​Kembara Xtra - Medicine - Hirsutism

​Kembara Xtra - Medicine - Hirsutism 
excessive terminal (coarse, pigmented) hair on the body and face in a male pattern; may be an ethnic trait present in healthy adults; may develop as a result of androgen excess; commonly seen in polycystic ovary syndrome (PCOS), which is characterized by hirsutism, acne, irregular menstrual cycles, and obesity; system(s) affected: dermatologic, endocrine, metabolic, reproductive

Epidemiology 

Prevalence 
5 to 10% of women in reproductive age

Pathophysiology and Etiology 
As a result of enhanced peripheral binding (idiopathic) or production of androgenic (male) hormones from the ovaries, adrenals, or body fat.
Exogenous pharmaceuticals
Can be a sign of a variety of causes, such as androgen-secreting tumors, virilizing diseases, PCOS, or the use of androgenic medications.
Genetics Multifactorial

Risk factors include family history, ethnicity (such as Ashkenazi Jews and people from Mediterranean ancestry), and obesity.

Prevention 

Women who have the severe early-onset childhood disorder congenital adrenal hyperplasia (CAH) should be advised that they may be carriers for the condition.

Accompanying Conditions 

Insulin resistance is a prevalent problem, and prolonged amenorrhea and anovulation are also frequent problems. PCOS is the most common cause of premenopausal hirsutism.
Depression and emotional anguish are frequent
Common acne

 Risk for endometrial hyperplasia or cancer, rare; central obesity; hypothyroidism/hyperthyroidism, rare; hyperprolactinemia, rare;
Cushing syndrome: marked by moon facies, striae, hypertension, and rapid virilization (rapid onset, clitoromegaly, baldness, and deeper voice)
Rare acromegaly

Low vitamin D levels

Presenting History: Weight; Psychosocial Impact on Patient; Menstrual and Fertility History; Anovulation (Defined as Ovulatory Cycle >35 Days); Severity, Time Course, and Age of Onset of Hirsutism;
Severe acne, especially if it is resistant to therapy; the presence of virilization; and a medication history that includes the use of glucocorticoids, testosterone, valproic acid, danazol, and topical androgens by a spouse or other person.

There is galactorrhea present.

clinical assessment 
Hair growth that is more abundant in premenopausal women, especially on their chins, necks, sideburns, lower backs, sternums, abdomens, shoulders, buttocks, and inner thighs.
Look for acanthosis nigricans (velvety black skin in the axillae or neck), striae, and acne on the skin.
Deep voice, male pattern baldness, increased muscle mass, and clitoromegaly are signs of virilization and indicate a malignancy risk.
The Ferriman-Gallwey scale, a tool for diagnosing hirsutism that measures hair growth in nine locations on a scale from 0 to 4, with >8 being positive, underrates patient impression of hirsutism and is influenced by prior cosmetic procedures. Scores between 8 and 15 are regarded as mild, 16 to 25 as moderate, and >25 as severe hirsutism.


Multiple Diagnoses 

 PCOS (72–82%)—infertility, irregular menstruation, high androgen levels, polycystic ovaries on ultrasound, and insulin resistance
Idiopathic hyperandrogenemia (6–15%), which is characterized by hirsutism with normal ovaries on ultrasound, increased androgen levels, and no other apparent etiology.
Idiopathic hirsutism (4–7%) is hirsutism with regular menstrual cycles, testosterone levels, and ovaries on ultrasound, with no other apparent etiology.
In amenorrheic patients, late-onset CAH (2-4%), a hereditary enzyme deficit linked to more severe and earlier-onset hirsutism, manifests in adolescence as severe hirsutism and irregular menstruation.
ovaries (benign or malignant) or adrenals (usually malignant); fast onset, virilization, and treatment resistance. Androgen-secreting tumor (0.2%)
Ovarian hyperthecosis, a theca cell-mediated rise in testosterone. Spontaneous virilization and the gradual onset of hirsutism, which primarily affect postmenopausal women
Thyroid dysfunction, hyperprolactinemia when galactorrhea or amenorrhea are present, and uncommon endocrine illnesses such Cushing syndrome and acromegaly


Laboratory Results 

In all women with an abnormal hirsutism score, check the testosterone levels. Guidelines advise evaluating early morning 17-hydroxyprogesterone levels to assess hyperandrogenemic women for NCCAH caused by 21-hydroxylase insufficiency.

Menstrual dysfunction, clinical or biochemical hyperandrogenemia, and polycystic ovaries were two of the three symptoms of PCOS that led to the diagnosis on US tests.
Lab testing is used to rule out rare pituitary disorders and underlying tumors.
Initial examinations (lab, imaging)
A total testosterone level +/- thyroid screen (TSH) is the first step in the evaluation of moderate hirsutism.

Testosterone: A random testosterone total level is typically adequate.
● About 40 to 60 ng/dL (1.4 to 2.1 nmol/L) of blood total testosterone is considered to be the normal upper range in adult females. Patients with PCOS-like symptoms but normal total testosterone levels should undergo further testing, preferably an early morning serum free testosterone level determined by sex hormone—binding globulin (SHBG) levels. Free testosterone in the morning is 50% more perceptive.

Consider an ovarian or adrenal tumor if your testosterone level is above 150 (some people use 200) ng/dL. also the ovaries and the adrenals, which also produce testosterone, should be scanned. CT is best for the adrenals, whereas US is ideal for the ovaries.
The American College of Obstetricians and Gynecologists (ACOG) suggests the following tests as part of the PCOS workup:
- Screening for metabolic syndrome using a fasting and 2-hour glucose following a 75-g glucose load, a lipid panel, waist circumference, and blood pressure; - looking for polycystic ovaries using an ultrasound of the ovaries; - checking prolactin, FSH, LH, TSH, and a pregnancy test if the patient is amenorrheic; - and if the patient is not pregnant. A LH/FSH ratio greater than 2 indicates PCOS.

