Symptom finder - The causes of hirsutism
Symptom finder - The causes of hirsutism
Hirsutism is a male pattern hair growth in women. The causes of hirsutism are adrenal causes such as androgen producing adrenal tumors, Cushing’s syndrome and congenital adrenal hyperplasia, pituitary causes such as acromegaly, Cushing’s disease and prolactinoma, ovarian causes such as androgen producing ovarian tumor, menopause and polycystic ovarian syndrome and drug such as minoxidil, anabolic steroids, testosterone, progestogens, corticosteroids, phenytoin ( anti - epileptic drug) and ciclosporin . Other causes are anorexia nervosa, familial and ethnicity.
Hirsutism is different from virilism. Virilism is the present of hirsutism and the development of male secondary sexual characteristic in female. Hypertrichosis is a term refer to excessive growth of hair which affect both sexes.
Rapid/sudden onset of hirsutism in women is an indication of serious pathological disorder such as androgen producing ovarian tumor or androgen producing adrenal tumor. Childhood onset of hirsutism is associated with congenital adrenal hyperplasia. Familial etiology is confirmed by asking if any family member may be suffering from hirsutism. Any BRCA gene mutation that run in the family will raise suspicion of the onset of ovarian carcinoma. Virilization does occur as a result of excessive androgen hormone which may present with deep voice and acne.
Side effect of drugs may lead to hirsutism. The drugs are minoxidil for treatment of hypertension, phenytoin for epilepsy, ciclosporin used in organ transplantation as immunosuppressive and anabolic steroid for body builders. The use of oral contraceptive pills or progestogen containing hormone replacement may be elicited from drug history.
Menstrual history is important. History regarding the onset , regularity and periodicity of the menstrual cycle is taken.Patient who complain of amenorrhea is associated with polycystic ovarian syndrome, prolactinoma (patient who suffer from prolactinoma may also suffer from galactorrhea) and congenital adrenal hyperplasia.
Besides hirsutism, enlargement of the feet, jaw, hands and face, increasing in shoe, hat and gloves sizes, joint pains and muscle weakness are the common feature of acromegaly as well as paraesthesia due to compression neuropathy. Pituitary adenoma may leads to prolactinoma, Cushing’s disease and acromegaly. The common symptoms of pituitary adenoma are visual filed loss vomiting and headache. Polycystic ovarian syndrome and Cushing’s syndrome are associated with weight gain. Proximal muscle weakness, abdominal striae and easy bruising are additional symptoms of Cushing’s syndrome. Polycystic ovarian syndrome and prolactinoma may lead to infertility.
Examination should focus on the distribution of hair growth. In hirsutism the distribution of the hair growth usually involve the extremities , chest and chin as well as the face.Male type of frontal balding and male pattern pubic hair may occur. Generalized obesity may occur with polycystic ovarian syndrome while truncal obesity may occur due to Cushing’ s syndrome. Acanthosis nigricans may also present with these disorders. Clitoris enlargement and increase in the mass of the shoulder - girdle are commonly associated with virilism.
Hirsutism is a male pattern hair growth in women. The causes of hirsutism are adrenal causes such as androgen producing adrenal tumors, Cushing’s syndrome and congenital adrenal hyperplasia, pituitary causes such as acromegaly, Cushing’s disease and prolactinoma, ovarian causes such as androgen producing ovarian tumor, menopause and polycystic ovarian syndrome and drug such as minoxidil, anabolic steroids, testosterone, progestogens, corticosteroids, phenytoin ( anti - epileptic drug) and ciclosporin . Other causes are anorexia nervosa, familial and ethnicity.
Hirsutism is different from virilism. Virilism is the present of hirsutism and the development of male secondary sexual characteristic in female. Hypertrichosis is a term refer to excessive growth of hair which affect both sexes.
Rapid/sudden onset of hirsutism in women is an indication of serious pathological disorder such as androgen producing ovarian tumor or androgen producing adrenal tumor. Childhood onset of hirsutism is associated with congenital adrenal hyperplasia. Familial etiology is confirmed by asking if any family member may be suffering from hirsutism. Any BRCA gene mutation that run in the family will raise suspicion of the onset of ovarian carcinoma. Virilization does occur as a result of excessive androgen hormone which may present with deep voice and acne.
Side effect of drugs may lead to hirsutism. The drugs are minoxidil for treatment of hypertension, phenytoin for epilepsy, ciclosporin used in organ transplantation as immunosuppressive and anabolic steroid for body builders. The use of oral contraceptive pills or progestogen containing hormone replacement may be elicited from drug history.
Menstrual history is important. History regarding the onset , regularity and periodicity of the menstrual cycle is taken.Patient who complain of amenorrhea is associated with polycystic ovarian syndrome, prolactinoma (patient who suffer from prolactinoma may also suffer from galactorrhea) and congenital adrenal hyperplasia.
