WHAT IS IT ?
Presence of terminal hairs in female, in a male like pattern .
That means-increased midline hair on the upper lip ,chin , ears , cheeks ,lower abdomen , back , chest and proximal limbs
WHY THE UNWANTED HAIR IN WOMEN , IN UNWANTED SITES ?
The answer to this is raised levels of androgens
Either there may be increased production of androgens OR increased sensitivity of the hair follicle to the androgens OR increased conversion of weak androgens to potent androgens .
FROM WHERE THESE ANDROGENS ARE PRODUCED ?
Ovaries and adrenal glands are main sources of androgens
AVAILABLE FORMS OF ANDROGENS IN BODY :
1) DHEAS: It’s an androgen precursor ,with much longer half life .Measurement of its level indicates adrenal gland activity .38-338 Microgm/dl indicate normal functioning of adrenal gland .
2) Androstenedione: It is less potent androgen .60-300 nanogrm/dl -normal levels in women .Produced from ovary and adrenal gland
3) Testosterone : Most potent androgen .20-80 nanogram/dl normal in women .Free form of testosterone is active ,it’s constitutes 1% only.80% bound to SHBG,19% to albumin .50% testosterone produced from ovary and adrenal gland .Remaing 50% from peripheral conversion of androstenedione to testosterone .Estrogen and Thyroid hormones increase the SHBG ,there by free form of testosterone is less and less androgenicity .Testosterone and Insulin decrease the SHBG ,there by increased androgen effects with normal androgen levels .
4) DHT ( dihydro testosterone ) : By the action of 5 alpha reductase Testosterone is converted to DHT .This enzyme present in skin .DHT is very potent androgen.It is primarily responsible for androgenic effects on hair follicle .Increased activity of 5 alpha reductase causes increased hair growth with normal androgen levels .
WHY THESE ANDROGEN LEVELS RAISED IN BLOOD ?
Probable causes are : Defects in ovary or adrenal glands OR Exogenous androgen production OR Drugs
1) Hyper androgenemic chronic anovulation syndrome ( PCOS ) : In these disorder women will have polycystic ovaries and high insulin levels ,there by raised androgen levels . Obesity , scanty menses ( oligo-amenorrheic ) ,hirsutism are features .
2) Late onset adrenal hyperplasia : In adrenalgland progesterone and 17-OHP are precursors of cortisol and androgens.17 OHP —— deoxy cortisol production mediated by 21 hydroxylase enzyme. This enzyme deficiency leads to accumulation of 17-OHP.This excess 17-OHP diverted to production of androgens ( androstenedione and testosterone ) .Morning serum basal levels of 17-OHP should be less than 200 ng/dl in anovulatory women .
3) Tumours : Androgen producing tumours of ovary and adrenal glands are responsible for hirsutism . These are quite rare.Few women presents with abdominal mass.Testosterone levels > 200 ng/dl is a warning sign in women ,indicates pelvic or adrenal tumour .DHEAS > 1000mcg/dl raises the suspicion of androgen producing adrenal tumour .
4) Idiopathic : In 5-15% women no cause found .All tests found to be normal .Increased skin sensitivity to androgens OR increased 5 alpha reductase activity ,producing more DHT may be the probable causes for hirsutism in these women .
5) Drugs : Danazol ,17 alpha ethinyl derivative of testosterone ,methyl testosterone causes hirsutism
THE TESTS ASKED BY UR HEALTHCARE PROVIDER :
- Serum free testosterone levels ,androstenedione levels
- DHEAS levels
- 17-OHP levels
- Thyroid hormone tests
- Fasting sugar levels
- Serum prolactin levels
- Fasting glucose / Insulin ratio
- Imaging tests : X ray ,USG ,CT ,MRI ( depending on cause )
THE WAYS TO GET RELEIF FROM HIRSUTISM :
Hirsutism is slow to respond to hormone suppression and results may not be seen for upto 6 months
Previously established hair pattern do not change with treatment
Reduction in diameter of terminal hair and cessation of new terminal hair growth are the benefits with the treatment
1) Mechanical methods : shaving , waxing ,depilators ,electrolysis ,laser hair removal helpful in removing the existing hair .
2) Drugs :
- OCP’S: Their usage results in decreased production of androgens .Androgen dependant new hair growth will not takes place .Progestins decrease the activity of 5 alpha reductase activity ,there by less DHT .Cyproterone acetate and Drosperinone are newer drugs . Cyproterone is better than drosperinone .
- MDPA : 10 mg every month for 10-12 days
- Spiranolactone : 100-200 mg/ day for 6 months gives results ,dose tapered to 25-50 mg / day .Inhibits activity of 5 alpha reductase ,by binding with DHT receptor .Avoid pregnancy during treatment period .Hyperkalemia ,diuresis are side effects .
- Flutamide : Non steroidal anti Androgen .Dose : 250 mg / day .Blocks Androgen receptors .Liver toxicity is a problem . Pregnancy avoided during treatment
- Finasteride : Inhibitor of type 2 ,5 alpha reductase activity , there by less DHT , less unwanted hair growth . 5 mg / day. Pregnancy avoidance on treatment.
- Metformin for insulin resistance
3) Surgery ,radiation ,chemotherapy for tumours .