26. Hyperandgrogenism

Question 1

What is hyperandrogenism?

Answer 1

Increased androgen production or action.

Question 2

What is hirsutism?

Answer 2

Growth of terminal hair in a male-pattern distribution that is socially undesirable.

Question 3

What is virilization?

Answer 3

Development of male secondary sexual characteristics in a woman (e.g., hirsutism, deepened voice, clitoromegaly, defeminization).

Question 4

What is acne vulgaris in the context of hyperandrogenism?

Answer 4

Hormonally influenced but not an endocrine disorder itself.

Question 5

How does hair grow?

Answer 5

In cycles, not continuously.

Question 6

What is the duration of the growth cycle in different body areas?

Answer 6

✅ Scalp: 5-7 years
✅ Face: 3-6 months

Question 7

What are the three types of hair based on androgen response?

Answer 7

✅ Non-sexual hair: Independent of androgens.
✅ Ambosexual hair: Stimulated by low androgen levels (e.g., pubic hair at puberty).
✅ Sexual hair: Stimulated by high androgen levels, develops in male pattern (e.g., beard, upper pubic triangle).

Question 8

What are the three types of hair?

Answer 8

✅ Lanugo: Fine, soft, silky prenatal hair coat.
✅ Vellus: Fine, usually non-pigmented, short.
✅ Terminal: Thick, dark, long.

Question 9

What are the three phases of the hair cycle?

Answer 9

✅ Anagen (Active Growth): 85-95% of scalp hair, lasts about 3 years.
✅ Catagen (Regression): 1% of scalp hair, lasts about 2 weeks.
✅ Telogen (Resting): 5-15% of scalp hair, lasts about 3-4 months.

Question 10

How many hair follicles are on the scalp?

Answer 10

About 100,000.

Question 11

How many hairs are lost per day?

Answer 11

20-75 hairs/day.

Question 12

How does the facial hair cycle differ from the scalp?

Answer 12

Facial hair: 4 months anagen vs 2 months telogen.

Question 13

What makes up the pilosebaceous unit?

Answer 13

Hair follicle + sebaceous gland.

Question 14

Why is the pilosebaceous unit important in androgen-related disorders?

Answer 14

✅ It is a sex steroid target with oestrogen + androgen receptors.
✅ It converts testosterone to 5α-DHT (the active androgen).

Question 15

What are the three main androgens?

Answer 15

✅ Testosterone (primary active androgen).
✅ Dehydroepiandrosterone (DHEA) – a prehormone converted to testosterone.
✅ Androstenedione – another prehormone converted to testosterone.

Question 16

What enzyme converts testosterone into its more potent form?

Answer 16

5α-reductase converts testosterone into dihydrotestosterone (DHT).

Question 17

What modulates androgen effects in the blood?

Answer 17

Sex hormone-binding globulin (SHBG) acts as a buffer system in androgen regulation.

Question 18

What is the role of Sex Hormone Binding Globulin (SHBG)?

Answer 18

SHBG binds androgens in circulation, modulating their effects and acting as a buffer system.

Question 19

What is the most common ovarian cause of hyperandrogenism?

Answer 19

Polycystic ovarian syndrome (PCOS).

Question 20

Which ovarian tumours can cause hyperandrogenism?

Answer 20

Androgen-producing tumours.

Question 21

Which adrenal disorders can cause hyperandrogenism?

Answer 21

Congenital adrenal hyperplasia (CAH), adrenal adenomas, adrenal carcinomas, and Cushing’s syndrome.

Question 22

What is pregnancy luteoma, and how does it cause hyperandrogenism?

Answer 22

A benign ovarian mass during pregnancy that produces excess androgens.

Question 23

How does obesity contribute to hyperandrogenism?

Answer 23

Increases peripheral conversion of androgens and reduces SHBG, leading to more free androgens.

Question 24

What endocrine disorders reduce SHBG, leading to more free androgens?

Answer 24

Hypothyroidism, hyperthyroidism, and hyperinsulinemia.

Question 25

What is idiopathic hyperandrogenism?

Answer 25

Increased androgen sensitivity in target tissues without elevated androgen levels.

Question 26

What medications can cause hyperandrogenism?

Answer 26

Testosterone, anabolic steroids, danazol.

Question 27

What happens in cases of combined ovarian and adrenal pathology?

Answer 27

Both sources contribute to hyperandrogenism, leading to severe symptoms.

Question 28

What key elements should be assessed in the history of a patient with hyperandrogenism?

