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let's now review the differential
diagnosis of hirsutism there can be non
androgen and causes of hirsutism one of
those being acromegaly here I have a
picture of a patient in 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 Phinney
toen 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 enzymatic
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 Android and 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 the 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 slides are you
ready here we go lets rule out Cushing's
syndrome what are the signs of elevated
cortisol in a patient who presents with
hirsutism they may have fat 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 one
distinguishing feature though is purple
striae these are not normal
stretch marks as you can see in panel B
this patient has purple striae 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 in a male
distribution pattern traditionally we
used a fair man Galloway score and a
score greater than 8 was associated with
hirsutism however 25% of patients who
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 but it's important
to note let's now go over a checklist if
you see evidence of clitoral megali you
should think that this patient has
androgen excess what if 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
the bonding 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
stimulation of the theca cells in the
ovary which ultimately leads to
decreased testosterone production if
there's decreased testosterone you
guessed 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 DHT s and we think that
progestin x'
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 in a mild diuretic it's an
effective therapy because it actually
blocks the Antron receptor decreases
5-alpha reductase and competes for the
binding of testosterone with sex hormone
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 androgen receptor blocker and
it's as 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 an inch and 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 pee or other
medical management the effect will not
be immediate so patients still need to
participate in cosmetic
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 papillae 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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you