Hirsutism is defined as excessive facial and body hair male topography in women after puberty.
The affected areas are mustache and beard, pubic hair, buttocks and thighs.
This excess hair growth is dependent on androgens. It is therefore sensitive to the anti-androgenic drugs.
The signs are moving towards hyperandrogenism hoarsely, accentuated musculature, enlarged clitoris, rules disorders, acne or hyperseborrhea.
The most common cause of hyperandrogenism is the polycystic ovary syndrome.
Hirsutism must be distinguished from hypertrichosis where excess hair growth key areas normally hairy in women, so not androgénosensibles. Hypertrichosis is often due to a family or ethnic character exists before puberty.
This is the etiologic diagnosis that will provide the appropriate treatment. The examination and clinical examination were here again important.
That ask the patient?
The practitioner seeks to specify:
– The start date of the excess hair growth, scalability;
– The possible relationship with menstrual cycles (date of menarche, regularity of cycles, premenstrual abdominal pain);
– Family history (Mediterranean origin notion of adrenal hyperplasia, ovarian dystrophy);
– Study of the temperature curve to see if the cycles are ovulatory or not;
– Drug taken, searching for possible androgen outlet, sometimes hidden (anabolic products, for example) or psychotropic.
On examination, the physician rating:
– The extent and importance of hirsutism;
– The existence of signs of virilization (deep voice, muscular hypertrophy, clitoral hypertrophy), signing an overproduction of androgens;
– The existence of any accompanying signs (seborrhea, acne, etc.);
– Gynecological examination for large ovaries;
– High blood pressure (hypertension) moving towards an adrenal hypertrophy challenge cit 11-α-hydroxylase;
– Visual disturbances with visual field defects, acromegaly, thyroid dysfunction moving towards a pituitary tumor (cf. pituitary adenomas)
– Association with obesity, diabetes, stretch marks evokes the rare possibility of Cushing’s syndrome.
What diagnostics can be readily evoked?
Some stereotyped tables can guide from the first consultation:
– Recent hirsutism, explosive, must seek a tumor origin;
– Hirsutism appeared on accompanied puberty menstrual disorders with presence of large ovaries must seek ovarian disease (polycystic ovary syndrome) ;
– A former hirsutism, important, with or without virilization in a woman in particular morphotype (small, stocky), with a family history and a delayed menarche has to search for hirsutism by enzymatic block;
– A former hirsutism, widespread among women of Mediterranean origin, family history, towards a idiopathic hirsutism.
What paraclinical elements are useful as first line?
In addition to studying the temperature curve already mentioned, the main biochemical assay to ask is that testosterone (Box 1).
Box 1. Biological Explorations
These biological explorations are prescribed by the specialist (endocrinologist, gynecologist).
The most useful tests are the first-line dosing of testosterone (free and total), the delta-4-androstenedione and 17-OH-progesterone.
The assays are performed at the beginning of cycle (between 5th and 8th day), stopping oral contraception during previous cycles 2-3 (judgment not necessary if a tumor is suspected causes).
Other assays may be useful as second line are those of prolactin, FSH (follicle stimulating hormone) and LH (luteinising hormone), sex hormone binding protein and DHEA sulfate (dehydroepiandrosterone).
Depending on testosterone levels (Table I), it is generally possible to state that: a high testosterone towards a hypersecretion of androgens (tumor, ovarian and adrenal hyperplasia hyperthecosis by enzymatic block to the high rates; syndrome Polycystic ovary to the median rates);
– Normal testosterone oriented more towards idiopathic hirsutism.
HIRSUTISM WITH HIGH RATE OF TESTOSTERONE:
Hirsutism tumor origin:
Testosterone is greater than or equal to 1.5 nmol / L. Hirsutism is important, often recent and explosive. Clinically, there are signs of virilization with deep voice, clitoral hypertrophy and muscle masses.