Answer 28

Family history, previous investigations, and past treatments.

Question 29

What aspects should be assessed during a physical examination for hyperandrogenism?

Answer 29

Signs of hirsutism, acne, virilization, obesity, and features of underlying endocrine disorders.

Question 30

How is hirsutism documented?

Answer 30

Using scoring systems such as the Ferriman-Gallwey score.

Question 31

How do FSH and LH levels help diagnose PCOS?

Answer 31

An inverted ratio (LH > FSH) is suggestive of PCOS.

Question 32

What does a very elevated testosterone level suggest?

Answer 32

Androgen-producing tumour.

Question 33

What does a mild elevation of testosterone suggest?

Answer 33

Ovarian source, such as PCOS.

Question 34

Why is the free androgen index (FAI) more useful than total testosterone?

Answer 34

FAI indicates the bioavailable testosterone, which is a better measure of androgen activity.

Question 35

How is FAI calculated?

Answer 35

FAI = (Total Testosterone × 100) / SHBG.

Question 36

What does an elevated DHEAS level suggest?

Answer 36

Adrenal origin of hyperandrogenism (e.g., adrenal tumour or CAH).

Question 37

What does an elevated 17α OH progesterone level suggest?

Answer 37

Congenital adrenal hyperplasia (CAH), possibly late-onset.

Question 38

When should Cushing’s syndrome be investigated?

Answer 38

If adrenal androgens are elevated or if there is clinical suspicion (e.g., central obesity, moon face, striae).

Question 39

What imaging is useful in diagnosing PCOS or ovarian tumours?

Answer 39

Ultrasound of the ovaries.

Question 40

What should be presumed if all investigations are normal?

Answer 40

End-organ hypersensitivity (often diagnosed as idiopathic hyperandrogenism).

Question 41

What is the general principle of treating hyperandrogenism?

Answer 41

Address the underlying cause and use targeted therapy to reduce androgen levels.

Question 42

How do corticosteroids help in hyperandrogenism?

Answer 42

They suppress adrenal steroidogenesis (useful for adrenal causes like CAH).

Question 43

How do combined oral contraceptives (COCs) help?

Answer 43

They suppress ovarian steroidogenesis and increase SHBG, which reduces free androgens.

Question 44

What is cyproterone acetate, and how does it work?

Answer 44

It is an anti-androgen that binds to DHT receptors and reduces 5α reductase activity.

Question 45

How does spironolactone help in hyperandrogenism?

Answer 45

It is an aldosterone antagonist with anti-androgen effects, binding to androgen receptors.

Question 46

What are the benefits of drospirenone?

Answer 46

It is a spironolactone analogue with anti-mineralocorticoid, anti-androgen, and progestogenic properties.

Question 47

What is the mechanism of action of finasteride?

Answer 47

It is a selective 5α reductase type II inhibitor, preventing the conversion of testosterone to DHT.

Question 48

Why must GnRH agonists be combined with COCs?

Answer 48

To prevent bone loss while inhibiting ovarian steroidogenesis.

Question 49

How does metformin help in hyperandrogenism?

Answer 49

It is an insulin-sensitizing agent, useful in women with PCOS and insulin resistance (IR).

Question 50

What combination provides the best therapeutic result?

Answer 50

Anti-androgens combined with COCs, as they enhance SHBG levels and regulate the cycle.

Question 51

Why is contraception essential when using anti-androgens?

Answer 51

Anti-androgens can be teratogenic and affect fetal development.

Question 52

How does weight loss improve hyperandrogenism?

Answer 52

It increases SHBG and reduces insulin resistance.

Question 53

Why is psychological support important?

Answer 53

Hirsutism and acne can cause distress and body image issues.

Question 54

What is the role of cosmetic therapy?

Answer 54

Laser treatment is highly effective and should be continued alongside medical therapy.

Question 55

How long does it take for acne to improve?

Answer 55

Approximately 6 weeks.

Question 56

How long does it take for facial hair to show improvement?

Answer 56

Around 6 months for initial improvement

Question 57

When should the dose be increased?

Answer 57

If there is no response after 6 months.

Question 58

When should treatment be reviewed?

Answer 58

If there is no response after 18–24 months.

Question 59

Which red flag symptoms require urgent investigation?

Answer 59

**- Testosterone > twice normal - Unilateral ovarian enlargement - Suspected Cushing’s syndrome - Virilization or rapid onset of symptoms - Failed therapy**