Hirsutism and Virilization — MCQs
A female patient presents with hirsutism, amenorrhea, and obesity. What is the most likely diagnosis?
Which of the following medications does not cause hirsutism?
Congenital adrenal hyperplasia is the most common cause of
According to the Ferriman Gallwey scoring system, hirsutism is diagnosed when the score is equal to or more than:
Adrenal hyperplasia due to 21-hydroxylase deficiency is treated with low dose:
Contraindicated in Androgenic Alopecia –
HAIR-AN syndrome consists of which of the following?
Which of the following does not cause female pseudohermaphroditism?
A 21-year-old woman presents with complaints of primary amenorrhea. Her height is 153 cm, and her weight is 51 kg. She has well-developed breasts. She has no pubic or axillary hair and no hirsutism. Which of the following is the most probable diagnosis?
What is the management for women with polycystic ovary syndrome (PCOS) and hirsutism?
Hirsutism and Virilization Indian Medical PG Practice Questions and MCQs
Question 1: A female patient presents with hirsutism, amenorrhea, and obesity. What is the most likely diagnosis?
- A. Androgen-secreting ovarian tumor
- B. Congenital adrenal hyperplasia
- C. Cushing's syndrome
- D. Polycystic Ovary Syndrome (PCOS) (Correct Answer)
Explanation: ***Polycystic Ovary Syndrome (PCOS)*** - **Hirsutism**, **amenorrhea** (or oligomenorrhea), and **obesity** are classic clinical features of PCOS, reflecting hyperandrogenism and insulin resistance [2]. - PCOS is a diagnosis of exclusion and involves chronic anovulation and polycystic ovaries on ultrasound [3], though these are not explicitly mentioned, the constellation of symptoms strongly points to it. *Androgen-secreting ovarian tumor* - While it can cause **hirsutism** and **amenorrhea**, the onset is typically **rapid** and severe, with very high androgen levels, and obesity is not a primary feature. - Ovarian tumors are generally less common than PCOS and may present with a palpable mass or specific imaging findings. *Congenital adrenal hyperplasia* - This genetic condition often presents in childhood or adolescence with varying degrees of **virilization** and menstrual irregularities due to enzyme deficiencies in cortisol synthesis [1]. - While it causes **hirsutism** and potentially **amenorrhea**, obesity is not a direct consequence, and the patient's age of presentation and specific symptom pattern are less typical for adult-onset CAH in this context. *Cushing's syndrome* - Characterized by **central obesity**, **moon facies**, **buffalo hump**, **striae**, and proximal muscle weakness due to chronic glucocorticoid excess. - Although it can cause **menstrual irregularities** and mild **hirsutism** [2], the overall clinical picture including the absence of other specific Cushingoid features makes it less likely than PCOS.
Question 2: Which of the following medications does not cause hirsutism?
- A. Flutamide (Correct Answer)
- B. Danazol
- C. Phenytoin
- D. Norethisterone
Explanation: ***Flutamide*** - **Flutamide** is an **anti-androgen** that blocks androgen receptors, thereby *reducing* the effects of androgens and preventing hirsutism. - It is used in conditions like prostate cancer to counteract androgenic effects and would not cause increased hair growth. *Norethisterone* - **Norethisterone** is a synthetic progestin that can have **androgenic effects** in some individuals. - These androgenic properties can lead to side effects like **hirsutism**, acne, and oily skin. *Danazol* - **Danazol** is a synthetic androgen that has **pronounced androgenic activity**. - Its androgenic effects are well-known to cause side effects such as **hirsutism**, acne, and deepening of the voice. *Phenytoin* - **Phenytoin** is an anticonvulsant medication that can induce **hirsutism** as a common side effect. - The mechanism is not fully understood but may involve stimulating hair follicle growth.
