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History
A 24-year-old woman with type VI skin reports an excess of facial hair and the develop-ment of hair over her chest. Her sister and mother are similarly affected, but more mildly.
She has become increasingly embarrassed by the problem and consequently has become reclusive. She takes no medication and is systemically well.
Examination
She has increased hair growth over the lateral borders of her face, on her chin and sub-mental regions (Fig. 90.1). Her mid-anterior chest has central dark terminal hairs which extend to the periareolar regions.
Questions
• What is the diagnosis?
• What possible underlying causes need to be excluded?
• How would you manage this patient?
Medicine
This patient feels she has an excess of facial and body hair, which is referred to as hir-sutism. This is a perceived excessive growth of terminal hair in women in a male pattern.
It is a very common problem that occurs predominantly over the upper lip, chin, periare- olar regions, abdomen, posterior trunk, shoulders and pubic area. The majority of patients have idiopathic hirsutism. Risk factors include familial and ethnic influences.
Possible underlying causes include ovarian diseases such as polycystic ovarian syndrome and virilizing tumours; adrenal causes, congenital adrenal hyperplasia and Cushing’s disease; and iatrogenic cause, androgens and progesterone. In patients presenting with hirsutism it is important to elicit a family and drug history and to look clinically for signs of virilization, which include androgenic alopecia, acne, clitoral hypertrophy and deepening of the voice. Most patients with hirsutism have a normal menstrual cycle and no signs of virilization. It is therefore unlikely that these patients have a significant endocrine cause. In such patients it is likely that there is increased end-order sensitivity to androgens. Androgens promote conversion of vellus hairs to terminal ones in androgen-sensitive hair follicles (sites such as the chin area.) Treatment is generally unsatisfactory. Temporary hair removal techniques include wax- ing, plucking, shaving and threading. More permanent techniques include electrolysis and hair-removal lasers. Anti-androgen therapies include cyproterone acetate, sprinolac- tone, cimetidine and the oral contraceptive pill.
KEY POINTS
• Hirsuitism is excessive growth of terminal hair in women in a male pattern.
• It occurs mainly over the upper lip, chin, periareolar regions and pubic area.
• Underlying causes include ovarian diseases and virilizing tumours.
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