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Hirsutism and hyperandrogenism in women
What is hirsutism?
Excess facial and body hair growth in women.
What is hyperandrogenism?
Increased levels of male hormone production in women.
Diagnostic classification of hyperandrogenism
These are the causes of hyperandrogenism and hirsutism in women:
Chronic anovulation - i.e. polycystic ovarian syndrome
Idiopathic hirsutism - excess hair growth with normal menstrual cycles and normal
androgen (male hormone) levels
Late onset congenital adrenal hyperplasia - an inherited disorder of hormone metabolism
that causes increased hair growth in women after puberty
Ovarian tumors - a rare cause of hirsutism
Adrenal causes - even more rare
Pregnancy related - rare, but interesting, e.g. luteoma of pregnancy
Drugs - some drugs can cause excess hair growth in women
Evaluation of hirsute women
Women with hirsutism have an increased production rate of testosterone and androstenedione.
The most commonly seen clinical problem is the typical story of irregular menstrual cycles
(anovulation), onset of hirsutism in the teens or early 20s, and gradually worsening
excess hair growth. These are the findings associated with a condition known as
polycystic ovarian syndrome.
Initial testing for hirsute women
Total testosterone
Dehydroepiandrosterone sulfate (DHEAS)
17-hydroxyprogesterone
If the woman is anovulatory, she also should have a prolactin, T4 and TSH.
A breast exam should be done to check for galactorrhea. If the woman has long-standing
anovulation, an endometrial biopsy may be indicated.
Late onset CAH
21-hydroxylase deficiency- relatively common
3-beta-hydroxysteroid dehydrogenase deficiency - subtle, accurate diagnosis not essential
11-beta-hydroxylase deficiency - rare
Late onset 21-hydroxylase deficiency
Autosomal recessive transmission - homozygous for the mild allele, or 1 mild and 1 severe
allele.
Late onset CAH affects about 1-5% of hyperandrogenic women.
The screening test for this condition is a morning 17-hydroxyprogesterone.
The 17-OHP result should be less than 200 ng/dl. A level of 200-800 ng/dl requires ACTH
stimulation testing to clarify the situation.
A level of over 800 ng/dl is diagnostic for late onset 21-hydroxylase deficiency.
Testosterone (T) levels
70% of women with anovulation and hirsutism have elevated plasma testosterone levels
(> 80 ng/dl)
Sex hormone binding globulin levels are decreased by androgen and insulin, so total
testosterone can be normal while the active, unbound testosterone is elevated.
If the total testosterone is over 200 ng/dl, a tumor should be considered as a possibility.
Tumor workup
Tumors causing hirsutism are rare and other causes are common.
A tumor workup is indicated in most cases if total testosterone is over 200 ng/dl (100
ng/dl if the woman is menopausal).
Indicated in most cases if DHEAS is over 700 ug/dl (400 ug/dl if menopausal).
Treatment of hyperandrogenism
Oral contraceptives
Androgen production by the ovaries can be suppressed with oral contraceptives. This
lowers LH levels and the estrogen in the pill increases androgen binding in the blood.
This leads to lower levels of free testosterone.
Medical therapy is slow and requires at least 6 months for a visible effect - shaving,
waxing, etc., can be used in the meantime.
Spironolactone
This aldosterone-antagonist diuretic inhibits synthesis of male hormones, competes for
androgen receptors in hair follicles, and directly inhibits 5-a-reductase. This is the
enzyme that converts testosterone to the active hormone dihydrotestosterone.
Dose to use is 100-200 mg/day. There are usually few side effects. But sometimes women
complain of increased urination in the first few days of use, fatigue, or problems with
their menstrual periods. Spironolactone works best when used in conjunction with oral
contraceptives. This also controls the menstrual cycle to avoid problems with dysfunctional
bleeding.
Flutamide
A nonsteroidal antiandrogen that can be used at a dose of 250 mg three times daily for
hirsutism. Its use seems to be relatively free of side effects. However, it should be
used in conjunction with a method of contraception.
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