Hirsutism: Differential Diagnosis, Examination and Management – Gynecology | Lecturio


[Music] let’s now review the differential diagnosis of hirsutism there can be non androgen and causes of hirsutism one of those being acromegaly here I have a picture of a patient in her younger years versus her later years is there anything you notice about the patient besides her aging have you guessed it I’ll give you a hint look closely at her features well if you said her features look course then you’re correct this is very common with acromegaly and this is a cause of hirsutism you can also have hirsutism with skin irritation such as with the application of retinoic acid certain medications can also lead to hirsutism including cyclosporine Phinney toen minoxidil calcium channel blockers and also other medications listed here there are again androgenic causes we have a whole lecture set entitled PCOS where you can learn more there is another phenomenon called the hair and syndrome and for more information download the slides associated with this lecture there’s also something called idiopathic hirsutism we really don’t know why but we think it’s enzymatic activity at the level of the hair follicle then there’s non-classical CAH for more information about congenital adrenal hyperplasia please see the slides entitled CAH or congenital adrenal hyperplasia and then very rarely we can see Android and secreting neoplasms in the ovary or the adrenal recall that elevated prolactin can also cause hirsutism luteum of pregnancy can also be an antigenic cause and this usually happens when the placenta also has some issue as well the collodion cysts are also associated with high maternal serum HCG remember that Cushing’s syndrome is a differential diagnosis in hirsutism this is often tested during the USMLE so pay close attention to the next slides are you ready here we go lets rule out Cushing’s syndrome what are the signs of elevated cortisol in a patient who presents with hirsutism they may have fat accumulation around the face and neck they may have a buffalo hump but this can also be seen in just an obese patient they typically have central obesity that means obesity around the abdomen belly one distinguishing feature though is purple striae these are not normal stretch marks as you can see in panel B this patient has purple striae they appear purple as opposed to dark like normal stretch marks this is because you can see the vessels in the thin skin of a patient who has elevated cortisol if you see this in a patient you definitely need to obtain a 24-hour urinary cortisol you may need to do this on several occasions before you can make a diagnosis there are other tests regarding how elevated cortisol that you can find in other lectures upon physical exam you can find hair growth in a male distribution pattern traditionally we used a fair man Galloway score and a score greater than 8 was associated with hirsutism however 25% of patients who have hirsutism use some sort of cosmetic treatment for excessive hair including bleaching plucking shaving and threading so this has become less useful as a clinical assessment but it’s important to note let’s now go over a checklist if you see evidence of clitoral megali you should think that this patient has androgen excess what if she has Galacta Rhea what would you expect if you said elevated prolactin that’s correct sometimes you can see abdominal pelvic masses that can actually secrete androgens which lead to hirsutism treatment of hirsutism is aimed at reducing the production or increasing the bonding and/or blocking the action of androgens since PCOS is by far the most common cause of hirsutism oral contraceptive pills are the first-line therapy the management of PCOS is discussed in a later lecture but let’s review it here sixty to a hundred percent of women who report hirsutism and then use OCPs have subsequent improvement if other medications are used a woman must be on contraception to prevent any anti-androgen effects in a male fetus oral contraceptive pills decrease LH secretion from the anterior pituitary this results unless a stimulation of the theca cells in the ovary which ultimately leads to decreased testosterone production if there’s decreased testosterone you guessed it there’s less free testosterone also the estrogen in the pill increases sex hormone binding globulin which binds more free testosterone remember in addition to actually suppressing LH secretion estrogen stimulates sex hormone binding globulin production also oral contraceptive pills decrease adrenal production of DHT s and we think that progestin x’ in contraceptives actually inhibit 5-alpha reductase activity in the skin there are other medications that we can use instead of oral contraceptive pills or with oral contraceptive pills these include medications that actually block androgen action one of these is spironolactone it’s an aldosterone antagonist in a mild diuretic it’s an effective therapy because it actually blocks the Antron receptor decreases 5-alpha reductase and competes for the binding of testosterone with sex hormone binding globulin flut amide is another alternative however caution this may be on your USMLE exam there have been reports of liver enzyme abnormalities and hepatitis also these patients get green urine which can be very distressing and excessive dryness of skin and scalp hair however it is known to be an androgen receptor blocker and it’s as as effective as spironolactone in the u.s. we do not have access to cpa however in other countries they do this is a strong progestin and it’s an anti-androgen that decreases circulating testosterone an inch and I own finally there’s finasteride which is a 5 alpha reductase inhibitor there are also some cosmetic solutions for hirsutism remember that even if you treat hirsutism with an OC pee or other medical management the effect will not be immediate so patients still need to participate in cosmetic of hair this can include laser hair removal electrolysis topical creams and this cream is actually a cream that actually inhibits the enzyme active in the dermal papillae that’s essential for hair growth however it is very expensive and it’s usually not covered by insurance in the u.s. women can also undergo waxing normal shaving threading and different agents that will actually cause the hair to fall out thank you for listening and good luck on your exam [Music] you

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