HIRSUTISM, ACNE. IRREGULAR PERIODS , POLY CYSTIC OVARY SYNDROME

HIRSUTISM and ACNE ( Pimples)  in Females:

Hirsutism is the presence of excess terminal hair ( thick hair)  in women in areas where it is not normally seen.  Presence of  excess thin non pigmented hair (hypertrichosis) is  not considered significant, where as the presence of terminal hair is significant. 

 Hypertrichosis is the generalized excess hair seen more in the hands and legs which not considered as hirsutism.   ( SOME AUTHORITES BELEIVE THAT EVEN HYPERTRICHOSIS IS SIGNIFICANT)

Terminal hair is the thick hair seen  in face, axilla and pubic area which is male hormone dependent. Normally in a female, terminal hair, (which is male hormone dependent)  is seen only in axilla and pubic area. Where as in males, it also seen above and below lips ( moustache and beard) , sides of face, chest, abdomen, upper and lower back, inner surface of arms and thighs. ( Picture courtesy: google images) 

  Presence of terminal hair in the above mentioned areas in a female is considered abnormal and indicate either presence of excessive male hormones or increased sensitivity of hair follicle to normal circulating levels of  male hormone.   

Testosterone, which is a male  hormone is also seen in females in small quantities, and  small amount of  estrogen  (female hormone)  is seen in males.  With in normal limits, they are important for physiological functions. However, if in a female, testosterone is produced in excess, that cause excess hair growth,  menstural irregulrities, anovulation, infertility etc. 

If the level of  male hormone is too high, other features like excess pimples ( acne),  muscular body, change of voice, hair loss from sides and front of scalp,  change in libido ( increased sex drive) and enlargement of clitoris etc may appear.  If these features are present,  another cause  other than PCOS ( Poly cystic ovary syndrome) should be suspected. 

 ( see the section on causes of Hirsutism below) 

                                                   Hair growth in Chin and face
                                             

                                           Hair growth in abdomen with upward growth of pubic hair
                                       

                                                    Enlarged Clitoris
                                           


Production of  Male hormone in Females:

The male hormones are, Testosterone which is produced by theca cells of ovary as well as the Dihydroepiandrosterone (DHEA) which is  produced in adrenal gland. In males, these are poduced by testes and adrenal gland.   In females, these hormones are further converted to estrogen.

  Minimal quantity of these male hormones are essential in females for the development of  axillary and pubic hair, sexual drive ( libido), as well as for the early development of ovaran follicles ( egg).  Absence of these hormones in females cause reduced or absent hair in axilla and pubic area, lack of energy and decreased sexual drive.

If these hormones are seen in excess, they cause excess hair growth in women in a male like pattern and may also cause menstural irregularities, anovulation, infertility etc. Production of these hormones are dependent on pituitary hormon,e LH ( Leutinizing hormone).  Other hormones like Thyroid hormones, prolactin, growth hormone, IGF-1, Insulin etc also influence the production and handling of male hormones. Hence disorders of these hormones also can cause hirsutism.


 FG Score ( FERRIMAN -GALLWEY SCORE):

Doctors often use this scoring system to quantify the amount of hirsutism. The areas selected are seen in this picture ( courtesy: google).
An  FG score > 8 is significant.  Accurate assessment is very important and this is observer dependent. Patients often over estimate or under estimate the scoring. Hence the clinician has to carefully do the scoring.

CAUSES OF HIRSUTISM:

1. Familial*
2. PCOS ( Poly cystic ovary syndrome)*
3. Ovarian hyperthecosis*
4. Hyper and hypothyroidism
5. High prolactin levels
6. Cushing's syndrome
7. Acromegaly
8. Presence of excess Insulin in body ( INSULIN RESISTANCE)
9. Congenital adrenal hyperplasia ( CAH)
10.Excess production of LH from pituitary like in a small tumour
11. Adrenal nodules
12. Adrenal tumours/cancers
13. Tumours of ovary
14) Use of certain drugs ( medicines)                                                    * ( common causes)
                                                                                 

Presence of hirsutism along with irregular periods from the onset of first  period /puberty  is suggestive of PCOS or congenital adrenal hyperplasia (CAH). Hirsutism can sometimes run in families too. However, one should also understand that both CAH and PCOS too run in families.

Late onset of hirsutism,( several years after the onset of periods), need further check up. Sudden or late  onset hirsutism associated with loss of hair from scalp, virilization ( husky voice,  enlargement of clitoris) etc points to a more serious condition associated with abnornalities of  either ovary, adrenal  or pituitary glands. Commonly they are nodules or tumours which overproduce male hormones.  However, occasionally, this can  also be seen in ovarian hyperthecosis ( a severe form of PCOS).

Insulin in excess ( Insulin Resistance)  can also cause excess hair growth. This is often associated with obesity and irregular periods. But this is also seen in some lean girls with Insulin resistance. Usually they have a skin pigmentation in neck, axilla, groin, knuckles etc called Acanthosis Nigricans ( see the picture below: courtsy: Google)

HENCE, IT IS IMPORTANT TO FIND OUT THE CAUSE OF HIRSUTISM. 
There can be associated high blood sugars, high cholesterol or hypertension in some patients.


PROBLEMS ASSOCIATED WITH HIRSUTISM:

1) Over weight or Obesity
2) Infertility
3) Depression and reduced self confidence
4) Associated Diabetes, high cholesterol, high blood pressure
5) Occasional association of endmetrial cancer
6) Causative factors like ovary and adrenal nodules.


DIAGNOSIS:

A good history including detailed history of menstural periods, headache, vision problems,  nipple discharge, duration and treatment done for Hirsutism, infertility, weight gain, change in voice.
A review of treatment for hirsutism including laser, waxing, shaving, epilation, hormonal pills etc should be asked.

A thorough physical examination looking for clues like vision changes,  acne ( pimples) , goiter, breast size and  nipple discharge, vaginal examination for  clitoris enlargement, examination of abdomen  for masses, assessment of severity of pimples and hair growth. BP has to be checked as well.

Blood tests include, tests for blood glucose, ( sometimes choleseterol too), thyroid functions, prolactin.
Other hormone tests like Testosterone, DHEA-S, LH, 17-hydroxy progesterone, dexamethasone suppression test etc may be necessary on a case to case basis, depending on the physical examination findings. These tests are ideally done in the morning in a fasting state, on the second or third day of the periods.
A good quality ultrasound of abdomen and pelvis by a radiologist is also done on third day of periods ( in a married woman, trans vaginal scan is preferred and in an unmarried woman, trans abdominal scan is done).  If the prolactin levels are quite  elevated, we may also do an MRI Scan of pituitary.


TREATMENT:

 I realize that this is a difficult topic and readers must be exhausted by now. I will write about the  treatment of Hirsutism  later. 

                            I welcome your  comments and suggestions.

Thank you


Dr.Binu P Pillai
               MD, DM, CIDC, FACE
              
Endocrinologist and Diabetes specialist
Sugar-Apollo, International Medical Centre
MUSCAT,
OMAN
+968 24794502
          24794503
                                             http://sugarimc.com




Note: This article is only for the purpose of public education and the opinion is not final. Readers are encouraged to read good quality articles in the internet regarding PCOS, Hirsutism.