Hirsutism in women

Probability diagnosis

Constitutional (physiological or familial)

Polycystic ovary syndrome (PCOS)

Serious disorders not to be missed

Cancer/tumour:

• virilising ovarian tumour

• adrenal tumours (cancer and adenoma)

• ectopic (paraneoplastic) hormone production (e.g. lung cancer, carcinoid)

Pitfalls (often missed)

Postmenopausal

Rarities:

• porphyria cutanea tarda

• congenital adrenal hyperplasia

Masquerades checklist

Drugs (many incl. phenytoin, danazol, minoxidil, anabolic steroids, cyclosporin, corticosteroids, OCP, phenothiazines, interferon 〈, penicillamine)

Thyroid/other endocrine (prolactinaemia, Cushing, acromegaly, hypothyroidism)

Is the patient trying to tell me something?

Consider anorexia nervosa

Key history

History of age of onset, extent and activity of the hair. Family history and past medical history including endocrine disorders and drugs especially those listed opposite.

Key examination

• General inspection including distribution and character of the hair growth, endocrine abnormalities (e.g. Cushing syndrome), skin, abdomen and breasts

Key investigations

• Consider pituitary hormones (e.g. FSH, LH, ACTH, TSH, prolactin)

• Serum thyroxine, testosterone, DHEAS

• Pelvic ultrasound (?PCOS)

• Urinary porphyrins

• Imaging of pituitary and adrenal regions

Diagnostic tips

• Mild longstanding hirsutism does not require investigation.

• Keep in mind possibility of self-medication, especially in athletes (anabolic steroids).

• Red flags include sudden appearance of hirsutism/virilisation and a pelvic or abdominal mass.