LOS ANGELES — Hirsutism may be the most reliable way to recognize polycystic ovary syndrome because excess hair is so common with the condition.
But be sure that the patient truly has hirsutism and not just hypertrichosis, Dr. Ricardo Azziz said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.
Hirsutism is more than a cosmetic problem. It is a sign of the single most common endocrine abnormality today, polycystic ovary syndrome (PCOS), a condition with significant morbidity and mortality, he said.
“There is a myth that perhaps the most common cause of hirsutism is idiopathic hirsutism, and that is incorrect,” said Dr. Azziz of the Center for Androgen-Related Disorders at Cedars-Sinai Medical Center, Los Angeles. “The vast majority of women with hirsutism will have a disorder.”
Hirsutism affects 7% of women, Dr. Azziz said. He reviewed records for 873 untreated women with known androgen excess and 659 untreated women who presented with hirsutism. Among the women with androgen excess, 76% had hirsutism, and 85% of those presenting with hirsutism had a defined androgen disorder. The most common androgen disorder, found in 78% of the 659 women who presented with hirsutism, was PCOS.
PCOS is a diagnosis of exclusion, Dr. Azziz said. Fortunately, tumors of the adrenal glands and the ovaries only occur in hirsute women at about the same rate as in the general population, according to his large series of patients.
Ninety-five percent of tumors are detected clinically, not by androgen testing, he said.
For ruling out other conditions, the history—Are the signs and symptoms new or established?—and physical examination—Is the patient cushingoid?—are key, he said.
Hirsutism needs to be distinguished from hypertrichosis, he said. Many women have fine, downy, villous hairs. But hirsutism requires terminal hairs—hairs more than 5 mm in length, with a hard core, often curly or pigmented—arranged in a male pattern.
If one looks for terminal hairs only on the chin and the belly, one will miss many cases of hirsutism. That's in part because those are the areas many women can see and pluck or shave, Dr. Azziz said.
“The most common mistake examiners make is that they don't do an undressed full-body exam,” he said.
He uses a modified Ferriman-Gallwey scale to rate hairiness in male-pattern areas, which does not include the lower arms and legs, where many nonhirsute women are hairy.
Once a physician gets acquainted with using the scale, it can be quite helpful, particularly since laboratory measurements of androgen levels are quite unreliable because the normal range is so great, he said.
“If you do it in all the patients, over time, your data will be reliable within your practice,” he said.
Medical therapy generally needs two arms, blocking androgen production and blocking its activity, according to Dr. Azziz.
The best approach to blocking androgen production is an oral contraceptive. Many endocrinologists recommend metformin for hirsutism. But metformin has a less direct effect on androgen production than an oral contraceptive, and its efficacy for hirsutism is “modest” at best, Dr. Azziz said.
Glucocorticoids should not be used because they induce insulin insensitivity and therefore can worsen the metabolic profile of patients with hirsutism.
In addition to inhibiting androgen production, treatment should block androgen activity also, because the hair follicles are already sensitized. Available medications include spironolactone, flutamide, and finasteride.
Of those, Dr. Azziz said he most often uses spironolactone, starting at a dose of 25 mg/day and escalating, if necessary, up to a maximum of 200 mg/day. Most patients will adjust and become tolerant to the diuretic effect of the medication.
Treated individuals need to have patience, he noted. When patients are treated with combination therapy for androgen excess, acne will resolve first, in about 2 months.
Anovulation, when that is part of the goal of treatment, will resolve in 2–3 months. But hirsutism takes between 2 and 8 months to begin improving.
About 80% of patients will have a good response with combination therapy.
In the meantime, good options for the patient include shaving and eflornithine HCL (Vaniqa), although eflornithine is approved only for use on the face, and it is not known what effect greater application might have.
Plucking is probably not a good idea, said Dr. Azziz, because it can cause folliculitis. Waxing removes hair, but it is essentially like plucking and does not destroy the hair follicle, except when it is used long term.
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