Hirsutism by samola90


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, ...

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 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
 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.
   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
 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
  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
 Progestogen of the 19 nor-testosterone
 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
   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 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
 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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