Question 3: Congenital adrenal hyperplasia is the most common cause of
- A. True hermaphroditism
- B. Female pseudohermaphroditism (androgenized female 46XX) (Correct Answer)
- C. Male pseudohermaphroditism (underandrogenized male 46XY)
- D. Turner's syndrome
Explanation: ***Female pseudohermaphroditism (androgenized female 46XX)*** - Congenital adrenal hyperplasia (CAH), particularly **21-hydroxylase deficiency**, leads to overproduction of **adrenal androgens**. [3] - In a 46,XX fetus, this excess androgen exposure results in masculinization of external genitalia, while internal female organs (uterus, ovaries) are present, defining **female pseudohermaphroditism**. [3] *True hermaphroditism* - Characterized by the presence of both **ovarian and testicular tissue** in the same individual. [2] - This condition is rare and not directly caused by the hormonal imbalances seen in CAH. *Male pseudohermaphroditism (underandrogenized male 46XY)* - Occurs in individuals with a **46,XY karyotype** who have testes but whose external genitalia are ambiguous or female due to **insufficient androgen production or action**. - Conditions like **androgen insensitivity syndrome** or defects in testosterone synthesis cause this, not CAH. [3] *Turner's syndrome* - A chromosomal disorder with a **45,XO karyotype**, primarily affecting females. [1] - It is characterized by features such as **short stature**, gonadal dysgenesis (streak gonads), and various congenital anomalies, and it is not a form of pseudohermaphroditism related to adrenal function. [1]
Question 4: According to the Ferriman Gallwey scoring system, hirsutism is diagnosed when the score is equal to or more than:
- A. 8 (Correct Answer)
- B. 12
- C. 16
- D. 20
Explanation: ***8*** - A Ferriman-Gallwey score equal to or greater than **8** is the standard cutoff for diagnosing hirsutism in most populations. - This threshold indicates an abnormal amount of **terminal hair growth** in androgen-sensitive areas of the body. *12* - While a score of 12 or higher certainly indicates hirsutism, it is **not the lower diagnostic cutoff**. - A score of 12 represents a **more severe degree** of hirsutism, but the diagnosis is established earlier. *16* - A score of 16 is considered **severe hirsutism** and suggests a significant increase in androgenic activity. - However, the diagnosis of hirsutism is made at a **much lower score** according to the established criteria. *20* - A score of 20 would represent **profound hirsutism**, often associated with conditions causing very high androgen levels. - This level is far beyond the **minimum diagnostic threshold** for hirsutism.
Question 5: Adrenal hyperplasia due to 21-hydroxylase deficiency is treated with low dose:
- A. Androgen
- B. Estrogen
- C. Anti-androgen
- D. Cortisone (Correct Answer)
Explanation: ***Cortisone*** - **Cortisone** (a glucocorticoid) is used to suppress excessive **ACTH** (adrenocorticotropic hormone) secretion from the pituitary, which drives the adrenal gland to overproduce precursors due to the enzyme deficiency [1]. - This treatment aims to reduce the synthesis of **androgens** and other steroid intermediates, thereby preventing virilization and salt-wasting crises [1]. *Androgen* - Administering **androgen** would worsen the symptoms of **adrenal hyperplasia**, such as virilization in females and precocious puberty in males, as the condition already involves excess androgen production [1]. - The goal of treatment is to *reduce* androgen levels, not increase them. *Estrogen* - **Estrogen** supplementation is not a primary treatment for 21-hydroxylase deficiency. While it might be used in specific cases for feminization in females with severe virilization, it does not address the underlying hormonal imbalance or the compensatory ACTH production. - Its use would not suppress the adrenal overstimulation that leads to increased androgen production. *Anti-androgen* - **Anti-androgens** can block the effects of excess androgens at target tissues and are sometimes used as adjunctive therapy, particularly for cosmetic issues like hirsutism in females. - However, anti-androgens do not address the root cause of adrenal overproduction or suppress the elevated **ACTH** levels; they merely mitigate the peripheral effects of the excess androgens.
Question 6: Contraindicated in Androgenic Alopecia –
- A. Minoxidil
- B. Testosterone (Correct Answer)
- C. Cyproterone
- D. Finasteride
Explanation: ***Testosterone*** - Androgenic alopecia, or **male-pattern baldness**, is driven by **androgens**, particularly **dihydrotestosterone (DHT)**, which is derived from testosterone. - Administering exogenous **testosterone** would exacerbate hair loss in individuals with androgenic alopecia by increasing the substrate available for conversion to DHT. *Minoxidil* - **Minoxidil** is a vasodilator that is commonly used topically to treat androgenic alopecia. - It works by **prolonging the anagen phase** of hair growth and increasing follicular size, making it a treatment option, not a contraindication. *Cyproterone* - **Cyproterone** is an **anti-androgen** that blocks androgen receptors and inhibits androgen synthesis. - It is used in some cases of severe androgenic alopecia in women, making it a treatment, not a contraindication. *Finasteride* - **Finasteride** is a **5-alpha-reductase inhibitor** that blocks the conversion of testosterone to dihydrotestosterone (DHT). - By reducing DHT levels, it slows or reverses hair loss in androgenic alopecia, making it a common treatment and not a contraindication.
Question 7: HAIR-AN syndrome consists of which of the following?
- A. Acanthosis nigricans
- B. Insulin resistance
- C. Hyperandrogenism
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - HAIR-AN syndrome is an acronym representing the combination of **HyperAndrogenism**, **Insulin Resistance**, and **Acanthosis Nigricans**. - This syndrome is often associated with **severe hyperinsulinemia** and is considered a severe form of polycystic ovarian syndrome (PCOS) [1]. *Acanthosis nigricans* - While **acanthosis nigricans** is a key component of HAIR-AN syndrome, it does not, by itself, define the entire syndrome. - This condition is characterized by **darkening and thickening of the skin**, particularly in body folds, and is a marker of insulin resistance. *Insulin resistance* - **Insulin resistance** is central to HAIR-AN syndrome, driving many of its metabolic and dermatological manifestations. - However, the definition of HAIR-AN syndrome requires the presence of hyperandrogenism and acanthosis nigricans in addition to insulin resistance to be complete. *Hyperandrogenism* - **Hyperandrogenism**, characterized by elevated androgen levels leading to symptoms like hirsutism and acne, is a critical feature of HAIR-AN syndrome [1]. - Similar to the other components, hyperandrogenism alone does not constitute the full syndrome, which necessitates the presence of insulin resistance and acanthosis nigricans.
