Hirsutism: what is it, symptoms, treatment, prognosis

What is hirsutism?

Hirsutism - This is excessive hair growth in women and children on those parts of the body where they are usually absent or minimal. Hair growth can be "masculine", which can be a sign of a more serious medical condition, especially if it develops well after puberty. Cultural stigma against hirsutism can cause serious psychological distress and social hardship. Facial hirsutism often leads to avoidance of social situations and to symptoms of anxiety and depression.

Hirsutism can be constitutional (in healthy women); occur when androgens or compounds similar to them in chemical structure are administered for therapeutic purposes; develop in a number of endocrine diseases - adrenogenital syndrome, ovarian and adrenal tumors, acromegaly, Itsenko-Cushing's disease. Sometimes hirsutism is observed during pregnancy and in menopause, as well as with brain lesions - tumors,

encephalitis, multiple sclerosis, epilepsy. In some cases, it is caused by a local effect on the skin or skin diseases. In a number of patients, hirsutism occurs due to a violation of the metabolism of androgens in the skin (idiopathic hirsutism).

Treatment may include birth control pills containing estrogen and progestin, antiandrogens, or insulin sensitizers.

Hirsutism affects 5 to 15% of all women of any ethnicity. Depending on the definition and background, it is estimated that about 40% of women have some degree of facial hair.

Signs and symptoms

Hirsutism is a male-patterned overgrowth of dark or coarse hair in women and children. In this case, hair can appear on the face (above the upper lip, on the chin or cheeks (sideburns)), trunk (around the nipples, on the chest, in the lower abdomen, or on the back) and limbs (on the shoulders or inside hips).

Causes and risk factors

Hirsutism can cause various endocrine and skin diseases, disorders affecting the brain. Below are some examples.

- Hyperandrogenic hirsutism.

Hirsutism most often occurs due to overproduction of androgens of ovarian or adrenal origin. Hyperandrogenism of tumor origin, very severe, should be distinguished from non-tumor hyperandrogenism, which is often minimal or moderate.

Polycystic ovary syndrome (PCOS).

It is the most common cause of hirsutism and causes about 75% of all cases. It affects 5% to 10% of women during sexual activity and 20% to 25% of adolescent girls. It is a heterogeneous and complex syndrome of unknown etiology, characterized by the end of follicle maturation with the accumulation of small follicles under the cortex and hyperplasia of the ovarian stroma.

Hirsutism appears during puberty, accompanied by a violation menstrual cycle, weight gain, dyslipidemia, insulin resistance, eels and black acanthosis. Women suffer from spaniomenorrhea (lengthening of the cycle for more than 35 days), oligomenorrhea (less heavy menstruation) and infertility. The ovaries may enlarge. May be present hypothyroidism or liver disease.

Androgen-secreting tumors.

Hyperandrogenism due to tumors of the ovaries or adrenal glands is rare. It accounts for only 0.2% of all cases of hirsutism. These androgen-secreting tumors are autonomous and therefore independent of the hypothalamic-pituitary system. Approximately 50% of these are malignant, and in these cases, plasma androgen levels are very high. They are also responsible for the rapid onset of virilization, hirsutism, and tumors in the pelvic or abdominal cavity.

Non-classical congenital hyperplasia of the cortex adrenal glands (adrenal glands)

It is a common autosomal recessive disorder caused by partial 21-hydroxylase deficiency and is the most common adrenal etiology of hyperandrogenism. Its prevalence varies greatly depending on the ethnicity of the patients. Thus, it is more common among the Ashkenazi Jewish population (3.7%) and the population of Central Europe (2%) and rarely among the Eurasians (0.1%). Like PCOS, NVHCN can manifest itself after puberty with hirsutism, oligomenorrhea, acne, infertility, alopecia and primary amenorrhea.

- Nonhyperandrogenic hirsutism.

Medicines.

Many drugs can cause hirsutism: androgens, glucocorticosteroids, progestins, antagonists estrogens (clomiphene, tamoxifen), minoxidil, cyclosporine, danazol, diazoxide, phenytoin, D-penicillamine and interferon.

It is important to know that hypertrichosis can also be caused by certain medications such as acetazolamide, phenytoin, latanoprost, streptomycin, psoralen, minoxidil, cyclosporine, and diazoxide.

Endocrinopathy.

The responsibility of endocrinopathies for the occurrence of hirsutism is rare, and other more specific symptoms and signs predominate in the clinical picture:

• Cushing's syndrome depends on adrenocorticotropic hormone (ACTH). The syndrome can cause hirsutism due to the stimulating action of ACTH on the mesh area, which can cause excessive secretion of androgens. Often the features of hypercortisolism come to the fore.
• Hyperthyroidism or hypothyroidism is rarely the cause of isolated hirsutism.
• Hyperprolactinemia is manifested by amenorrhea, galactorrhea, infertility, and rarely hirsutism.
• Acromegaly is also a rare cause of isolated hirsutism.

Other reasons.

Moderate hirsutism can occur in pregnant women (physiological secretion of prolactin) and in postmenopausal women (relative hyperandrogenism due to the cessation of ovarian estrogen production).

Idiopathic hirsutism.

