{"id":4422452,"date":"2025-01-11T19:32:39","date_gmt":"2025-01-12T01:32:39","guid":{"rendered":"https:\/\/myendoconsult.com\/learn\/topics\/hirsutism\/"},"modified":"2025-01-26T14:16:50","modified_gmt":"2025-01-26T20:16:50","slug":"hirsutism","status":"publish","type":"oen_topic","link":"https:\/\/myendoconsult.com\/learn\/topics\/hirsutism\/","title":{"rendered":"Hirsutism"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\">HIRSUTISM AND VIRILIZATION<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">Definitions<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Hirsutism<\/strong>: Excessive male-pattern terminal hair growth in women (e.g., on face, midline chest\/abdomen, back).<\/li>\n\n\n\n<li><strong>Virilization<\/strong>: A more severe androgen excess in women, manifested by masculinizing signs (deepening voice, clitoromegaly, temporal balding, increased muscle mass, breast atrophy).<\/li>\n\n\n\n<li><strong>Hypertrichosis<\/strong>: Diffuse increased total body hair (not male-pattern), which may be drug-induced (e.g., minoxidil) or associated with anorexia nervosa, malnutrition, etc.<\/li>\n<\/ul>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">HAIR GROWTH CYCLE AND ANDROGEN EFFECTS<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Hair Growth Phases<\/strong>:\n<ol class=\"wp-block-list\">\n<li><strong>Anagen<\/strong> (growth)<\/li>\n\n\n\n<li><strong>Catagen<\/strong> (involution)<\/li>\n\n\n\n<li><strong>Telogen<\/strong> (rest)<\/li>\n<\/ol>\n<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"2100\" height=\"2101\" src=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Cross-section-of-a-hair-follicle-unit.png\" alt=\"\" class=\"wp-image-4422910\" srcset=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Cross-section-of-a-hair-follicle-unit.png 2100w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Cross-section-of-a-hair-follicle-unit-300x300.png 300w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Cross-section-of-a-hair-follicle-unit-150x150.png 150w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Cross-section-of-a-hair-follicle-unit-768x768.png 768w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Cross-section-of-a-hair-follicle-unit-1536x1536.png 1536w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Cross-section-of-a-hair-follicle-unit-2048x2048.png 2048w\" sizes=\"auto, (max-width: 2100px) 100vw, 2100px\" \/><figcaption class=\"wp-element-caption\">Anatomy of a hair follicle<\/figcaption><\/figure>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Hair Follicles<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Two main types: <strong>Vellus hair<\/strong> (fine, unpigmented) vs. <strong>Terminal hair<\/strong> (coarse, pigmented).<\/li>\n\n\n\n<li>Androgens \u2192 enlarge follicle, increase hair diameter, prolong anagen phase in androgen-sensitive areas.<\/li>\n\n\n\n<li>At the <strong>scalp<\/strong>, androgens can reduce anagen duration \u2192 hair thinning (male-pattern baldness).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"3603\" height=\"2101\" src=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Hair-Follicle-Cycle-Illustrated.png\" alt=\"Stages of Hair growth\" class=\"wp-image-4422904\" srcset=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Hair-Follicle-Cycle-Illustrated.png 3603w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Hair-Follicle-Cycle-Illustrated-300x175.png 300w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Hair-Follicle-Cycle-Illustrated-768x448.png 768w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Hair-Follicle-Cycle-Illustrated-1536x896.png 1536w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/Hair-Follicle-Cycle-Illustrated-2048x1194.png 2048w\" sizes=\"auto, (max-width: 3603px) 100vw, 3603px\" \/><figcaption class=\"wp-element-caption\">Stages of Hair growth<\/figcaption><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">CLINICAL ASSESSMENT OF HIRSUTISM<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Modified Ferriman-Gallwey Score<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Grades terminal hair growth (0\u20134) at 9 body sites: upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, upper arms, thighs.<\/li>\n\n\n\n<li>Scores &lt;8 are generally normal; &gt;8 suggests hirsutism.