Hirsutism
Hirsutism: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Hirsutism is the excessive growth of coarse body hair in females. Excessive androgen (male hormone) production stimulates hair growth on the pubic region, axillae, chin, upper lip, cheeks, anterior neck, sternum, linea alba, forearms, abdomen, back, and upper arms. This condition may also occur with normal levels of androgens when there’s an increased sensitivity of the skin to the hormones. In mild hirsutism, fine and pigmented hair appears on the sides of the face and the chin (but doesn’t form a complete beard) and on the extremities, chest, abdomen, and perineum. In moderate hirsutism, coarse and pigmented hair appears on the same areas. In severe hirsutism, coarse hair covers the whole beard area, the proximal interphalangeal joints, and the ears and nose.
Depending on the degree of excess androgen production, hirsutism may be associated with acne and increased skin oiliness, increased libido, and menstrual irregularities (including anovulation and amenorrhea). Extremely high androgen levels cause further virilization, including such signs as breast atrophy, loss of female body contour, frontal balding, and deepening of the voice. (See Recognizing signs of virilization, page 358.)
Hirsutism may result from endocrine abnormalities and idiopathic causes. It may also occur in pregnancy from transient androgen production by the placenta or corpus luteum and in menopause from increased androgen and decreased estrogen production.
CULTURAL CUE:Some patients have a strong familial predisposition to hirsutism, which may be considered normal in the context of their genetic background, culture, and race. Although hirsutism is a female characteristic, excessive hair growth may be present in female and male family members.
History
Begin by asking the patient where on her body she first noticed excessive hair. How old was she then? Where and how quickly did other hirsute areas develop? Does she use any hair removal technique? If so, how often does she use it, and when did she use it last? Next, obtain a menstrual history: the patient’s age at menarche, the duration of her menses, the usual amount of blood flow, and the number of days between menses.
Also ask about medications. If the patient is taking a drug containing an androgen or progestin compound, or another drug that can cause hirsutism, find out its name, dosage, schedule, and therapeutic aim. Does she sometimes miss doses or take extra ones?
Physical assessment
Examine the hirsute areas. Does excessive hair appear only on the upper lip or on other body parts as well? Is the hair fine but pigmented, or dense and coarse? Is the patient obese? Observe the patient for signs of virilization.
Medical causes
Acromegaly
About 15% of patients with acromegaly (a chronic, progressive disorder) display hirsutism. Acromegaly also causes enlarged hands and feet, coarsened facial features, prognathism, increased diaphoresis and need for sleep, oily skin, fatigue, weight gain, heat intolerance, and lethargy.
Adrenocortical carcinoma
Adrenocortical carcinoma produces rapidly progressive hirsutism along with truncal obesity, buffalo hump, moon face, oligomenorrhea, amenorrhea, muscle wasting, and thin skin with purple striae. The patient also exhibits muscle weakness, excessive diaphoresis, poor wound healing, weakness, fatigue, hypertension, hyperpigmentation, and personality changes.
Androgen overproduction by ovaries
The most common cause of hirsutism, androgen overproduction is associated with anovulation that progresses slowly over several years. Other signs of virilization may also become apparent, such as deepening of the voice, acne, and clitoral enlargement.
Cushing’s syndrome
Cushing’s syndrome commonly causes increased hair growth on the face, abdomen, breasts, chest, or upper thighs. Other findings include truncal obesity, buffalo hump, moon face, thin skin, purple striae, ecchymoses, petechiae, muscle wasting and weakness, poor wound healing, hypertension, weakness, fatigue, excessive diaphoresis, hyperpigmentation, menstrual irregularities, and personality changes.
Hyperprolactinemia
Hyperprolactinemia produces hirsutism, hypogonadism, galactorrhea, amenorrhea, and acne. The patient may also have a history of infertility. If a pituitary tumor is the cause of elevated prolactin levels, visual field defects may also be present.
Idiopathic hirsutism
In patients with normal-sized ovaries, normal menses, and no evidence of adrenal hyperplasia or adrenal or ovarian tumors, excess hair appears at puberty and increases into early adulthood. It’s accompanied by acne, obesity, infrequent menses or anovulation, and thick, oily skin. Idiopathic hirsutism with regular ovulation and no menstrual abnormalities may be hereditary or related to certain ethnic groups who are hypersensitive to androgens.
Ovarian tumor
An ovarian tumor can cause rapidly progressing hirsutism — but only if the tumor produces androgens. Amenorrhea and rapidly developing virilization are additional findings. However, some ovarian tumors produce no symptoms.
Polycystic ovary disease
Ovarian cysts, particularly chronic ones, can cause hirsutism. This hirsutism usually occurs after the onset of menstrual irregularities, which may begin at puberty. The patient may also be obese and have amenorrhea, oligomenorrhea, menometrorrhagia, infertility, and acne.
Other causes
Drugs
Hirsutism can result from drugs containing androgens or progestins or from aminoglutethimide, glucocorticoids, metoclopramide, cyclosporine, and minoxidil.
Special considerations
Prepare the patient for tests to determine blood levels of luteinizing hormone, follicle-stimulating hormone (FSH), prolactin, and other hormones. Other tests may include computed tomography scan and ultrasonography.
Pediatric pointers
Childhood hirsutism can stem from congenital adrenal hyperplasia. This disorder is usually detected at birth because affected infants have ambiguous genitalia. Hirsutism that occurs at or after puberty commonly results from polycystic ovary disease.
Geriatric pointers
Hirsutism can occur after menopause if peripheral conversion of estrogen is poor.
Patient counseling
Help relieve the patient’s anxiety by explaining the cause of excessive hair growth and by encouraging her to talk about her self-image problems or fears. Involve the family in your discussions.
Tell the patient that hormonal treatment stops further hair growth but doesn’t always reverse hair growth that has already occurred. Treatment requires a minimum of 6 to 24 months and may be lifelong.
At the patient’s request, provide information on hair removal methods, such as bleaching, tweezing, hot wax treatments, chemical depilatories, shaving, and electrolysis. Advise the patient that electrolysis should be done only by a licensed professional.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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HIRSUTISM (Differential Diagnosis in Primary Care)
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