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EXCESSIVE HAIRGROWTH IN

ADOLESCENTDr. DPankar BanerjiConsulting Gynecologist

Infertility SpecialistIdeal Fertility :IVF and Genetic

Center

Jabalpur, India

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EXCESSIVE HAIR

GROWTHIT MAY BE EITHER

HIRSUTISM

VIRILIZATION

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DEFINITION

HIRSUTISM : APPEARANCE OF

EXCESSIVE COARSE

(TERMINAL)HAIR IN A PATTERN NOTNORMAL IN THE FEMALE

Definition highlights the abnormal

distribution of excess hair growth ,suchas facial ,chest,or upper abdominal hair

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DEFINITION

HYPERTRICHOSIS : GROWTH OF HAIR

IN EXCESS OF THE NORMAL WHILE

LIMITED TO A NORMAL PATTERN OFDISTRIBUTION

It is frequently associated with the use

of medication such as antiepileptics

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DEFINITION

VIRILIZATION : REFERS TO CONCURRENTPRESENTATION OF HIRSUTISMWITH ABROAD RANGE OF SIGNS SUGGESTIVEOFANDROGEN EXCESS,SUCH AS

ACNE,

FRONTOTEMPORAL BALDING,

DEPPENING OF THE VOICE ,A DECREASE IN BREAT SIZE

CLITORAL HYPERTROPHY

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DEFINITION

INCREASED MUSCLE MASS

AMENORREA / OLIGOMENORRHEA

Virilization is seen less frequently thanhirsutism and may reflect a severe underlyingpathologic condition ,such as malignancy

Hirsutism and virilization are closely linked

and hirsutism may actually be the firstmanifestation of a condition that ultimately willlead to virilization in left untreated

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BASIC FACTS ABOUT

HAIRHair grows from a individual hair follicle thatare part of a pilosebaceous gland unit

Number of hair follicles is set from birthMain difference between sexes is the degreeof differentiation of the hair

Human hair growth is continuous

Hair grows in a mosaic pattern(in a givenarea ,hair are in different stages ofdevelopment)

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BASIC FACTS ABOUT

HAIRSome condition may cause a high level

of synchrony between the growth cycles

of hair ,leading to the appearance ofeither massive hair loss (alopecia)or

excess hair for a limited period of time

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BASIC FACTS ABOUT

HAIRGrowth cycle of the Hair: ACT

Anagen : Growth phase,85- 90 % of the life

cycleCatagen : rapid involution Phase

Telogen : Quiescent phase

The growth phase or the anagen phase is

primarily influenced by disorders thatstimulate hair growth as well as therapeuticmidalities.

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BASIC FACTS ABOUT

HAIRThree types of Hair :

Lanugo : Body hair seen in the fetus and

newbornVellus : Fine adult hair covering the body

Terminal hair : Thick pigmented hair of scalpand pubic area

Thickness of the terminal hair varies form oneindividual to other depending upon genetic,and possibly nutritional

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BASIC FACTS ABOUT

HAIRAndrogen sensitive hair : depend upon

androgen input for hair growth.

Face,neck,chest,abdomen,axillary,upperarms ,inner thighs and pubic hair,+ part

of the scalp hair.

Less Androgen independent :

Forearms ,hands .lower legs

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BASIC FACTS ABOUT

HAIRPITUITARY

ADRENALOVARY

PITUITARY

ADRENAL

OVARY

DHEAS

DHEA

AND,STEN,ONE

PERIPHERAL

CONVERSION

TESTOSTERONE

HAIR FOLLICLE

DIHYDROTESTERONE

DHEASACTH

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PRESENTATION

Most of the cases of virilization seen

clinically are acute and striking in nature

and seldom go unrecognized andusually prompt immediate medical

intervention

Hirsutism may present in variety ofways

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PRESENTATION OF

HIRSUTISMHIRSUTISM ALONE

HIRSUTISM AND ASSOCIATED

PILOSEBACEOUS UNITOVERACTIVITY (ACNE)

HIRSUTISM AND OVULATORY

DISORDERSHIRSUTISM AND SIGNS OFVIRILIZATION

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PRESENTATION OF

HIRSUTISMHirsutism alone is the greatest

challenge,patients usually go to dermatologist

Hirsutism wIth acne is frequently in teenagegirls

Hirsutism with ovulatory disorders comes

mostly to gynecologist

Hirsutism with virilization requires immediate

work-up

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CAUSES OF HIRSUTISM

Excess androgen production

Relative circulating androgen excess

and low binding globulins

Excess end organ response

Patient perception

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DISORDERS OF EXCESS

ANDROGEN PRODUCTION

Source of androgen :

