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hi in this lecture we will review
hirsutism in women hirsutism is defined
as excessive hair growth and woman wear
it should not be this can be a facial
distribution or a central body
distribution consistent with a male
pattern let's talk about hair follicles
in the embryo
when do hair follicles actually develop
do you know it's okay if you don't
because I'm going to tell you now eight
to ten weeks is usually when we see hair
follicles develop from the epidermal
cells here's another question for you
after how many weeks do we not have new
follicle development in a in a fetus
well the answer to that is after 22
weeks after 22 weeks no new hair
follicles are made there are three
growing phases of the hair follicle here
is a diagram of the anatomy of the hair
follicle I doubt you'll have any exam
questions about this but it's just
helpful to know as I discuss hirsutism
and women there are three growing phases
antigen the growth phase catagen the
transition phase intelligent the
quiescent phase let's discuss sexual
hair sexual hair responds to androgens
specifically DHT or dihydrotestosterone
the most active form of testosterone
sexual hair primarily grows on the face
normally in a man abnormally in women
which is a cause for hirsutism sometimes
you can find chest hair and women this
is also abnormal but you do see a male
distribution on a man you can have it on
the lower abdomen and this sometimes is
abnormal and women pubic hair is also
controlled by DHT as well as hair and
the axilla let's now talk about the
development of terminal hair first let's
define vellus hair which is the
pre-pubertal stage then with puberty
onset usually villus hair is changed to
terminal hair terminal hair tends to be
coarser than Bellis hair estrogens
actually result in the slow growth of
finer and lighter hair and progestins
have little to no effect on hair growth
at all viralization is not to be
confused with hirsutism hirsutism is a
less severe symptomatology of
hyperandrogenism be realization is more
severe let's review the different signs
and symptoms of v realization when it
may suffer from temporal balding they
may also have deepening of the voice
they may also have breast atrophy which
is distressing for many women and they
can have overall changes in their body
habitus with more muscular ization
overall women can also experience
clitoral megali when the clitoris
becomes enlarged or lengthened hirsutism
is different again however there is an
excessive male pattern facial and body
hair distribution in women which is
abnormal
remember that hirsutism reflects the
interaction between circulating and room
levels and the sensitivity of hair
follicles to Andrew and stimulation this
suggests that actually different women
may be stimulated differently at the
level of the hair follicle this is a
high-yield fact it's often quizzed on
your exams let's now review the normal
physiology of adrenal cortex and ovarian
and reproduction when it comes to
testosterone the adrenal cortex
Texts makes about 25% Anderson down 50%
DHEA another 50% and DHEA s are sulfated
DHEA a hundred percent you can have
peripheral conversion of DHEA s to DHEA
sulphate ace will cleave the sulfate
group you can also have ovarian
production of Anderson down as well as
DHEA and testosterone recall that as
women go into menopause all of these
hormones will go down now let's talk
about testosterone and men versus women
men usually have a total circulating
testosterone between 200 and 800
nanograms per deciliter in a normal
woman you may see between 20 and 80
nanograms per deciliter however not all
that testosterone is bioavailable some
of it is actually free and men 3% is
free however overwhelmingly the vast
majority is bound to either albumin or
sex hormone binding globulin in a normal
woman we
see that about 1% is free and the
majority is bound however in a hurry
woman we find that the percent that is
free is actually doubled however most of
the free testosterone is still bound to
either albumin or SHBG let's now talk
about how you would actually evaluate a
patient who has hirsutism first and
foremost you would like to get a
thorough gynecologic history this
includes the age of menarche and as
you'll recall from other lectures the
average age is 12 then you want to ask
about a description of cycles does she
have a legume in area Holyman area all
of these are important then you'd like
to ask about the duration of menses that
means how long does she actually bleed
then you'd like to review other
diagnoses as well as an OB history that
means how many times she's been pregnant
which is a G versus how many times she's
delivered which is a P gravity' and para
is the way we communicate in ob/gyn we
also want to know a family history does
her mother have hirsutism does her
sister have hirsutism we also want to
know is the family generally obese has
there been a history of infertility in
her family and what is her ethnicity as
certain ethnicities can have higher
incidences of hirsutism associated with
certain diseases such as CAH then you'd
like to know what the patient is taking
is she taking a medication that can
cause an issue let's now talk about
Andrew and excess in general this is a
study that has consecutive experience
with more than a thousand patients the
differential diagnosis in these patients
were included in this study if you'd
like to know more information you can
download this and to look at it later
I doubt you'll have any examination
questions regarding this table but it
may be helpful to know let's now review
androgen secreting neoplasms this is an
uncommon cause for Android and access
and women but needs to be remembered in
the evaluation ASN accounts for 5% of
all ovarian tumors
most are sertoli late Excel tumors lipid
theca and cell tumors are also known to
cause hyperandrogenism as well as Hylas
cell tumors
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