HIRSUTISM
HIRSUTISM: Excerpt from Differential Diagnosis in Primary Care
The vast majority of women presenting to the clinician with excessive
hair on the face or body are normal and healthy. Nevertheless, one should be
alert to the pathologic consequences of this symptom.
Anatomy is the best basic science to use in recalling the various
causes. Simply by visualizing the endocrine glands and proceeding from the
head caudally, one may come up with the most significant pathologic causes
of hirsutism. If these are ruled out, the patient most likely has idiopathic
hirsutism and nothing needs to be done.
Pituitary. Acromegaly and a basophilic adenoma of the pituitary
may cause hirsutism.
Thyroid. Congenital and juvenile hypothyroidism are associated
with hirsutism but not virilism.
Adrenal gland. Adrenal carcinomas, adenomas, and hyperplasia may
all be associated with hirsutism. With the exception of Cushing syndrome,
there is usually virilism as well. Congenital adrenal hyperplasia may become
manifest at puberty, in which case there will be both hirsutism and
virilism.
Ovary. Polycystic ovary syndrome (Stein–Leventhal syndrome)
will be recalled by visualizing this endocrine gland. It is second only to
idiopathic hirsutism in frequency. There is usually no virilism, but it does
occur occasionally. However, obesity and hypomenorrhea are common. The ovary
is also the site of arrhenoblastomas, hilus cell tumors, and luteomas that
may cause hirsutism. There is usually associated virilism with these tumors.
Ovarian failure (menopause) may also be associated with hirsutism, but there
is no associated virilism.
Anatomy will not be useful in recalling the many drugs that may produce
hirsutism. These include phenytoin, diazoxide, minoxidil, anabolic steroids,
androgens, and glucocorticoids. Hirsutism may also be found in porphyria,
anorexia nervosa, and the Cornelia de Lange syndrome (Amsterdam dwarfism).
Approach to the Diagnosis
Clinically it is most important to look for obesity and virilism. A
history of hypomenorrhea or amenorrhea is also important. The workup
initially should include serum cortisol or 24-hour urine
17-hydroxycorticoids or 17-ketosteroids, and a thyroid profile. A skull
x-ray and flat plate of the abdomen may be helpful. A cortisone suppression
test may be required. An endocrinologist should be consulted before
proceeding with CT scans of the brain, abdomen, and pelvis. A pituitary
microadenoma may only be found by an MRI of the pituitary.
Other Useful Tests
-
Serum follicle-stimulating hormone (FSH) and luteinizing hormone
(LH) assay (acromegaly)
- Serum growth hormone assay (acromegaly)
- Laparoscopy (polycystic ovaries)
- Thyrotropin level (hypothyroidism)
- Selective venous sampling of adrenal veins for androgens (adrenal
carcinoma)
- Isotope scanning of adrenal glands (Cushing syndrome)
- Exploratory surgery
- Serum prolactin level (pituitary tumor)
- Serum testosterone
CASE PRESENTATION #47
A 19-year-old, 6-month-pregnant Hispanic woman complained of increasing
hair growth on her face. Otherwise, she is doing well aside from increasing
obesity.
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, 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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