Hirsutism and Hypertrichosis

Definitions & Distinction - Hair Necessities

Hirsutism: Etiology - Hormone Havoc

Hirsutism: Caused by ↑ androgen production (ovarian/adrenal) or ↑ hair follicle sensitivity to androgens.

• Ovarian (Most Common):
  • Polycystic Ovary Syndrome (PCOS): Functional ovarian hyperandrogenism. Often insulin resistance.
  • Androgen-secreting tumors: Sertoli-Leydig, hilus cell. Rapid/severe onset is red flag.
• Adrenal:
  • Congenital Adrenal Hyperplasia (CAH): Late-onset 21-hydroxylase deficiency most frequent.
  • Adrenal tumors (adenoma/carcinoma), Cushing's syndrome (excess cortisol, may ↑ androgens).
• Drug-induced:
  • Anabolic steroids, Danazol, certain Progestins (high androgenicity), Phenytoin, Minoxidil.
• Idiopathic Hirsutism:
  • Diagnosis of exclusion: normal serum androgens, regular menses. Likely ↑ local 5α-reductase.

📌 Key Causes: PCOS (most common), Congenital Adrenal Hyperplasia (CAH), Ovarian/Adrenal Tumors, Cushing's Syndrome, Drugs.

⭐ Polycystic Ovary Syndrome (PCOS) is the most common cause of hirsutism, accounting for 70-80% of cases.

Hirsutism: Evaluation - Score & Sleuth

• History: Onset (gradual/rapid), progression, menstrual regularity, medications (e.g., OCPs, androgens, valproate), family Hx (PCOS, CAH).
• Examination: Signs of virilization (clitoromegaly, voice deepening, ↑muscle bulk, temporal balding), acanthosis nigricans, galactorrhea, Cushingoid features.
• Ferriman-Gallwey (FG) Score: Assesses 9 androgen-sensitive areas (0-4 each).
  • 
  • Interpretation:

    Score	Severity
    < 8	Normal
    8-15	Mild Hirsutism
    ≥ 16	Moderate/Severe

  • Hirsutism defined as FG score ≥ 8.

⭐ Rapid onset severe hirsutism + virilization strongly suggests an androgen-secreting neoplasm.

Hirsutism: Management - Taming the Mane

A stepwise approach is key, starting with lifestyle and cosmetic options, then pharmacological if needed.

• Cosmetic/Mechanical: Shaving, waxing, laser, electrolysis, topical eflornithine.
• Pharmacological (Trial for ≥6 months):
  • OCPs: Suppress ovarian androgens.
  • Antiandrogens:
    • Spironolactone 50-200 mg/day (androgen receptor blocker).
    • Finasteride 2.5-5 mg/day (5α-reductase inhibitor).
  • Combination (OCP + antiandrogen) often superior.

⭐ Oral contraceptive pills (OCPs) are first-line medical therapy for most women with hirsutism, especially those with PCOS.

Hypertrichosis Overview - Fur Real Facts

Hypertrichosis: Excessive hair growth (density, length) anywhere on the body, not androgen-dependent. Affects men and women equally.

• Types:
  • Congenital (e.g., Hypertrichosis Lanuginosa Congenita)
  • Acquired (e.g., drug-induced, paraneoplastic)
  • Generalized or Localized
• Key Causes:
  • Drugs: Minoxidil, phenytoin, cyclosporine
  • Porphyria Cutanea Tarda
  • Anorexia nervosa
  • Malignancy (Acquired Hypertrichosis Lanuginosa)
• Management: Address underlying cause; cosmetic (shaving, waxing, laser).

⭐ Acquired hypertrichosis lanuginosa ('malignant down') is a rare but important paraneoplastic sign, often associated with internal malignancies like lung, colon, or breast cancer.

High‑Yield Points - ⚡ Biggest Takeaways

• Hirsutism is excess terminal hair growth in androgen-dependent areas in females; hypertrichosis is generalized, non-androgenic hair growth.
• Polycystic Ovary Syndrome (PCOS) is the most common cause of hirsutism.
• Use the Ferriman-Gallwey score to objectively assess and quantify hirsutism.
• Idiopathic hirsutism presents with normal androgens and regular menses.
• Drugs like minoxidil, phenytoin, and anabolic steroids can cause hirsutism or hypertrichosis.
• Sudden onset with virilization signs (e.g., clitoromegaly) strongly suggests an androgen-secreting tumor.