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Ethnic Variation<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Same androgen levels can manifest differently (e.g., Asian and American Indian women have minimal body hair, Mediterranean women have more).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"807\" height=\"505\" src=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/grading-of-hirsutism.png\" alt=\"\" class=\"wp-image-4422912\" style=\"width:807px;height:auto\" srcset=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/grading-of-hirsutism.png 807w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/grading-of-hirsutism-300x188.png 300w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/grading-of-hirsutism-768x481.png 768w\" sizes=\"auto, (max-width: 807px) 100vw, 807px\" \/><figcaption class=\"wp-element-caption\">Modified Ferriman Gallwey Score<\/figcaption><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">PATHOPHYSIOLOGY: ANDROGEN PRODUCTION AND ACTION<\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Androgens and 5\u03b1-Reductase<\/strong>\n<ul class=\"wp-block-list\">\n<li><strong>Testosterone<\/strong> \u2192 <strong>Dihydrotestosterone (DHT)<\/strong> (more potent) via 5\u03b1-reductase in hair follicles.<\/li>\n\n\n\n<li>Local tissue 5\u03b1-reductase activity + androgen receptors \u2192 net androgen effect (hair growth or thinning).<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Adrenal Androgens<\/strong>\n<ul class=\"wp-block-list\">\n<li><strong>DHEA<\/strong> and <strong>androstenedione<\/strong> from <a href=\"https:\/\/myendoconsult.com\/learn\/the-formation-and-structure-of-the-adrenal-cortex\/\" data-wpil-monitor-id=\"217\">adrenal cortex<\/a>.<\/li>\n\n\n\n<li>DHEA is weakly androgenic, mainly a substrate for peripheral conversion to androstenedione \u2192 testosterone.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Ovarian Androgens<\/strong>\n<ul class=\"wp-block-list\">\n<li>The ovary secretes ~1\/3 of total testosterone in premenopausal women.<\/li>\n\n\n\n<li>The rest (2\/3) from <strong>peripheral conversion<\/strong> of androstenedione in adipose\/skin.<\/li>\n\n\n\n<li><strong>High Testosterone<\/strong> usually reflects <strong>ovarian<\/strong> source; <strong>High DHEA-S<\/strong> usually reflects <strong>adrenal<\/strong> source.<\/li>\n\n\n\n<li>Excess androstenedione may come from either adrenal or ovarian origin.<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"960\" height=\"672\" src=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/adrenal-steroidogenesis-1.png\" alt=\"\" class=\"wp-image-4422915\" srcset=\"https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/adrenal-steroidogenesis-1.png 960w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/adrenal-steroidogenesis-1-300x210.png 300w, https:\/\/myendoconsult.com\/learn\/wp-content\/uploads\/adrenal-steroidogenesis-1-768x538.png 768w\" sizes=\"auto, (max-width: 960px) 100vw, 960px\" \/><figcaption class=\"wp-element-caption\">Summary of androgen steroidogenesis in women<\/figcaption><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">COMMON CAUSES OF HIRSUTISM AND VIRILIZATION<\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong><a href=\"https:\/\/myendoconsult.com\/learn\/pathophysiology-of-pcos\/\" data-wpil-monitor-id=\"218\">Polycystic Ovary Syndrome<\/a> (PCOS)<\/strong>\n<ul class=\"wp-block-list\">\n<li>Most frequent cause of androgen excess.<\/li>\n\n\n\n<li>Associated with obesity, anovulatory cycles, oligomenorrhea\/amenorrhea, infertility, and signs of hyperandrogenism (hirsutism, acne).<\/li>\n\n\n\n<li>Typically starts soon after menarche; progresses gradually.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Other Causes<\/strong>\n<ul class=\"wp-block-list\">\n<li><strong>Idiopathic\/Constitutional Hirsutism<\/strong> (familial, ethnic disposition).<\/li>\n\n\n\n<li><strong>Nonclassic <a href=\"https:\/\/myendoconsult.com\/learn\/topics\/congenital-adrenal-hyperplasia-cah\/\" data-wpil-monitor-id=\"216\">congenital adrenal hyperplasia<\/a> (late-onset CAH)<\/strong>.<\/li>\n\n\n\n<li><strong>Androgen-secreting tumors<\/strong> (ovary or adrenal).<\/li>\n\n\n\n<li><strong>Medications<\/strong> (e.g., anabolic steroids, certain progestins).