1. General Medicine Conference “Hirsutism” General Medicine Conference “Hirsutism” Selim Krim, MD Assistant professor Texas Tech University Health Sciences Center

2. OBJECTIVES Define hirsutism Get familiar with the Ferriman-Gallway scale to evaluate the extent of hair growth Understand the pathogenesis of hirsutism Be familiar with available therapies Use a stepwise approach when evaluating for hirsutism

3. CASE A 19-year-old woman seeks care for slowly progressive hair growth. Since high school, she has shaved her upper lip weekly and waxed her abdomen and thighs monthly. Her menstrual periods are regular. Physical examination is unremarkable except for a body- mass index (the weight in kilograms divided by the square of the height in meters) of 31 and trace hair over the abdomen and thighs, with a moderate amount over her back. There is no clitorimegaly. How should this patient be evaluated and treated?

4. DEFINITION “Excessive terminal hair that appears in a male pattern (i.e., sexual hair) in women” “Excessive terminal hair that appears in a male pattern (i.e., sexual hair) in women” Deplewski et al. Endocr Rev 2000;21:363-92

5. CLASSIFICATION

6. PATHOGENESIS

7. DIFFERENTIAL DIAGNOSIS HYPERTRICHOSIS Generalized excessive hair growth secondary to heredity or medications ( Steroids, phenytoin, Cyclosporine). Hair is distributed in a generalized, non sexual pattern. Not caused by excess of androgens

8. ETIOLOGIES Normal androgen levels: Idiopathic hirsutism Excess androgen levels: Polycystic ovary syndrome Congenital adrenal hyperplasia Androgen secreting tumors Cushing’s syndrome HyperprolactinemiaAcromegaly Thyroid dysfunction Androgenic medications

9. DIAGNOSIS History and physical exam helps ruling out other causes of virilizing disorders, polycystic ovary syndrome, medication use or other endocrinopathies. Look for evidence of anovulation, obesity, metabolic syndrome. A rapid pace of development or progression of hirsutism or evidence of virilization (Clitoromegaly or increasing muscularity) should raise concern that an androgen- secreting tumor is present

10. STEPWISE APPROACH TO HIRSUTISM

11. MANAGEMENT Cosmetic and physical measures Hormonal treatments Estrogen-progestin oral contraceptives Antiandrogens Other hormonal therapies: (Glucocorticoids, 5 alpha- reductase inhibitors, metformin and thaizolidinediones)

12. AVAILABLE THERAPY

13. CASE A 19-year-old woman seeks care for slowly progressive hair growth. Since high school, she has shaved her upper lip weekly and waxed her abdomen and thighs monthly. Her menstrual periods are regular. Physical examination is unremarkable except for a body-mass index (the weight in kilograms divided by the square of the height in meters) of 31 and trace hair over the abdomen and thighs, with a moderate amount over her back. There is no clitorimegaly. How should this patient be evaluated and treated? Based on Ferriman-Gallway scale, this patient has mild hirsutism There are no signs of virilization and her menstrual cycles are regular However the increase in her weight may warrant further testing Free testosterone levels

14. CASE A trial of eflornithine chloride cream may be tried for facial hirsutism Encourage weight control If hirsutism remains uncontrolled, oral contraceptives may be used over a 9 to 12 months period May also discuss the potential permanent benefit, risks, and cost of laser hair removal

15. Questions ? Questions ?

16. Thank you Thank you