The clinical evaluation of hirsutism is important for determining the appropriate treatment

Hirsutism is a hair production disorder that afflicts women worldwide. Unwanted hair growth is its primary and apparent manifestation. However, underlying this distressful problem could be a number of serious ailments that need to be clinically diagnosed and evaluated for any kind of comprehensive treatment. Let us check out how to go about an effective evaluation process.

The Ferriman–Gallwey scoring system for hirsutism

A detailed clinical evaluation of hirsutism should start with an scientific assessment of the degree of the hair growth disorder. The Ferriman–Gallwey (F–G) scoring system, established in 1961, is a common method to that end. Initially the scoring was based on hair growth in 11 body parts but later it took into account nine areas. The score chart is from 0 (zero terminal hairs) to 4 (widespread terminal hair production) and the numbers are summed up to a maximum count of 36. While most experts opine that a modified F–G count of 8 or above indicates hirsutism, some also suggest a final tally of 6. Based on this scorecard and associated clinical tests, hirsutism can be diagnosed as mild, moderate or severe.

However, there are some experts who advice that this semi quantitative method that is heavily dependent on interobserver divergence must be combined with more specific quantitative investigations such as that of general medical history, medication use, hair weight, growth rate, and diameter, balding pattern, acne, skin ailments etc, for a complete evaluation.

Moreover, since a number of ailments can cause hirsutism, they must be also detected (at the backdrop of their history and a physical examination) for a proper evaluation process.

Evaluation of ailments causing hirsutism

There are various diseases that can cause hirsutism, which can be grouped as androgenic and non-androgenic disorders. Since androgens are the main hormone that triggers hair growth, this categorization is obvious. Let us check out the evaluation methods for each of the disorders, based on this two-fold grouping.

1. Androgenic causes

• Polycystic Ovarian Syndrome (PCOS): This is the most common cause of hirsutism. However, other diagnoses need to be excluded before any conclusions. A history of excessive hair growth among family members might be an indicator. Associated symptoms include irregular menses, obesity, infertility, diabetes, hypertension, family history of PCOS. Medical tests should consist of fasting glucose, insulin and lipid profile, blood pressure and ultrasound.
• Hyperandrogenism: Major symptoms are regular menses, acne and hirsutism without noticeable endocrine cause. Clinical tests include those for increased androgen levels and serum progesterone in luteal phase. This apart, checking for a previous use of 13-cis retinoic acid for acne cure is a helpful indicator of hyperandrogenism.
• Hypothyroidism: Symptoms are weakness, weight increase, record of thyroid ablation, untreated hypothyroidism and amenorrhea. Must involve a test for TSH.
• The hyperandrogenic insulin-resistant acanthosis nigricans syndrome (HAIR-AN): Main symptoms include brown velvety hyper-pigmented skin (acanthosis nigricans), obesity, hypertension, hyperlipidemia, established family history of diabetes. Important examinations must consist of fasting glucose and lipid profile, BP, fasting insulin level or insulin level on 3-hour glucose tolerance test.
• 21-hydroxylase non-classic I adrenal hyperplasia (late-onset CAH): This syndrome is marked by acute hirsutism or virilization, established family history of CAH, stunted height and signs of masculinity. Major medical evaluation are 17-HP level before and after ACTH stimulation test>10ng/dL, CYP21 genotyping.
• 21-hydroxylase-deficient congenital adrenal hyperplasia: The signs are more or less similar to late-onset CAH, with congenital virilization. Key lab test is the 17-HP levels.
• Hyperprolactinemia: It is a rare cause of hirsutism and additional tests should first rule out other disorders. Otherwise, indicators are amenorrhea, galactorrhea, infertility and clinical test is that for prolactin.
• Androgenic tumors: This is also a rare cause of hirsutism. A speedy hair growth pattern and virilization over a span of 3–6 months is a major sign. PCOS triggered hirsutism develops over several years. This apart, the patient should be checked for pelvic masses. Medical examination should include pelvic ultrasound or abdomen/pelvic CT scan and a serum testosterone and DHEAS.
• Cushing’s syndrome: Rounded facies, a buffalo hump, truncal obesity, hypertension, purple striae and proximal muscle infirmity could suggest Cushing’s syndrome. A CT scan for review of the adrenal glands, a 24-hour urinary free cortisol and blood pressure tests are the main clinical investigations.
• Hyperthecosis: Clinical imaging can help detect hyperthecosis that causes hirustism. An enlarged ovary without follicular formations is the main indicator. A testosterone examination is also necessary to confirm it. For if circulating testosterone test result is 2.5 or more times the upper limits of normal or 200 or more ng/dL, it could be androgen-secreting tumors. However, only 20 to 30 percent of women recording such levels will have androgenic tumors, since most will have either a hyperthecosis or hilar cell hyperplasia. One can also use a gonadotropin-releasing hormone agonist in the evaluation of postmenopausal virilization due to ovarian hyperthecosis.

2. Non-androgenic causes

Hirsutism caused by factors other than androgenic disorders, is less prevalent and can be divided as below:

• Acromegaly: Amenorrhea, galactorrhea, infertility could be general expressions. However, one needs to check for other problems first since it is a rare cause of hirsutism. The evaluator should conduct tests for prolactin.
• Chronic skin ailments: Since a major function of the hair is to protect the skin, skin ailments can lead to hirsutism. Clinical evaluation for skin diseases is necessary.
• Non-androgenic anabolic drugs also often trigger a general growth of many tissues, particularly hair. A proper evaluation must include a detailed drug and medication history including use of Danazol, Norplant, and anabolic steroids that have hirsutism as a possible side effect. One must also exclude the possibility of vellus hypertrichosis.

3. Idiopathic hirsutism

Idiopathic hirsutism is the second most common diagnosis of hirsutism after PCOS. Though a lot more research needs to be conducted in this field, cases with this kind of hirsutism show a probable excess peripheral 5 alpha-reductase action in skin and hair follicle, other variations in androgen metabolism or greater sensitivity of the androgen receptor but regular menses and normal serum androgen levels. Medical tests must include regular basal body temperature charting, luteal phase serum progesterone, DHEAS, testosterone, either follicular phase basal 17-OH progesterone levels or a Cortrosyn stimulation III test.