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let's now review the differential
diagnosis of hirsutism there can be non
antigenic causes of hirsutism one of
those being acromegaly here I have a
picture of a patient and her younger
years versus her later years is there
anything you notice about the patient
besides her aging
have you guessed it I'll give you a hint
look closely at her features
well if you said her features look
course then you're correct this is very
common with acromegaly and this is a
cause of hirsutism you can also have
hirsutism with skin irritation such as
with the application of retinoic acid
certain medications can also lead to
hirsutism including cyclosporine
phenytoin minoxidil calcium channel
blockers and also other medications
listed here there are again androgenic
causes we have a whole lecture set
entitled PCOS where you can learn more
there is another phenomenon called the
hair and syndrome and for more
information download the slides
associated with this lecture there's
also something called idiopathic
hirsutism we really don't know why but
we think it's into manic activity at the
level of the hair follicle
then there's non-classical CAH for more
information about congenital adrenal
hyperplasia please see the slides
entitled CAH or congenital adrenal
hyperplasia and then very rarely we can
see androgen secreting neoplasms in the
ovary or the adrenal recall that
elevated prolactin can also cause
hirsutism luteum of pregnancy can also
be an antigenic cause and this usually
happens when the placenta also has some
issue as well see collodion cysts are
also associated with high maternal serum
HCG remember that Cushing's syndrome is
a differential diagnosis in hirsutism
this is often tested during the USMLE so
pay close attention to the next slide
are you ready here we go
lets rule out Cushing's syndrome where
the signs of elevated cortisol in a
patient who presents with hirsutism they
may have that accumulation around the
face and neck they may have a buffalo
hump but this can also be seen in just
an obese patient they typically have
central obesity that means obesity
around the abdomen belly when
distinguishing features though is purple
striae these are not normal
stretch marks as you can see in panel B
this patient has purple stray they
appear purple as opposed to dark like
normal stretch marks this is because you
can see the vessels in the thin skin of
a patient who has elevated cortisol if
you see this in a patient you definitely
need to obtain a 24-hour urinary
cortisol you may need to do this on
several occasions before you can make a
diagnosis there are other tests
regarding how elevated cortisol that you
can find in other lectures upon physical
exam you can find hair growth and a male
distribution pattern traditionally we
used a theremin Galilei score and a
score greater than 8 was associated with
hirsutism however 25 percent of patients
whose have hirsutism use some sort of
cosmetic treatment for excessive hair
including bleaching plucking shaving and
threading so this has become less useful
as a clinical assessment what's
important to know let's now go over a
checklist if you see evidence of
clitoral megali you should think that
this patient has an Jun excess what she
has Galacta Rhea what would you expect
if you said elevated prolactin that's
correct
sometimes you can see abdominal pelvic
masses that can actually secrete
androgens which lead to hirsutism
treatment of hirsutism is aimed at
reducing the production or increasing
reviving and/or blocking the action of
androgens since PCOS is by far the most
common cause of hirsutism oral
contraceptive pills are the first-line
therapy the management of PCOS is
discussed in a later lecture
but let's review it here sixty to a
hundred percent of women who report
hirsutism and then use OCPs have
subsequent improvement if other
medications are used a woman must be on
contraception to prevent any
anti-androgen effects in a male fetus
oral contraceptive pills decrease LH
secretion from the anterior pituitary
this results unless a
a stimulation of the sinka cells in the
ovary which ultimately leads to decrease
testosterone production if there's
decreased testosterone you guess it
there's less free testosterone also the
estrogen in the pill increases sex
hormone-binding globulin which binds
more free testosterone remember in
addition to actually suppressing LH
secretion estrogen stimulates sex
hormone-binding globulin production also
oral contraceptive pills decrease
adrenal production of dhes and we think
that progestin in contraceptives
actually inhibit 5-alpha reductase
activity in the skin there are other
medications that we can use instead of
oral contraceptive pills or with oral
contraceptive pills
these include medications that actually
block androgen action one of these is
spironolactone it's an aldosterone
antagonist and a mild diuretic it's an
effective therapy because it actually
blocks the androgen receptor decreases
5-alpha reductase and competes for the
binding of testosterone with sexual and
binding globulin flut amide is another
alternative however caution this may be
on your USMLE exam there have been
reports of liver enzyme abnormalities
and hepatitis also these patients get
green urine which can be very
distressing and excessive dryness of
skin and scalp hair however it is known
to be an antigen receptor blocker and
it's as effective as spironolactone in
the u.s. we do not have access to cpa
however in other countries they do this
is a strong progestin and it's an
anti-androgen that decreases circulating
testosterone and indeed I own finally
there's finasteride which is a 5 alpha
reductase inhibitor there are also some
cosmetic solutions for hirsutism
remember that even if you treat
hirsutism with an OC P or other medical
management the effect will not be
immediate so patients still need to
participate in cost
medic removal of hair this can include
laser hair removal electrolysis topical
creams and this cream is actually a
cream that actually inhibits the enzyme
active in the dermal papilla that's
essential for hair growth however it is
very expensive and it's usually not
covered by insurance in the u.s. women
can also undergo waxing normal shaving
threading and different agents that will
actually cause the hair to fall out
thank you for listening and good luck on
your exam
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