Besides hirsutism, enlargement of the feet, jaw, hands and face, increasing in shoe, hat and gloves sizes, joint pains and muscle weakness are the common feature of acromegaly as well as paraesthesia due to compression neuropathy. Pituitary adenoma may leads to prolactinoma, Cushing’s disease and acromegaly. The common symptoms of pituitary adenoma are visual filed loss vomiting and headache. Polycystic ovarian syndrome and Cushing’s syndrome are associated with weight gain. Proximal muscle weakness, abdominal striae and easy bruising are additional symptoms of Cushing’s syndrome. Polycystic ovarian syndrome and prolactinoma may lead to infertility.
Examination should focus on the distribution of hair growth. In hirsutism the distribution of the hair growth usually involve the extremities , chest and chin as well as the face.Male type of frontal balding and male pattern pubic hair may occur. Generalized obesity may occur with polycystic ovarian syndrome while truncal obesity may occur due to Cushing’ s syndrome. Acanthosis nigricans may also present with these disorders. Clitoris enlargement and increase in the mass of the shoulder - girdle are commonly associated with virilism.
The next step is to identify any features of endocrine disorder such as acromegaly that present with wide interdental separation, poor occlusion of the jaw, enlarged feet and hands, macroglossia, prognathism, broad nose, prominent supraorbital ridging and thick greasy skin. Cushing’s syndrome commonly present with skin bruising , buffalo hump, truncal obesity, moon like facies, proximal muscle weakness and striae. Acromegaly and Cushing’s disease commonly present with diabetes and hypertension. Congenital adrenal hyperplasia may also present with hypertension and visual field defect may occur as a result of Cushing’s disease, prolactinoma and acromegaly. Any large pelvic or abdominal mass also should be excluded to rule out large ovarian tumor or adrenal tumor.
The investigation require are urea and electrolytes, urine dipstick, serum testosterone and DHEA, serum glucose, plasma prolactin, IGF-1 , 24 hour urinary free cortisol, CT scan, MRI scan of the head, CT scan of the pelvis and abdomen, ultrasound of the pelvis and abdomen, CA 125, plasma 17 hydroxyprogesterone, oral glucose tolerance test, series of growth hormone suppression and low dose dexamthasone suppression test.
Urea and electrolytes studies may reveal low potassium level in congenital adrenal hyperplasia. Urine dipstick may detect the present of glucose as a result of diabetes. Diabetes is a common features/ symptoms of acromegaly and Cushing’s syndrome. Insulin resistance is also associated with polycystic ovarian disease. Highly elevated level of DHEA and serum testosterone are highly suggestive of excess androgens from a neoplastic origin and further investigations are required. Serum glucose may be associated with Cushing’s syndrome, polycystic ovarian syndrome and acromegaly due to insulin resistance and diabetes. Plasma prolactin is raised due to prolactinoma. IGF-1 will rise with acromegaly. Cushing’s syndrome is presented with elevation of 24 hour urinary free cortisol. Pituitary tumor is detected with CT scan/MRI scan of the head. CT scan /MRI scan of the pelvis and abdomen may reveal the present of ovarian carcinoma and adrenal carcinoma. Raised CA 125 ( tumor marker) is associated with ovarian carcinoma. Raised plasma 17 hydroxyprogesterone is associated with congenital adrenal hyperplasia. Acromegaly may present with increasing or failure to suppress growth hormone while performing oral glucose tolerance test with series of growth hormone estimation. Cushing’s syndrome is confirmed by failure of suppression while performing low dose dexamethasone suppression test.
The investigation require are urea and electrolytes, urine dipstick, serum testosterone and DHEA, serum glucose, plasma prolactin, IGF-1 , 24 hour urinary free cortisol, CT scan, MRI scan of the head, CT scan of the pelvis and abdomen, ultrasound of the pelvis and abdomen, CA 125, plasma 17 hydroxyprogesterone, oral glucose tolerance test, series of growth hormone suppression and low dose dexamthasone suppression test.
Urea and electrolytes studies may reveal low potassium level in congenital adrenal hyperplasia. Urine dipstick may detect the present of glucose as a result of diabetes. Diabetes is a common features/ symptoms of acromegaly and Cushing’s syndrome. Insulin resistance is also associated with polycystic ovarian disease. Highly elevated level of DHEA and serum testosterone are highly suggestive of excess androgens from a neoplastic origin and further investigations are required. Serum glucose may be associated with Cushing’s syndrome, polycystic ovarian syndrome and acromegaly due to insulin resistance and diabetes. Plasma prolactin is raised due to prolactinoma. IGF-1 will rise with acromegaly. Cushing’s syndrome is presented with elevation of 24 hour urinary free cortisol. Pituitary tumor is detected with CT scan/MRI scan of the head. CT scan /MRI scan of the pelvis and abdomen may reveal the present of ovarian carcinoma and adrenal carcinoma. Raised CA 125 ( tumor marker) is associated with ovarian carcinoma. Raised plasma 17 hydroxyprogesterone is associated with congenital adrenal hyperplasia. Acromegaly may present with increasing or failure to suppress growth hormone while performing oral glucose tolerance test with series of growth hormone estimation. Cushing’s syndrome is confirmed by failure of suppression while performing low dose dexamethasone suppression test.