Tests in the Future & Special Considerations
17-hydroxyprogesterone (17-OHP) - Elevated levels of 17-OHP (>300) may be a sign of late-onset CAH. Patients with an early onset or those in a high-risk group (Ashkenazi Jews) should be taken into consideration.
– order a corticotropin stimulation test if it is elevated.
Pituitary MRI if prolactin level is high
If PCOS is identified, ACOG advises testing for dyslipidemia and type 2 diabetes.

● In women with PCOS, recent investigations have found an inverse relationship between vitamin D levels and insulin resistance.
Vitamin D supplementation and screening of women who are at risk for vitamin D insufficiency may be recommended.

 Recommends against checking eumenorrheic women with undesired local hair growth for high androgen levels.
Checking DHEA-S (dehydroepiandrosterone sulfate) levels during virilization is advised.
- Levels more than 700 may signify an adrenal tumor.

Management The aim of treatment is to improve metabolic abnormalities and reduce new hair growth, depending on patient desire and psychosocial effects.
If the patient wants to get pregnant, ovulation inducement may be required.
Offer contraceptives as necessary.
All PCOS patients who are overweight are advised to follow a diet with calorie restrictions. The metabolic profile, hirsutism, and fertility are all improved by losing weight. Treat supplementary acne.

First Line of Medicine
For mild hirsutism, direct hair removal or pharmaceutical treatment is advised.

Oral contraceptives are the first line of treatment for hirsutism/acne and monthly irregularities (3)[A]; they alleviate metabolic syndrome, slow but do not stop hair growth, and inhibit ovarian androgen production.
- Ethinyl estradiol doses of 20 to 35 g significantly reduce ovarian androgen synthesis. More androgen is blocked by those containing progestins, such as norgestimate, desogestrel, or drospirenone, but these drugs are also more likely to cause DVTs, especially in individuals who are very fat.
– They continue for years and take six months to show results.
– Since oral medications pass via the liver and trigger the generation of SHBG, they are more effective at controlling hirsutism and acne than vaginal or transdermal treatments (1).
- The lowest dose of an oral contraceptive based on ethinyl estradiol and a low-risk oral contraceptive based on progesterone are advised for people with a high risk of VTE.

If estrogens are not advised, progesterone (oral depot or intermittent) may be utilized.

Apply Eflornithine (Vaniqa) HCl cream BID at least 8 hours apart. It is the only FDA-approved treatment for hirsutism and lowers facial hair in 40% of women.

It has been demonstrated that laser therapy with eflornithine cream produces faster results.
Oral contraceptives combined with antiandrogens are not recommended as a first line treatment unless there is severe hirsutism, significant emotional distress, or no success with oral contraceptives alone (therapy failure after six months).
Next Line
Drugs that block androgens further reduce hirsutism to 15–25%. if outcomes are not satisfactory, is often started six months following first-line therapy. To avoid menorrhagia and possible fetal toxicity, oral contraceptives must be used in conjunction with this medication. Pregnancy calls for the avoidance of all.
50 to 200 mg/day of spirolactone Slow to take effect; use in conjunction with oral contraceptives to avoid menorrhagia. Watch for hyperkalemia, especially if using OCP (Yasmin) that contains drospirenone; do not use during pregnancy.
- Finasteride, which is not FDA-approved and reduces androgen binding by 5 mg per day. Use along with contraception (category X pregnancy).
- Cyproterone, which is not accessible in the United States, is coupled with ethinyl estradiol at a dose of 20 to 50 g for the fifth through fifteenth days of the cycle.
– Due to possible hepatotoxicity, flutamide is not advised.
- The use of topical antiandrogen treatment is not advised.
It is advised against treating hirsutism with insulin-lowering medications alone.

Steroids are used to treat late-onset CAH.
- Dexamethasone: 2 mg/day Hair removal techniques are included in the cosmetic treatment.
Shaving, chemical depilation, plucking, and waxing are temporary methods. Laser epilation and photoepilation are permanent methods that are preferred to electrolysis (4)[C].
- For direct hair removal, ladies with blonde or white hair are advised to use electrolysis rather than photoepilation.
- Pharmacologic treatment is advised to reduce regrowth.
Considerations for Pregnancy May be associated with infertility As hormone balance improves, fertility may increase; use contraception as necessary.
Several therapy drugs should not be utilized during pregnancy.

Healthcare Alternatives 

In modest (50 persons) and brief (12 weeks) research, it has been demonstrated that a number of herbal supplements, such as spearmint tea, saw palmetto, licorice, fennel, and soy, can reduce hair size or androgen levels.


Follow-up patient monitoring Keep an eye out for any recognized drug side effects.

Diet Low-calorie, low-glycemic index diets increase fertility in obese PCOS individuals who are experiencing anovulatory infertility.
Hormonal therapy improves but does not reverse existing hair and stops future hair development.
Cosmetic measures may be required for the existing hair; treatment takes six months to take effect and may need to be lifelong.

Prognosis: Moderate to poor for reversing present hair growth; good (with long-term therapy) for stopping future hair growth


Complications Anemia may result from dysfunctional uterine bleeding if PCOS is present.
Anovulation may raise the risk of endometrial hyperplasia and uterine cancer if PCOS is present.
Androgenic excess may have a negative impact on bone density, heart risk, and cholesterol status.

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