The main tumors are adrenal or ovarian origin. Imaging tests (ultrasound, CT) are especially effective in the search for adrenal tumors. Tumors of the ovaries may be very small and difficult to detect. An ultrasound and an abdominal-pelvic scan is requested. For ovarian cancer, an endo-vaginal pelvic ultrasound and possibly MRI are useful.
The patient is assigned to a specialist. The tumor must be removed surgically to cure hirsutism by removing its cause.
Hirsutism by ovarian hyperthecosis:
Testosterone levels are also high.
There is hyperplasia of the ovarian stroma resulting in increased secretion of androgens (testosterone and androstenedione-delta-4).
This secretion is held back by the hormonal outlet.
The patient should be referred to a specialist. Ovarian venous catheterization says the bilateral nature of the androgen hypersecretion.
A ovariotomy with partial resection and histological examination is performed.
Hirsutism by adrenal hyperplasia by enzymatic block:
This is mostly a block 21-hydroxylase, rarely a block in 11-hydroxylase.
Morphotype of women is suggestive:
– Small size;
– Muscle hypertrophy;
– Clitoral hypertrophy contrasting with breast hypotrophy; puberty was abnormal with inconstancy of the installation rules.
There is often a family history.
A later revelation is possible, incomplete block without menstrual disorders.
The patient should be referred to an endocrinologist in charge to make hormonal exploration.
The biological profile is particular with:
– Testosterone levels ≥ 1.5 nmol / L;
– Lowered or normal cortisol;
– Low or normal ACTH levels;
– Rate of moderately basic high 17-OH-progesterone, greatly increasing after ACTH outlet (adrenocorticotrophic hormone) (17-OH-progesterone ≥ 10 ng / mL).
Treatment is based on hydrocortisone supplementation (Hydrocortisone® 20 mg / day orally), taking cyproterone acetate (Androcur®) and estradiol on the same terms as in ovarian dystrophies, weight restriction and Waxing Power when esthetic demand.
HIRSUTISM RATE WITH MIDDLE OF TESTOSTERONE:
PCOS or ovarian dystrophies
This is the most common cause of hyperandrogenism.
Hirsutism appeared at puberty, is accompanied by menstrual disorders, possibly overweight of dyslipidemia, insulin resistance, a acne, acanthosis nigricans. The patient reports a well spaniomenorrhea (elongation cycle beyond 35 days), oligomenorrhea (less heavy periods), infertility. The ovaries may be increased in size. Thyroid dysfunction or liver disease may be present.
Assays performed by the specialist show:
– Testosterone levels between 0.8 and 1.5 nmol / L, therefore moderately high;
– A high rate of delta-4-androstenedione (> 2.5 ng / mL);
– A LH levels 2-3 times higher than the
FSH with exclusive response to LHRH (luteinising hormone-releasing hormone).
Treatment is based on ovarian braking.
Different regimens are possible.
For example, the patient can take cyproterone acetate (Androcur®) from 5th to 25th day of the cycle, with percutaneous estradiol (OEstrogel®) during the 21-day cycle, otherwise the Diane® 35, including contraceptive for cyproterone acetate and ethinyl estradiol (off-label) at a dose of one tablet for 21 days with an interval of 7 days.
HIRSUTISM RATE WITH NORMAL TESTOSTERONE:
Hirsutism is old and not explosive, be accentuated gradually; it is not accompanied by signs of virilization or menstrual disorders.
There is a family history, often in a patient of Mediterranean origin.
Testosterone is normal and regular, ovulatory menstrual cycle.
Treatment depends on the request of the patient.
It can be aesthetic or hormone on the same terms as in ovarian dystrophies.
A moderate hirsutism can be observed in postmenopausal women (relative hyperandrogenism due to the cessation of production of ovarian estrogens) and pregnant women (physiological prolactin secretion).
The aesthetic treatment of hirsutism is a common demand of women with disabilities because of their excess hair growth. Rather advise an electrolysis or laser chin, avoid hair removal creams and shaving, and propose discoloration of hair.