Hyper-androgenism, hirsutism, PCOS Flashcards
(52 cards)
Which androgens does the ovary produce?
Testosterone, androstenedione and dehydroepiandrostendione (DHEA)
Which androgens does the adrenal gland produce?
Dehydroepiamdrpsterone sulphate (DHEA-S) with androstendione and DHEA
(Very little testosterone)
Do androstenedione and DHEA have androgenic activity?
No, converted to testosterone in peripheral tissues
What % testosterone produced from ovaries?
2/3, normally overproduction caused by increased ovarian function
What % of testosterone is bound? To which molecules?
85% sex hormone binding globulin - inactive
10-15% albumin - active
1-2% free - active
Which hormone converts testosterone to its active form dihydrotestosterone?
5 alpha reductase, increase in hormone → androgen excess
List causes of hyper androgenism
1) Exogenous - testosterone/anabolic steroids/danazol/androgenic steroids
2) Ovarian - PCOS/stromal hyperthecosis, ovarian tumours (sertoli, hilus cell, krenkenburg)
3) Adrenal - tumour, cushings, adult onset adrenal hyperplasia
4) Androgen excess in pregnancy
5) Idiopathic hirsutism - increased 5-a reductase
6) Abnormal gonadal/sexual development
If rapidly progressive hirsutism and virilisation, what should be the concern?
Androgen secreting tumour
What questions should be asked in history for high androgen?
Note timing of onset and rate of progression - puberty / pregnancy; rapid progression suggestive of adrenal / ovarian tumour
History of virilisation - reduction in breast size, deepening of voice, clitoral enlargement, change in physique, male pattern baldness, hair-loss
Hirsutism - onset, progression, psychological impact
Mood change - change in libido, aggression
Other symptoms - menstrual irregularity, acne, infertility
Exclude iatrogenic, exogenous androgens
Family history - late onset congenital adrenal hyperplasia
What should be assessed for in clinical examination for hyper-androgenism?
BP - hypertension
Hirsutism - grade using the Ferriman-Gallway system
Acanthosis nigricans
Identify signs of virilisation and exclude abnormalities of the external genitalia
Identify signs of Cushing’s syndrome - plethora, moon face, increased pigmentation, central obesity, hypertension, striae, proximal muscle wasting, glycosuria
Abdominal and pelvic examination for abdomino-pelvic mass
During Ix for hyper-androgenism, which androgens suggest which source?
Source of androgen
High testostone = ovarian
Very high testosterone= tumour
Is suspecting Cushing syndrome, what test to order?
Overnight dexamethasone suppression test
For Late onset CAH what test.
ACTH stimulation test, increase 17 hydroxyprogesterone
What imaging should be ordered to Ix hyper-androgenism?
Pelvic USS - ?PCO or tumour
Abdominal CT/MRI - adrenal tumour
Any other test for hyper-androgenism?
Consider SHBG, androstenedione, free adrogen index
If virilisation → karyotype
Consider lipids, OGTT
What is the treatment for late onset CAH
Glucocorticoids
What is manamgnet for stromal hyperthecosis?
TAH + BSO
Who does ovarian hyperthecosis present in?
Postmenopasual women
Severe hyperandrogenism and insulin resistence (T2DM, CVD)
Which cancer do you need to consider in patients with ovarian hyperthecosis?
Endometrial cancer, testosterone is converted into oestrogen, risk endometrial hyperplasia, carcinoma
What would be seen in investigations for ovarian hyperthecosis?
High levels androstenedione
DHEA-S normal
USS: BL enlarged ovariaes
Definition of hirsutism
Terminal hair on body of women in same pattern/sequence seen in post pubertal male
Causes of hirsutism?
1) Exogenous / iatrogenic androgens - testosterone, anabolic steroids, androgenic progestogens, danazol
2) Increased ovarian androgens - Polycystic ovary syndrome / stromal hyperthecosis / ovarian tumours (Sertoli-Leydig cell tumours, Hilus cell tumours
3) Adrenal - tumours, Cushing’s syndrome, adult onset congenital adrenal hyperplasia
4) Androgen excess in pregnancy - luteoma
5) Idiopathic hirsutism - due to increased 5-alpha reductase activity in pilosebaceous unit
6) Abnormal gonadal / sexual development
7) Drugs - phenytoin, cortisone, minoxidil, diazoxide, cyclosporin A - alter the texture and extent of hair growth the pattern is non-androgenic and is referred to as hypertrichosis.
What grading system if used to score hirsutism?
Ferriman-Gallway grading system
0 (no terminal hair)
4 score at 11 sites
How does weight loss help treat hirsutism?
Reduced peripheral conversion androstenedione to testosterone
