Symptom Finder - Hirsutism
The vast majority of women presenting to the clinician with excessive hair on the face or body are normal and healthy. Nevertheless, one should be alert to the pathologic consequences of this symptom.
Anatomy is the best basic science to use in recalling the various causes. Simply by visualizing the endocrine glands and proceeding from the head caudally, one may come up with the most significant pathologic causes of hirsutism. If these are ruled out, the patient most likely has idiopathic hirsutism and nothing needs to be done.
Pituitary: Acromegaly and a basophilic adenoma of the pituitary may cause hirsutism.
Thyroid: Congenital and juvenile hypothyroidism are associated with
hirsutism but not virilism.
Adrenal gland: Adrenal carcinomas, adenomas, and hyperplasia may all be associated with hirsutism. With the exception of Cushing syndrome, there is usually virilism as well. Congenital adrenal hyperplasia may become manifest at puberty, in which case there will be both hirsutism and virilism.
Ovary: Polycystic ovary syndrome (Stein–Leventhal syndrome) will be recalled by visualizing this endocrine gland. It is second only to idiopathic hirsutism in frequency. There is usually no virilism, but it does occur occasionally. However, obesity and hypomenorrhea are common. The ovary is also the site of arrhenoblastomas, hilus cell tumors, and luteomas that may cause hirsutism. There is usually associated virilism with these tumors. Ovarian failure (menopause) may also be associated with hirsutism, but there is no associated virilism.
Anatomy will not be useful in recalling the many drugs that may produce hirsutism. These include phenytoin, diazoxide, minoxidil, anabolic steroids, androgens, and glucocorticoids. Hirsutism may also be found in porphyria, anorexia nervosa, and the Cornelia de Lange syndrome (Amsterdam dwarfism).
Approach to the Diagnosis
Clinically it is most important to look for obesity and virilism. A history of hypomenorrhea or amenorrhea is also important. The workup initially should include serum cortisol or 24-hour urine 17-hydroxycorticoids or 17-ketosteroids, serum prolactin, and a thyroid profile. A skull x-ray and flat plate of the abdomen may be helpful. A cortisone suppression test may be required. Ultrasonography of the ovaries may reveal a neoplasm or polycystic ovaries. An endocrinologist should be consulted before proceeding with CT scans of the brain, abdomen, and pelvis. A pituitary microadenoma may only be found by an MRI of the pituitary.
Other Useful Tests
1. Serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) assay (acromegaly or polycystic ovary syndrome)
2. Serum growth hormone assay (acromegaly)
3. Laparoscopy (polycystic ovaries)
4. Thyrotropin level (hypothyroidism)
5. Selective venous sampling of adrenal veins for androgens (adrenal
6. Isotope scanning of adrenal glands (Cushing syndrome)
7. Exploratory surgery
8. Serum DHEA and androstenedione (adrenal carcinoma)
9. Serum testosterone