Chapter 90 - Hirsutism and Hypertrichosis

Question 1

TABLE 90-1
Causes of Hirsutism

FINDINGS
- Regular ovulation and normal to slightly elevated androgen levels
- Often presents with mild to moderate hirsutism

Answer 1

Idiopathic hirsutism (IH)

Question 2

TABLE 90-1
Causes of Hirsutism

FINDINGS
Hyperandrogenism; menstrual irregularities, including oligomenorrhea, amenorrhea, and infertility; and impaired glucose tolerance, hyperlipidemia, and obesity

Answer 2

Polycystic ovarian syndrome (PCOS)

Question 3

TABLE 90-1
Causes of Hirsutism

FINDINGS
- Autosomal recessive inheritance of 21-hydroxylase deficiency
- Rarely secondary to 11β-hydroxylase deficiency
- Hirsutism, acne, alopecia, anovulation, and menstrual dysfunction

Answer 3

Nonclassic congenital adrenal hyperplasia

Question 4

TABLE 90-1
Causes of Hirsutism

FINDINGS
- Hyperandrogenism, insulin resistance, and acanthosis nigricans
- Considered a subtype of PCOS

Answer 4

HAIR-AN
Hyperandrogenism (HA), insulin resistance (IR), and acanthosis nigricans (AN)

Question 5

TABLE 90-1
Causes of Hirsutism

FINDINGS
Seborrhea, acne, hirsutism, and alopecia

Answer 5

SAHA

Question 6

TABLE 90-1
Causes of Hirsutism

FINDINGS
Presents with amenorrhoea, galactorrhea, and infertility

Answer 6

Hyperprolactinemia

Question 7

TABLE 90-1
Causes of Hirsutism

FINDINGS
Centripetal fat distribution, thinning of the skin with striae, glucose intolerance, osteoporosis, and proximal muscle weakness; signs and symptoms of hyperandrogenism and menstrual irregularities

Answer 7

Cushing syndrome

Question 8

TABLE 90-1
Causes of Hirsutism

FINDINGS
Most common areas involved are the upper abdomen, lower abdomen, lower back, upper lip, and thighs

Answer 8

Pregnancy

Question 9

TABLE 90-1
Causes of Hirsutism

FINDINGS
Elevated random serum GH and IGF-1

Answer 9

Acromegaly

Question 10

TABLE 90-1
Causes of Hirsutism

COMMENT
Mean age, BMI, and hip and waist circumference higher in these patients vs patients with metabolic disturbance

Answer 10

Idiopathic hirsutism (IH)

Question 11

TABLE 90-1
Causes of Hirsutism

COMMENT
- Cutaneous findings of acanthosis nigricans may also be observed in 5% of obese women with insulin resistance
- Warrants endocrinology evaluation for impaired glucose tolerance as increased risk for type 2 diabetes mellitus

Answer 11

Polycystic ovarian syndrome (PCOS)

Question 12

TABLE 90-1
Causes of Hirsutism

COMMENT
Patients often present accelerated bone age maturation and increased basal or stimulated 17-OHP

Answer 12

Nonclassic congenital adrenal hyperplasia

Question 13

TABLE 90-1
Causes of Hirsutism

COMMENT
Insulin elevated; elevated or high-normal levels of testosterone and androstenedione but normal levels of LH and prolactin

Answer 13

HAIR-AN
Hyperandrogenism (HA), insulin resistance (IR), and acanthosis nigricans (AN)

Question 14

TABLE 90-1
Causes of Hirsutism

COMMENT
Associated with stress, pituitary adenoma, pregnancy, drug intake, and primary hypothyroidism with elevated TSH

Answer 14

Hyperprolactinemia

Question 15

TABLE 90-1
Causes of Hirsutism

COMMENT
Multiple causes:
- Adrenal neoplasm
- Ectopic ACTH-secreting tumor
- Pituitary tumor (Cushing disease)

Answer 15

Cushing syndrome

Question 16

TABLE 90-1
Causes of Hirsutism

COMMENT
- Serum total testosterone levels and mFG score increase with the progression of this condition
- Associated with physiological changes of this condition

Answer 16

Pregnancy

Question 17

TABLE 90-1
Causes of Hirsutism

COMMENT
Patients can present with abnormal growth of the hands and feet, arthritis, sleep apnea, headache, and impaired vision

Answer 17

Acromegaly

Question 18

TABLE 90-2
Pharmacologic Treatment of Hirsutism

MECHANISM OF ACTION
- Suppress ovarian androgen synthesis
- Increase SHBG

Answer 18

Oral contraceptive pills (OCPs)

Question 19

TABLE 90-2
Pharmacologic Treatment of Hirsutism

MECHANISM OF ACTION
- Competitive inhibitor of AR and 5α-reductase
- Increases SHBG
- Decreases androgen synthesis

Answer 19

Spironolactone

Question 20

TABLE 90-2
Pharmacologic Treatment of Hirsutism

MECHANISM OF ACTION
Competes with DHT for binding to the androgen receptor

Answer 20

Cyproterone acetate

Question 21

TABLE 90-2
Pharmacologic Treatment of Hirsutism

MECHANISM OF ACTION
Nonsteroidal competitive inhibitor of androgen receptor binding