<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n\n\n\n<h3 class=\"wp-block-heading\">Virilization-Related Causes<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Markedly increased androgens<\/strong>: ovarian\/adrenal tumors, severe CAH, exogenous androgens \u2192 clitoromegaly, voice deepening, male body habitus changes.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Hyperthecosis<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Definition<\/strong>: A severe variant of PCOS caused by increased ovarian stromal tissue with luteinized theca cells distributed among sheets of fibroblast-like cells.<\/li>\n\n\n\n<li><strong>Pathophysiology<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Positive correlation between degree of hyperthecosis and insulin resistance.<\/li>\n\n\n\n<li>Hyperinsulinism \u2192 stimulates proliferation of thecal interstitial cells.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Clinical Note<\/strong>: Some patients develop virilization due to markedly increased serum testosterone levels.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Idiopathic Hirsutism<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Second most common diagnosis<\/strong> in women with hirsutism.<\/li>\n\n\n\n<li><strong>Clinical Features<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Normal menstrual cycles.<\/li>\n\n\n\n<li>Normal blood androgen levels.<\/li>\n\n\n\n<li>No identifiable cause of hirsutism after evaluation.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Possible Mechanism<\/strong>: Increased <strong>cutaneous 5\u03b1-reductase<\/strong> activity.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Congenital Causes of Virilization in Female Neonates<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Congenital Adrenal Hyperplasia (CAH)<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Enzymatic defect in cortisol synthesis.<\/li>\n\n\n\n<li><strong>ACTH<\/strong> not suppressed normally \u2192 adrenal glands produce DHEA + androgenic precursors.<\/li>\n\n\n\n<li>Newborn may show <strong>clitoral hypertrophy<\/strong>, hirsutism.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Maternal Androgen Excess<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Exogenous androgenic hormones (pills\/injections) in early pregnancy.<\/li>\n\n\n\n<li>Secretory ovarian or adrenal tumor in pregnant mother \u2192 androgens cross placenta \u2192 fetal virilization.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Late-Onset (Nonclassic) CAH<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Partial 21-hydroxylase deficiency.<\/li>\n\n\n\n<li>Typically presents after puberty with hirsutism + oligomenorrhea (similar to PCOS).<\/li>\n\n\n\n<li>More common in certain ethnic groups (e.g., Ashkenazi Jewish, central European, Hispanic).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Androgen-Secreting Tumors<\/h3>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Ovarian Tumors<\/strong>\n<ul class=\"wp-block-list\">\n<li><strong>Sertoli-Leydig cell (arrhenoblastoma)<\/strong><\/li>\n\n\n\n<li><strong>Granulosa-theca cell<\/strong> tumors<\/li>\n\n\n\n<li><strong>Hilum-cell<\/strong> tumors<\/li>\n\n\n\n<li>Clinical presentation:\n<ul class=\"wp-block-list\">\n<li>Rapidly progressive androgen excess.<\/li>\n\n\n\n<li>Markedly elevated serum testosterone.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Sertoli-Leydig<\/strong>: Usually large.<\/li>\n\n\n\n<li><strong>Hilum-cell<\/strong>: Often small, can evade detection on imaging.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Adrenal Androgen-Secreting Tumors<\/strong>\n<ul class=\"wp-block-list\">\n<li>Typically <strong>adrenocortical carcinoma<\/strong> producing excess DHEA.<\/li>\n\n\n\n<li>Rarely, a benign adenoma or carcinoma hypersecreting testosterone.<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n\n\n\n<h3 class=\"wp-block-heading\">Other Situations<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Post-Menopausal Facial Hair<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Related to adrenal androgens unopposed by estrogen after ovarian failure.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Medication-Induced<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Anabolic steroids, other androgenic drugs.