Hirsutism – excess hair growth on the body and face in women according to the male pattern. It is caused by the interaction of plasma androgens and the hair follicle sensitive to this hormone.
Most hirsutism is due to androgen excess (≥80%), and most women with hirsutism (70% to 80%) have polycystic ovary syndrome (PCOS), in which there is gonadotropin-dependent functional ovarian hyperandrogenism. Idiopathic hirsutism ranges from 5% to 20%.
The article estet-portal.com will help in choosing the tactics of the diagnostic and treatment course in the management of a patient with hirsutism in the premenopausal period.
Diagnosis of hirsutism in the perimenopausal period
A meta-analysis comparing the available 37 randomized controlled trials for the diagnosis and pharmacological treatment of hirsutism resulted in a new Guideline for the management of premenopausal hirsutism on March 7, 2018.
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Required Diagnostic Actions:
1. testing for elevated androgen levels in all women with abnormal hirsutism;
2. Screening hyperandrogenic women to detect adrenal hyperplasia due to 21-hydroxylase deficiency by measuring morning 17-hydroxyprogesterone levels in the follicular phase or on a different day for patients with amenorrhea or infrequent menstruation.
Recommended Diagnostics:
• pregnancy test in patients with amenorrhea;
• dehydroepiandrosterone sulfate measurement to screen for adrenal hyperandrogenism;
• Search for Cushing's Syndrome;
• assessment of thyroid function;
• detection of acromegaly and hyperprolactinemia;
• ultrasonography of the pelvis (preferably transvaginal) to detect ovarian neoplasms.
Diagnostic program to clarify the etiology of hyperandrogenemia
If hyperandrogenemia is confirmed in a postmenopausal patient with hirsutism, additional examinations are needed to identify the etiology:
1. measurement of serum androstenedione (an immediate precursor of testosterone);
2. evaluation of response to corticotropin 17-hydroxyprogesterone, 17-hydroxypregnenolone and 11-deoxycortisol and/or genotyping to rule out rare forms of congenital adrenal hyperplasia;
3. assessment of urinary corticoid metabolites by mass spectrometry to exclude visible cortisone reductase deficiency;
4. dexamethasone suppression test;5. adrenal computed tomography, transvaginal ultrasound;
6. test with gonadotropin-releasing hormone.
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1.
Combined oral estrogen-progestin contraceptives are used in patients with hirsutism as initial therapy.
2.For women who do not plan pregnancy, have undergone operative sterilization or are using long-acting reversible contraception, it is recommended to use either COCs or antiandrogens (spironolactone 100 mg/day, finasteride 2.5-5 mg/day and flutamide 500 mg/day).
3.For women with hirsutism at increased risk of thrombosis (eg, those who are obese or patients over 39 years of age), COC therapy containing a low effective dose of ethinyl estradiol (usually 20 mcg) is recommended.
4.If hirsutism cannot be corrected despite 6 months of COC monotherapy, it is recommended to add antiandrogen drugs.
Flutamide is hepatotoxic! It is necessary to control the level of transaminases when prescribing flutamide.5.
In patients with severe hirsutism causing emotional stress and/or those women who have previously used COCs and have not improved sufficiently, it is recommended to start combination therapy with COCs and antiandrogen drugs.
6.In case of suboptimal response to COC and/or antiandrogens, or intolerance to these drugs, the use of glucocorticoids (prednisone 4-6 mg per day or dexamethasone 0.25 mg/day) is acceptable.
Lifestyle changes (diet, exercise) resulted in weight loss, decreased serum testosterone levels and insulin concentrations, which contributed to the treatment of hirsutism.
Non-pharmacological ways to deal with hirsutism
Cosmetic methods to combat hirsutism include methods that remove hair from the surface of the skin (depilation) and those that pull the hair out of the hair follicle (epilation).
Direct hair removal methods for premenopausal hirsutism include:
• photoepilation with Nd:YAG laser or diode laser, for those who have unwanted hair - chestnut, brown or black. For women who desire a faster response to photoepilation, fluoronitine cream may be used;Paradoxical hypertrichosis after photoepilation in women with facial hirsutism – a rare but psychologically traumatic, long-term and potentially permanent side effect after photoepilation.
• electrolysis for white or blonde hair.
Hirsutism – it is a clinical diagnosis that is indicative of a hyperandrogenic condition that may require specific treatment and has undesirable consequences for fertility, increasing the risk of complications. There is a wide range of approaches used by professionals to diagnose the disorder.
The purpose of diagnostic measures is to attempt to determine a specific etiology and provide hormonal correction.
You may be interested in an article on our website estet-portal.com in the "Dermatology" section;
How to assess the degree of increased female body hair
Adapted from The Journal of Clinical Endocrinology & Metabolism
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