Answer 21

Flutamide and bicalutamide

Question 22

TABLE 90-2
Pharmacologic Treatment of Hirsutism

MECHANISM OF ACTION
Suppress adrenal function

Answer 22

Glucocorticoids

Question 23

TABLE 90-2
Pharmacologic Treatment of Hirsutism

MECHANISM OF ACTION
Suppresses gonadotropin and ovarian androgen secretion

Answer 23

GnRH agonist
(Leuprolide acetate, depot suspension)

Question 24

TABLE 90-2
Pharmacologic Treatment of Hirsutism

MECHANISM OF ACTION
Cytochrome P450 enzyme inhibitor and decreases adrenal steroid production

Answer 24

Ketoconazole

Question 25

TABLE 90-2 Pharmacologic Treatment of Hirsutism MECHANISM OF ACTION Inhibits 5α-reductase

Answer 25

Finasteride

Question 26

TABLE 90-2 Pharmacologic Treatment of Hirsutism MECHANISM OF ACTION Insulin-sensitizing agent

Answer 26

Metformin

Question 27

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Oral contraceptive pills (OCPs)

Answer 27

Single pill a day

Question 28

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Spironolactone

Answer 28

Starting dosage is 50 mg twice daily and may be increased to a total daily dose of 200 mg

Question 29

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Cyproterone acetate

Answer 29

Low dose (2 mg) in OCPs 12.5-100 mg as monotherapy or with estrogen

Question 30

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Flutamide

Answer 30

62.5–250 mg, twice daily

Question 31

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Bicalutamide

Answer 31

25 mg/day

Question 32

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Prednisone

Answer 32

5-7.5 mg by mouth at bedtime

Question 33

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Dexamethasone

Answer 33

0.5 mg at bedtime

Question 34

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE GnRH agonist (Leuprolide acetate, depot suspension)

Answer 34

7.5 mg monthly intramuscularly, with 25–50 ug of transdermal estradiol

Question 35

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Ketoconazole

Answer 35

400–600 mg by mouth daily

Question 36

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Finasteride

Answer 36

1–5 mg by mouth

Question 37

TABLE 90-2 Pharmacologic Treatment of Hirsutism DOSAGE Metformin

Answer 37

850 mg twice a day or 500 mg three times a day

Question 38

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Headaches - Migraines - Risk of venous thromboembolic event - Melasma - Alopecia (upon discontinuation)

Answer 38

Oral contraceptive pills (OCPs)

Question 39

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Polyuria - Hypotension - Headaches - Fatigue - Syncope - Hyperkalemia - Irregular menses - Teratogen - Decreased libido

Answer 39

Spironolactone

Question 40

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Fluid retention - Depression - Menstrual irregularities - Teratogen - Increased risk of liver dysfunction

Answer 40

Cyproterone acetate

Question 41

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Teratogen - Hepatotoxicity - Diarrhea - Nausea - Vomiting

Answer 41

Flutamide and bicalutamide

Question 42

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Hyperglycemia - Hypertension - Cushingoid changes - Esophageal reflux and peptic ulcer disease - Psychosis and agitation - Increased risk of infections - Adrenal suppression

Answer 42

Glucocorticoids

Question 43

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS Osteoporosis if not combined with estrogen–progestin

Answer 43

GnRH agonist (Leuprolide acetate, depot suspension)

Question 44

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Headache - Nausea - Hair loss

Answer 44

Ketoconazole

Question 45

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Headaches - Decreased libido

Answer 45

Finasteride

Question 46

TABLE 90-2 Pharmacologic Treatment of Hirsutism ADVERSE EFFECTS - Rare lactic acidosis - GI distress

Answer 46

Metformin

Question 47

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS - First-line therapy (in women not seeking to conceive) - Contradictions: -- Uncontrolled HTN -- Thromboembolic disorder -- Breast cancer -- Active smoker (absolutely if older than 35 yr) -- Cardiovascular disease

Answer 47

Oral contraceptive pills (OCPs)

Question 48

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS - Avoid combination with other potassium-sparing diuretics and thiazides - Contraindicated in patients with renal failure - Recommend combination with OCPs - Pregnancy Category C

Answer 48

Spironolactone

Question 49

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS - Not available in the United States - Contraindicated during pregnancy and breastfeeding and with liver diseases

Answer 49

Cyproterone acetate

Question 50

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS - Recommend combination with OCPs - Pregnancy Category D

Answer 50

Flutamide and bicalutamide

Question 51

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS - Indicated for hirsutism secondary to CAH - Not recommended in patients with uncontrolled diabetes and hypertension - When used as monotherapy, does not significantly improve hirsutism - Pregnancy Category C

Answer 51

Glucocorticoids

Question 52

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS (2) Pregnancy Category X

Answer 52

1. GnRH agonist (Leuprolide acetate, depot suspension) 2. Finasteride

Question 53

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS Pregnancy Category C

Answer 53

Ketoconazole

Question 54

TABLE 90-2 Pharmacologic Treatment of Hirsutism COMMENTS - Must ensure normal renal function before starting - Pregnancy Category B

Answer 54

Metformin