Endocrine Abstracts (2004) 7 S26

The clinical management of Hirsutism: evidence based practice

R Azziz

Department of Obstetrics and Gynecology, Cedras-Sinai Medical Center, Los Angeles, CA, USA; Department of Obstetrics and Gynecology, The David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; Department. of Medicine, The David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; The Center for Androgen Related Disorders, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Hirsutism is the appearance of terminal hairs in areas of the body that are exclusively 'masculine'. Hirsutism is primarily a sign of an underlying endocrine abnormality, androgen excess. The principal causes of androgen excess are: the polycystic ovary syndrome (PCOS) in 80-90%, idiopathic hirsutism (IH) in 5-10%, the Hyperandrogenic-Insulin Resistant-Acanthosis Nigricans (HAIRAN) syndrome in 2-4%, 21-hydroxylase deficient non-classic adrenal hyperplasia (NCAH) in 1-10%, and androgen-secreting ovarian tumors in 1/300 to 1/1000. All other etiologies are extremely rare.

A thorough history and physical will usually suggest the cause of the hirsutism, and the estimation of hirsutism should be standardized by using a graphic scoring system. Laboratory evaluation is of value primarily in the exclusion of disorders, including metabolic abnormalities or ruling out other causes of oligo-ovulation (e.g. hyperprolactinemia and thyroid dysfunction), escept for when screening for and diagnosing NCAH. Hirsute patients that claim to have 'regular menstrual cycles' should be evaluated by basal body temperature charting and luteal phase serum progesterone levels, as about 40% are actually oligo/anovulatory.

Hormonal therapy for hirsutism involves suppression of androgen secretion and blockade of androgen action. Ovarian androgen suppression can be achieved using most commonly oral contraceptives (OCPs), and rarely long-acting GnRH analogs or ketoconazole. More recently, insulin-sensitizing agents (e.g. metformin) in patients with PCOS have also demonstrated a modest suppressive effect on hirsutism. Adrenal (corticosteroid) androgen suppression may be effective for the treatment of acne, but not for the treatment of hirsutism. Peripheral acting agents are the mainstay of the treatment of hirsutism, and include spironolactone (100-300 mg/day), cyproterone acetate (alone or in combination with ethinyl estradiol as an OCP), flutamide (250 once or twice daily), and finasteride (5 mg/day). There is little difference in response to these agents, with the exception of side-efects. It is important to emphasize that therapy for hirsutism may take six or eight months for a difference to be observed, and should be continued long-term.

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