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Hirsutism

What is Hirsutism?

Hirsutism refers to the growth of coarse, dark hair in areas where women typically grow fine hair or no hair at all. It is characterized by excessive terminal hair that appears in a male pattern (androgen-dependent areas) in women.

Prevalence and Impact

Prevalence:

Hirsutism affects a significant number of women, with varying degrees of severity.

Psychological Impact:

It can lead to anxiety and depression, significantly affecting the quality of life. Studies have shown high rates of anxiety (30%) and depression (75%) among women with hirsutism.

Differential Diagnosis

Hirsutism can be caused by various underlying conditions, including:

  • Polycystic Ovary Synd0rome (PCOS): The most common cause, accounting for 82.02% of cases.
  • Non-Classical Adrenal Hyperplasia (NCAH): A less common cause, accounting for 3.78% of cases.
  • Idiopathic Hirsutism (IH): Hirsutism without an identifiable cause, accounting for 4.47% of cases.

Clinical Evaluation

The Modified Ferriman-Gallwey (mFG) score is used to assess the severity of hirsutism. A score of 8 to 15 indicates mild hirsutism, while a score greater than 15 indicates moderate or severe hirsutism.

Diagnosis

Diagnosis involves a combination of medical history, physical examination, and laboratory tests:

Medical History:

Includes menstrual cycle patterns, weight changes, and family history of hirsutism.

Physical Examination:

Assessment of hair growth patterns and other signs of androgen excess.

Laboratory Tests:

Measurement of hormone levels, including testosterone, DHEAS, 17-hydroxyprogesterone, TSH, and prolactin.

Imaging:

Pelvic ultrasound to assess for polycystic ovaries or tumors.

Treatment Options

Treatment aims to manage symptoms and address underlying causes:

  • Lifestyle Modifications: Weight loss and a healthy diet can improve symptoms, especially in PCOS-related hirsutism.

Medications:

  • Oral Contraceptives (OCPs): Help regulate menstrual cycles and reduce androgen levels.
  • Antiandrogens: Medications like spironolactone and flutamide reduce androgen effects.
  • Insulin Sensitizers: Used in cases of insulin resistance, common in PCOS.
  • Cosmetic Measures: Hair removal techniques such as laser therapy and electrolysis.
  • Combination Therapy: Often, a combination of treatments is most effective.

Case Study

A typical case might involve a young woman with long-term excessive hair growth, acne, irregular menstrual cycles, and a family history of hirsutism. Clinical evaluation and laboratory tests would help confirm the diagnosis and guide treatment.

Detailed Treatment Approaches

Diagnosis involves a combination of medical history, physical examination, and laboratory tests:

Oral Contraceptives (OCPs)

  • Mechanism: OCPs work by reducing the levels of androgens in the body. They increase the levels of sex hormone-binding globulin (SHBG), which binds to testosterone, reducing its activity.
  • Types of Progestins: Different generations of progestins have varying effects on androgen levels. The choice of progestin can influence the effectiveness of the treatment.

Antiandrogens

  • Spironolactone: Blocks androgen receptors and inhibits androgen production.
  • Flutamide: Non-steroidal antiandrogen that blocks androgen receptors.
  • Finasteride: Inhibits 5-alpha-reductase, an enzyme that converts testosterone to its more potent form, dihydrotestosterone (DHT).
  • Finasteride: Inhibits 5-alpha-reductase, an enzyme that converts testosterone to its more potent form, dihydrotestosterone (DHT).

Insulin Sensitizers

  • Metformin: Commonly used to treat insulin resistance in PCOS, which can help reduce androgen levels and improve menstrual regularity.
  • Weight Loss Approach: There is growing evidence of improvement in PCOS symptoms and complications through weight loss achieved with a combination of pharmacological agents for weight loss and lifestyle changes.

Cosmetic Measures

  • Laser Hair Removal: Uses laser light to target and destroy hair follicles, reducing hair growth over time.
  • Electrolysis: Uses electric current to destroy hair follicles, providing a more permanent solution to unwanted hair.

Quality of Life (QOL) Assessment

The PCOSQ (Polycystic Ovary Syndrome Questionnaire) is used to assess the impact of hirsutism on quality of life. It includes questions on emotions, body hair, body weight, fertility, and menstruation. Lower scores indicate higher degrees of patient concern and a lower quality of life.

Hirsutism is a manageable condition with a comprehensive approach involving lifestyle changes, medications, and cosmetic treatments. Early diagnosis and tailored treatment plans can significantly improve the quality of life for affected women.

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