Hirsutism
Hirsutism: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Hirsutism is the excessive growth of coarse body hair in females. Excessive production of androgens (male hormones) stimulates hair growth on the pubic region, axillae, chin, upper lip, cheeks, anterior neck, sternum, linea alba, forearms, upper arms, abdomen, and back. This condition may also occur in a patient with normal levels of androgens whose skin is more sensitive 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 also 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.)
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. Some patients have a strong familial predisposition to hirsutism, which may be considered normal for their genetic background, culture, and race. Although hirsutism is a female characteristic, excessive hair growth may also be present in male family members.
History and physical examination
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 periods, the usual amount of blood flow, and the number of days between periods.
Ask about medications, too. 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?
Next, examine the hirsute areas. Does excessive hair appear only on the upper lip or on other body parts as well? Is the hair fine and pigmented, or dense and coarse? Is the patient obese? Observe her for other signs of virilization.
Medical causes
Acromegaly
About 15% of patients with this 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
This disorder 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, this condition is associated with anovulation that progresses slowly over several years.
Cushing’s syndrome (hypercortisolism)
This disorder 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 with purple striae, ecchymosis, petechiae, muscle wasting and weakness, poor wound healing, hypertension, weakness, fatigue, excessive diaphoresis, hyperpigmentation, menstrual irregularities, and personality changes.
Hyperprolactinemia
This disorder produces hirsutism, hypogonadism, galactorrhea, amenorrhea, and acne.
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 may produce no symptoms, or it can cause rapidly progressing hirsutism (only if the tumor produces androgens) as well as amenorrhea and rapidly developing virilization.
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, insulin resistance and diabetes, 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, prolactin, and other hormones. Other tests may include computed tomography scan and ultrasonography.
At the patient’s request, provide information on hair removal methods, such as bleaching, tweezing, hot wax treatments, chemical depilatories, shaving, and electrolysis. Inform the patient that electrolysis should be done only by a licensed professional.
Pediatric pointers
Childhood hirsutism can stem from congenital adrenal hyperplasia. This disorder is usually detected at birth because affected infants have ambiguous genitalia. Rarely, a mild form becomes apparent after puberty when hirsutism, irregular bleeding or amenorrhea, and signs of virilization appear. Hirsutism that occurs at or after puberty often results from polycystic ovary disease.
Give the parents as well as the child emotional support and clear explanations about the cause of hirsutism. Allow the parents and child to express their concerns separately.
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 at least 6 to 24 months and may be lifelong.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 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 (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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