Exogenous

Endogenous (most common)

Two primary endogenous sources :

Adrenal glandsOvaries

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DISORDERS OF EXCESS

ANDROGEN PRODUCTION

ADRENAL ANDROGEN EXCESS

May be linked to genetically determined

steroid synthesis enzyme deficiency

Malignant adrenal neoplastic process

Other conditions like Cushings syndrome

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DISORDERS OF EXCESS

ANDROGEN PRODUCTIONADRENAL ANDROGEN EXCESS

Three recognised adrenal enzyme deficiencies :

21 alpha Hydroxylase defieiency11-beta-Hydroxylase deficiency

3-beta-ol-dehydrogenase deficiency

Classical forms are usually presented in

prenatal or neonatal period as ambiguousgenitalia in female

Nonclassic forms are linked with hirsutism

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DISORDERS OF EXCESS

ANDROGEN PRODUCTION21-alpha-Hydroxylase deficiency:

Most common ,10%

Prevalence depends on ethnicorigin(common in slavs,1/50 Hispanics 1/40,ashkenazi jews 1/27

Cushings syndrome :Hirsutism with weight gain

and growth retardation as the primarymanifestation,with acne and other cutaneousproblems

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DISORDERS OF EXCESS

ANDROGEN PRODUCTION

OVARIAN ORIGIN

Most common cause is

POLYCYSTIC OVARIAN SYMDROME

Other

Neoplastic ovarian disease

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Lab.Evaluation of

HirsutismThree basic hormonal evaluation

1. Total testosterone

2. DHEAS

3. AM 17-hydroxyprogesterone

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Total Testosterone

Normal Value (0.2

0.9 ng/ml)

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DHEAS (600 2800 ng/ml)

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AM 17

hydroxyprogesterone(0.1 0.8ng/ml )

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RELATIVE ANDROGEN

EXCESS AND SHBG

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EXCESS REPONSIVITY

TO ANDROGENTESTOSTERONE TARGET CELLS

5-ALPHA -REDUCTASE

DIHIDROTESTOSTERONE RECEPTOR

Excessive response of the receptor to DHT(may be

due to mutation of the highly polymorphic region in

gene of the receptor located on X ChromosomeOver activity of the 5-alpha-reductase (Type1 and

Type 2,type1 is involved in hirsutism )

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BASIC APPROACH TOTHE DIAGNOSIS OF

HIRSUTISM AND

VIRILIZATION

SYMPTOMS AND HISTORY

SIGNSPHYSICAL EXAMINATION

INVESTIGATION

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APPROACH TO

DIAGNOSISIt should be methodical.

First step : True nature of presentation

Patient may present with ovulatory problemsand hirsutism may not be reported

There may be normal hair pattern but patient

complains about hirsutism

Evident virilization should investigated at

once

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APPROACH TO

DIAGNOSISCareful history regarding the timing of

onset and chronological progression

Precocious puberty with androgenexcess suggests adrenal enzyme defect

Family history : androgen excess

disorders

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APPROACH TO

DIAGNOSISPhysical examination

Establish presence of hirsutism and

quantifying itPresence of acne and virilization andrule out hypertrichosis

Skin hyperpigmentation,acanthosisnigricans suggests insulinresistance.Often associated with PCO

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APPROACH TO

DIAGNOSISMeasurement of weight and height andblood pressure: defects relates to

adrenal enzyme defectsGalactorrhoea

Tanner staging : Hirsutism beforeTanner stage 3 to 4 is alarming andsuggests a serious pathology

Visual genital examination for virilization

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APPROACH TO

DIAGNOSISSemiobjective scoring system :

Ferriman and Gallwey system ,between

6-12 is the lower limit.