Idiopathic hirsutism - hirsutism that occurs in connection with regular menstruation, normal ovarian morphology and normal plasma androgen levels. This is a diagnosis of exclusion after the elimination of another etiology. It accounts for about 10% of all cases of hirsutism and 50% of cases of mild hirsutism. This may be due to hypersensitivity of the pilosebal follicle receptors to androgens and peripheral the reaction induced by testosterone 5-reductase to dihydrotestosterone, ten times more active on follicle block. It has a genetic determinism and is common in women of East Indian and Mediterranean descent.

Epidemiology

The exact prevalence of hirsutism is not known. It can be 10% or even more than 50%. The psychological problem that this disease causes depends on ethnic and sociocultural factors. Indeed, in some societies where the lack of hair is considered an important criterion for female beauty, the minimum hirsutism can be considered a serious illness, whereas in other societies it is possible to accept a much more pronounced hirsutism.

Hirsutism is most common in dark-skinned people. Hirsutism can occur in men, but is difficult to recognize. In children, hirsutism is a sign of premature puberty.

Hirsutism also occurs in women who stop taking oral contraceptives and gain weight.

Pathophysiology

Hirsutism is an androgen-dependent disease resulting from the interaction between circulating androgen levels and the sensitivity of the hair follicle to androgens. The skin can retain testosterone in the more active androgen, dihydrotestosterone (DHT) by an enzyme 5alpha-reductase, two isoenzymes of which, types 1 (chromosome 5) and 2 (chromosome 2), are present in the skin and hair follicle. In addition, the skin and hair follicle have androgen receptors (AR).

After exogenous intake of androgens is excluded, hirsutism occurs either due to hypersecretion of androgens the ovaries or adrenal glands, or due to increased cutaneous sensitivity of the skin to normal androgen levels in blood. The last case is “idiopathic hirsutism”.

Diagnostics

Before starting more extensive research, a complete physical examination should be performed, the researcher must distinguish between widespread body hair enlargement and virilization by male type. One of the methods for assessing hirsutism is the Ferriman-Gollway scale, which gives an estimate based on the amount and location of hair growth in a woman. After the physical examination, laboratory tests and imaging can be done to rule out further causes.

Diagnosis of patients with even mild hirsutism should include ovulation and ovarian ultrasound due to the high prevalence polycystic ovary syndrome (PCOS), as well as 17α-hydroxyprogesterone (due to the possibility of detecting nonclassical insufficiency 21-hydroxylase). Many women present with elevated serum levels of dehydroepiandrosterone sulfate. Levels above 700 mcg / dL indicate dysfunction adrenal glands, especially congenital hyperplasia of the adrenal cortex due to 21-hydroxylase deficiency. However, PCOS and idiopathic hirsutism account for 90% of cases.

Other blood counts that can be assessed on hirsutism testing include:

• androgens; androstenedione, testosterone;
• thyroid function panel; thyroid stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4);
• prolactin;

If an underlying cause cannot be determined, the condition is considered idiopathic.

Treatment

- Pharmacological treatment.

Treatment for non-neoplastic hirsutism continues to include oral contraception. It suppresses the hypothalamic-pituitary system with its gestagen and, consequently, the production of androgens by the ovaries; due to its estrogen increases SHBG. It is combined with antiandrogenic treatment: flutamide, spironolactone, cyproterone acetate, finasteride are used with different but comparable results ..

Oral contraceptives are the first choice because they suppress androgen production by the ovaries. However, they often don't work. In addition, this treatment may not be ideal for a woman looking to become pregnant.

Spironolactone is known to block androgen receptors and is the second most common treatment. It can even be combined with an oral contraceptive. However, improvement is slow and takes many months. Thus, adherence to the spironolactone regimen is low.

Finasteride is used to treat hirsutism and is preferred because it has no estrogenic or progesterone activity. However, it is not recommended for women of childbearing age, as there is a risk of ambiguous genital formation in the fetus. Flutamide is another new treatment, and while it does help, it is expensive and can potentially cause liver damage.

Adrenal hyperandrogenism is slowed down by low doses corticosteroidspossibly related to the previously mentioned treatment.

Fine hair growth can be slowed down by applying eflornithine twice a day. Electrolysis is now less commonly used, with the exception of coarse gray hair, and in polycystic ovary disease without insulin resistance.

- Non-pharmacological treatment.

Since the effect of drug treatment occurs only after 1-2 years, doctors use cosmetic approaches, which are also suitable for hypertrichosis: shaving, hair removal, hydrogen peroxide discoloration, chemical depilation. Fine hair growth can be suppressed by applying eflornithine twice daily. Electrolysis is not used as often as before, with the exception of coarse gray hair. It was replaced by long-term depilation using tools such as depilatory lasers and various intense pulsed light devices.

- Surgery.

With a tumor process, surgical removal is necessary. Ovariectomy may be indicated for severe hyperandrogenism in menopausal or perimenopausal women.

Prophylaxis

Hirsutism usually cannot be prevented. But losing weight while being overweight can help reduce hirsutism, especially if the patient has polycystic ovary syndrome.

Forecast

Hirsutism has a significant morbidity, and some women with malignant diseases have a very poor prognosis. Postmenopausal hirsutism is associated with a high risk osteoporosis and fractures.