Clinical Evaluation of Hirsutism
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.
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.
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
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
- The hyperandrogenic insulin-resistant acanthosis nigricans syndrome
(HAIR-AN): Main symptoms include brown velvety hyper-pigmented skin
obesity, hypertension, hyperlipidemia, established family history of
diabetes. Important examinations must consist of fasting glucose and lipid
BP, fasting insulin level or insulin level on 3-hour glucose tolerance
- 21-hydroxylase non-classic I adrenal hyperplasia (late-onset
CAH): This syndrome is marked by acute hirsutism or virilization, established
history of CAH, stunted height and signs of masculinity. Major medical
evaluation are 17-HP level before and after ACTH stimulation test>10ng/dL,
- 21-hydroxylase-deficient congenital adrenal hyperplasia:
The signs are more or less similar to late-onset CAH, with congenital
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.
galactorrhea, infertility and clinical test is that for prolactin.
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
- Cushing’s syndrome: Rounded facies, a buffalo
hump, truncal obesity, hypertension, purple striae and proximal
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
- Hyperthecosis: Clinical imaging can help detect
hyperthecosis that causes hirustism. An enlarged ovary without
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
only 20 to 30 percent of women recording such levels will have
since most will have either a hyperthecosis or hilar cell hyperplasia.
One can also use a gonadotropin-releasing hormone agonist in
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.
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
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
peripheral 5 alpha-reductase action in skin and hair follicle, other variations
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