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APPROACH TO

DIAGNOSISINVESTIGATION:

FOR VIRILIZATION :

Work-up focuses of the identification on thesource of androgen excess

Rule out exogenous androgen

Evidence of endogenous androgen excess:

Serum total testosteroneSerum dehydroepiandrosterone sulfate

(DHEAS)

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APPROACH TO

DIAGNOSISINVESTIGATION:

FOR VIRILIZATION

Imaging studies:Pelvic sonographyAdrenal imaging(USG,CT)

Specialized studies :

Selective venous catherization(adrenal orovarian)

Radioisotope studies

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APPROACH TO

DIAGNOSISINVESTIGATION :

HIRSUTISM: Goal is to rule out seriouspotential life threatening conditions and gaininformation that helps in treatment

Evaluation of Androgen excess:

Testosterone ,total preferred

DHEASIn selected cases : 17-OHP(fasting morningsample)

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APPROACH TO

DIAGNOSISEvaluation of accompanying medical disorder

Ovulation disorder :FSH,LH

Thyroid dysfunction:TSHHyperprolactinemia :PRL

Other investigations ( inselected cases)

Androgen production :Androstenedione,

3-alpha Androstenediol glucuronide

Provocative tests : Corticotropin stimulationtests,Insulin resistance determination

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THERAPEUTIC OPTIONS

VIRILIZATION

GOAL: Identify the underlying cause

and correcting it

Usually related to malignant process

and requires surgical approach

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THERAPEUTIC OPTIONS

HIRSUTISM

GOAL:

The prevention of further stimulation of

hair growth

Cosmetic correction of the problem

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THERAPEUTIC OPTIONS

BASIC STEPS OF MANAGEMENT OFHIRSUTISM ARE:

DEFINE THE PROBLEM

QUANTIFY THE DEGREE OF HIRSUTISM

INDENTIFY THE PATHOPHYSIOLOGY

CORRECT THE PROBLEM,WHETHER

ACUTE OR CHRONICDEFINE SUCESSWITH THE PATIENT

FOLLOW UP

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THERAPEUTIC OPTIONS

A key element of any therapeutic plan is

to define what will ultimately be viewed

and successful therapyRegular follow up is indicated at

appropriate intervals,usually every 3- 6

months

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THERAPEUTIC OPTIONS

GENERAL MEASURES :

Eliminating causative factors

Optimizing weightManage hair

Bleaching

Cutting or shavingElectrolysis

Laser epilation

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THERAPEUTIC OPTIONS

Management of excess ovarian androgen

production :

Standard therapy is :combined E+P,mostcommonly OCs

It reduces ovarian androgen production

It increases SHBG

It induces competition at the cellular level for

binding to the androgen receptor

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THERAPEUTIC OPTIONS

Choice of OC

EE + Norgestimarte approved in USA

Cyproterone acetate used as progesteronecomponent in Ocs

OVARIAN SUPPRESSION BY LONG ACTINGGnRH ANALOGUE

Can be used for functional ovarian androgenoverproduction and even for malignantcondition

But to be used for long with back-up

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THERAPEUTIC OPTIONS

Long acting GnRH analogues used

But there is doubt that this therapy will

be beneficial over Ocs

INSULIN SENSITIZING AGENTS:

For PCO with acanthosis nigicans

Commonly used agent is : Metformin and

Troglitazone,Pioglitazone,Rosiglitazone

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THERAPEUTIC OPTIONS

MANAGEMENT OF EXCESS

ADRENAL ANDROGEN PRODUCTION

Metabolic correction of thedisorder,usually with exogenous

steroids

Dexamethasone,mostly used,ButLIMITED ROLE

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THERAPEUTIC OPTIONS

Management directed to the target organ

and cells

Competition with Androgenreceptors:Spironolactone,Flutamide,

Ketoconazole,Cyproterone acetate

5-alpha reductase Inhibitors :Finasteride

THERAPEUTIC OPTIONS

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THERAPEUTIC OPTIONS

androgen receptors

competitorsSIPRONOLACTONE:

Best studied and as Gold standard

Mechanism :Androgen receptors blockade

Suppression of Androgen biosynthesis

Increased metabolic clearance of teststerone

( Testosterone

Estrogen )50-200 mg/day in two divided doses

Spironolactone + OC is well establishedregimen

THERAPEUTIC OPTIONS

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THERAPEUTIC OPTIONS

androgen receptors

competitorsFLUTAMIDE :

Blocks the androgen receptors

Decreases androgen production

May have therapeutic value in cases of

PCOS

Usually used with OcsKETOCONAZOLE:

Equally effective but danger of liver toxicity

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THERAPEUTIC OPTIONS

SELECTING BEST THERAPY:

Correct underlying medical problem

Correct thyroid/hyperprolactinemiaPCO :oral contraceptives

Ocs + spironolactone is usually the choice

7580% patients shows responseAtleast 6 months is needed for evidence of

response

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THERAPEUTIC OPTIONS

If response is seen in 6 months then

treatment should be continued for

further 6 months and in most cases fornumber of years