cell
3. Mixed ovarian & adrenal
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
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
Hyperprolactinemia; (prolactin stimulates
the production of DHAS by adrenal gland).
Increase production of adrenal androgen
through corticotropin androgen stimulating
6. Iatrogenic drugs:
Danazol is a 17 alpha ethinyl testosterone
Progestogen of the 19 nor-testosterone
Androgen is sometimes used for treatment
of postmenopausal osteoporosis.
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
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
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
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
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
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