Question 8: Which of the following does not cause female pseudohermaphroditism?
- A. Congenital adrenal hyperplasia
- B. Leydig cell tumor
- C. Hilus cell tumor
- D. Theca cell tumor (Correct Answer)
Explanation: ***Theca cell tumor*** - Theca cell tumors (thecomas) are typically **estrogen-producing tumors** and do not cause virilization or female pseudohermaphroditism. - They are more commonly associated with symptoms related to **estrogen excess**, such as abnormal uterine bleeding or endometrial hyperplasia. *Hilus cell tumor* - Hilus cell tumors are **androgen-producing tumors** of the ovary (containing Leydig cells) that secrete **testosterone and other androgens**, leading to virilization. - This can cause **female pseudohermaphroditism** (external virilization of a 46,XX individual) if occurring prenatally or post-natal virilization in adulthood. *Congenital adrenal hyperplasia* - **Congenital adrenal hyperplasia (CAH)**, particularly 21-hydroxylase deficiency, is the **most common cause** of female pseudohermaphroditism due to **excess adrenal androgen production** during fetal development. - Increased androgens lead to **virilization of external genitalia** in 46,XX fetuses. *Leydig cell tumor* - Ovarian Leydig cell tumors are extremely rare androgen-producing tumors. The more common androgen-producing ovarian tumor is the **Sertoli-Leydig cell tumor** (androblastoma). - **Sertoli-Leydig cell tumors** are sex cord-stromal tumors that produce **androgens**, causing **virilization** in affected individuals, which can lead to masculinization and ambiguous genitalia.
Question 9: A 21-year-old woman presents with complaints of primary amenorrhea. Her height is 153 cm, and her weight is 51 kg. She has well-developed breasts. She has no pubic or axillary hair and no hirsutism. Which of the following is the most probable diagnosis?
- A. Turner's syndrome
- B. Stein-Leventhal syndrome
- C. Premature ovarian failure
- D. Complete androgen insensitivity syndrome (Correct Answer)
Explanation: ***Complete androgen insensitivity syndrome*** - This syndrome presents with **primary amenorrhea**, **well-developed breasts**, and **absent pubic/axillary hair** due to the inability of androgen receptors to respond to testosterone. - Patients are typically **genetically male** (XY) but phenotypically female, with undescended testes and a blind-ending vagina. *Turner's syndrome* - Characterized by **short stature**, a **webbed neck**, and **ovarian dysgenesis**, leading to absent breast development and amenorrhea. - Lacks the feature of well-developed breasts noted in the patient. *Stein-Leventhal syndrome* - Also known as **Polycystic Ovary Syndrome (PCOS)**, this typically presents with secondary amenorrhea or oligomenorrhea, **hirsutism**, acne, and obesity. - The patient's lack of hirsutism and primary amenorrhea make PCOS less likely. *Premature ovarian failure* - Involves the **cessation of ovarian function before age 40**, leading to primary or secondary amenorrhea. - Patients typically present with symptoms of **estrogen deficiency**, including poor breast development, which contradicts the well-developed breasts in this case.
Question 10: What is the management for women with polycystic ovary syndrome (PCOS) and hirsutism?
- A. Ethinyl estradiol + Cyproterone Acetate (Correct Answer)
- B. Ethinyl estradiol
- C. Levonorgestrel
- D. Ethinyl estradiol + Levonorgestrel
Explanation: ***Ethinyl estradiol + Cyproterone Acetate*** - This combination is effective for managing **hirsutism** in PCOS because ethinyl estradiol suppresses **gonadotropins** and ovarian androgen production, while **cyproterone acetate** is a potent **anti-androgen** that blocks androgen effects at the receptor level. - The anti-androgenic properties of cyproterone acetate directly address the excess androgen activity responsible for hirsutism. *Ethinyl estradiol* - While ethinyl estradiol (an estrogen) can suppress **gonadotropins** and thus reduce ovarian androgen production, it alone is not primarily effective in directly addressing and reversing existing hirsutism. - It would not sufficiently counteract the effects of high androgens on hair follicles without an additional anti-androgen. *Levonorgestrel* - Levonorgestrel is a **progestin** with **androgenic properties**, particularly at higher doses. - This would potentially worsen hirsutism rather than improve it, as it contributes to androgenic effects. *Ethinyl estradiol + Levonorgestrel* - This combination is a common component of oral contraceptive pills, but **levonorgestrel** has some **androgenic activity**, which means it could worsen or fail to improve hirsutism. - While ethinyl estradiol lowers androgens, the mild androgenic effect of levonorgestrel might counteract the desired anti-androgenic effect needed to treat hirsutism effectively.
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