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Rare Causes<\/strong>:\n<ul class=\"wp-block-list\">\n<li><strong>Cushing syndrome<\/strong><\/li>\n\n\n\n<li><strong>Glucocorticoid resistance syndrome<\/strong><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Evaluation of Hirsutism and Hyperandrogenism (Endocrinology Lecture 003)\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/gYqCU5igbeQ?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">EVALUATION OF WOMEN WITH HIRSUTISM<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">Testosterone Circulation<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Testosterone Forms<\/strong>:\n<ol class=\"wp-block-list\">\n<li>Tightly bound to sex hormone\u2013binding globulin (SHBG).<\/li>\n\n\n\n<li>Loosely bound to albumin.<\/li>\n\n\n\n<li>Unbound (free).<\/li>\n<\/ol>\n<\/li>\n\n\n\n<li><strong>Bioavailable Testosterone<\/strong> = Loosely bound + Free fractions.<\/li>\n\n\n\n<li><strong>SHBG Reduction<\/strong> (e.g., obesity, hypothyroidism, liver disease) \u2192 increased bioavailable T.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Common Causes of Elevated Testosterone in Hirsute Women<\/h3>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Polycystic Ovary Syndrome (PCOS)<\/strong><\/li>\n\n\n\n<li><strong>Nonclassic CAH<\/strong><\/li>\n\n\n\n<li><strong>Hyperthecosis<\/strong><\/li>\n\n\n\n<li><strong>Hypothyroidism<\/strong><\/li>\n\n\n\n<li><strong>Androgen-Secreting Tumor<\/strong> (ovarian or adrenal)<\/li>\n<\/ol>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Tumor Suspicion<\/strong>: If serum testosterone is &gt;3\u00d7 upper limit of normal.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Additional Diagnostic Tests<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Serum DHEA-S, Androstenedione<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Elevated in adrenal tumors, some CAH.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Serum TSH<\/strong>: To exclude hypothyroidism.<\/li>\n\n\n\n<li><strong>8 AM 17-Hydroxyprogesterone<\/strong> (baseline + post-cosyntropin):\n<ul class=\"wp-block-list\">\n<li>Abnormal in most CAH patients.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>LH, FSH<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Increased ratio (LH&gt;FSH) consistent with PCOS.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>24-Hour Urinary-Free Cortisol<\/strong>:\n<ul class=\"wp-block-list\">\n<li>To exclude Cushing syndrome.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Imaging<\/strong>:\n<ul class=\"wp-block-list\">\n<li>Transvaginal ultrasound (ovarian masses).<\/li>\n\n\n\n<li>CT scan (adrenal masses).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p><a href=\"https:\/\/myendoconsult.com\/learn\/download\/4423049\/\">Download my lecture slides here (sign in to download)<\/a><\/p>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>HIRSUTISM AND VIRILIZATION Definitions HAIR GROWTH CYCLE AND ANDROGEN EFFECTS CLINICAL ASSESSMENT OF HIRSUTISM PATHOPHYSIOLOGY: ANDROGEN PRODUCTION AND ACTION COMMON CAUSES OF HIRSUTISM AND VIRILIZATION Virilization-Related Causes Hyperthecosis Idiopathic Hirsutism Congenital Causes of Virilization in Female Neonates Androgen-Secreting Tumors Other Situations EVALUATION OF WOMEN WITH HIRSUTISM Testosterone Circulation Common Causes of Elevated Testosterone in Hirsute [&hellip;]<\/p>\n","protected":false},"featured_media":0,"template":"","oen_topic_chapter":[685],"class_list":["post-4422452","oen_topic","type-oen_topic","status-publish","hentry","oen_topic_chapter-reproductive-disorders","post-wrapper","thrv_wrapper"],"_links":{"self":[{"href":"https:\/\/myendoconsult.com\/learn\/wp-json\/wp\/v2\/oen_topic\/4422452","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myendoconsult.com\/learn\/wp-json\/wp\/v2\/oen_topic"}],"about":[{"href":"https:\/\/myendoconsult.com\/learn\/wp-json\/wp\/v2\/types\/oen_topic"}],"version-history":[{"count":13,"href":"https:\/\/myendoconsult.com\/learn\/wp-json\/wp\/v2\/oen_topic\/4422452\/revisions"}],"predecessor-version":[{"id":4423051,"href":"https:\/\/myendoconsult.com\/learn\/wp-json\/wp\/v2\/oen_topic\/4422452\/revisions\/4423051"}],"wp:attachment":[{"href":"https:\/\/myendoconsult.com\/learn\/wp-json\/wp\/v2\/media?parent=4422452"}],"wp:term":[{"taxonomy":"oen_topic_chapter","embeddable":true,"href":"https:\/\/myendoconsult.com\/learn\/wp-json\/wp\/v2\/oen_topic_chapter?post=4422452"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}