Hirsutism Evaluation and Treatment Guidelines

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Questions and Answers

What is the primary defining characteristic of hirsutism?

Localized hair growth in women

Excessive terminal hair growth in women in a male pattern (correct)

Reduced hair growth in androgen-dependent areas

Excessive body hair growth in men

Which scoring method is considered the gold standard for evaluating hirsutism?

Modified Ferriman–Gallwey score (correct)

Bristow score

Bartholin score

Hormonal evaluation score

In the Ferriman–Gallwey score, what does a score of 0 indicate?

Mild hirsutism

No hair growth in that area (correct)

Normal hair growth

Severe hirsutism

What percentage of the population is used as a threshold for diagnosing hirsutism?

95th percentile Signup and view all the answers

For the treatment of hirsutism, which type of oral contraceptive (OC) is mentioned as equally effective?

OCs containing levonorgestrel Signup and view all the answers

How is excessive terminal hair classified when it appears in areas sensitive to androgens?

Hirsutism Signup and view all the answers

Which of the following is not a characteristic of hirsutism?

Increased sebum production Signup and view all the answers

Which statement is true about antiandrogens compared to other oral contraceptives?

They were found equally effective as other OCs Signup and view all the answers

What is the effect of antiandrogenic progestins on hirsutism scores compared to other oral contraceptives?

They lead to slightly lower Ferriman–Gallwey scores. Signup and view all the answers

How do androgenic progestins affect testosterone production?

They reduce testosterone production. Signup and view all the answers

What were the results of the trials pooling antiandrogens together in terms of effectiveness compared to placebo?

Antiandrogens were significantly more effective than placebo. Signup and view all the answers

What is a possible clinical implication of the difference in hirsutism scores among various progestins?

The difference is probably not clinically important. Signup and view all the answers

What role does sex hormone-binding globulin (SHBG) play regarding androgens in serum?

It increases androgen binding in serum. Signup and view all the answers

What is one of the doses of spironolactone used to manage hirsutism?

It exhibits dose-dependent competitive inhibition. Signup and view all the answers

Which progestin is noted to have a relatively androgenic effect among oral contraceptives?

Levonorgestrel Signup and view all the answers

What is a significant concern associated with flutamide use?

Hepatic toxicity Signup and view all the answers

What is a proposed mechanism for how antiandrogenic progestins affect hirsutism?

They stimulate production of sex hormone-binding globulin. Signup and view all the answers

Which dose of flutamide is most frequently used in randomized controlled trials?

500 mg/d Signup and view all the answers

In the treatment of hirsutism, what is a common recommendation regarding glucocorticoid therapy for women with classic congenital adrenal hyperplasia?

Long-term administration to suppress adrenal androgens Signup and view all the answers

Which of the following statements about low-dose flutamide and hirsutism is accurate?

Retrospective studies suggest low doses may be effective. Signup and view all the answers

What role do glucocorticoids have in the management of women with nonclassic 21-hydroxylase deficiency?

They help in ovulation induction. Signup and view all the answers

What is the primary reason for using flutamide in combination therapies?

For dose-response inhibition of the androgen receptor. Signup and view all the answers

What percentage of women studied experienced elevated serum alanine aminotransferase and/or aspartate aminotransferase while taking low doses of flutamide?

11% Signup and view all the answers

What is a noted outcome of suppressing adrenal androgens in highly sensitive patients using glucocorticoids?

Minor improvements in hirsutism. Signup and view all the answers

What is suggested against as initial therapy for most women with hirsutism?

Antiandrogen monotherapy Signup and view all the answers

What is the primary reason for not recommending antiandrogen monotherapy as initial therapy?

Teratogenic potential of these medications Signup and view all the answers

What should be considered when prescribing antiandrogen medication for women with hirsutism?

Use of adequate contraception Signup and view all the answers

In the context of hirsutism, what condition may be evaluated through checking androgen levels?

Polycystic ovary syndrome (PCOS) Signup and view all the answers

What does the abbreviation 'NCCAH' stand for in the context of adrenal conditions?

Nonclassical congenital adrenal hyperplasia Signup and view all the answers

What is the purpose of testing androgen levels in women presenting with hirsutism?

To rule out underlying endocrine disorders Signup and view all the answers

Which hormone is not typically related to hirsutism?

Luteinizing hormone (LH) Signup and view all the answers

What does the acronym 'RCT' stand for in clinical studies related to hirsutism?

Randomized controlled trial Signup and view all the answers

What is the expected prevalence of NCCAH among hyperandrogenic women?

4.2% Signup and view all the answers

What percentage of hirsute women are classified as having idiopathic hirsutism?

5% to 20% Signup and view all the answers

Which disorder must clinicians consider in the differential diagnosis when evaluating hirsutism?

Cushing syndrome Signup and view all the answers

What might exacerbate the features of PCOS in women?

Obesity Signup and view all the answers

What condition is characterized by androgen-secreting tumors, which are malignant in over half of the cases?

Androgen-secreting tumors Signup and view all the answers

Which of the following hormonal conditions is least likely to be involved in the assessment of hirsutism?

Insulin resistance Signup and view all the answers

What is the common hormonal change associated with hirsutism in women with no other clinical evidence of PCOS?

Hyperandrogenemia Signup and view all the answers

What percentage of eumenorrheic women with mild hirsutism may have idiopathic hirsutism?

50% Signup and view all the answers

What is the relationship between estrogen dose and VTE risk?

VTE risk is significantly related to estrogen dose but only weakly. Signup and view all the answers

Which combined oral contraceptive does NOT refer to the content discussed?

Oral progestin-only contraceptives. Signup and view all the answers

What is a potential increased risk factor for VTE when using certain OCs?

Presence of PCOS. Signup and view all the answers

Which type of progestins are linked to a higher VTE risk according to the text?

Recent-generation low-androgenicity progestins. Signup and view all the answers

What does the evidence suggest about the risk posed by DSP in relation to VTE?

DSP risk was not found in a prospective study of first-time users. Signup and view all the answers

Which progestins are considered to have low androgenicity?

Desogestrel, gestodene, and norgestimate. Signup and view all the answers

What conclusion did the Pharmacovigilance Risk Assessment Committee reach regarding CPA?

The benefits of CPA outweigh the risks. Signup and view all the answers

How does the absolute risk of VTE with combined OCs compare to that during pregnancy?

It is low and far less than that seen during pregnancy. Signup and view all the answers

Study Notes

Evaluation and Treatment of Hirsutism in Premenopausal Women

Objective: Update a 2008 Endocrine Society clinical practice guideline.
Participants: Endocrine Society-appointed task force of seven medical experts and a methodologist.
Evidence: Developed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Used systematic reviews and best available evidence from other publications.
Consensus Process: Group meetings, conference calls, and email communications. Endocrine Society committees, members, and cosponsoring organizations reviewed and commented on the drafts.
Conclusion: Suggest testing for elevated androgen levels in all women with abnormal hirsutism scores. Do not test eumenorrheic women with unwanted local hair growth (without abnormal hirsutism scores).
Treatment for Hirsutism: For women with patient-important hirsutism despite cosmetic measures (shaving, plucking, waxing), suggest starting with pharmacological therapy and adding direct hair removal (electrolysis, photoepilation) if needed. Mild hirsutism with no endocrine disorder can use either approach (pharmacological therapy or direct hair removal).

Diagnosis of Hirsutism

Testing Recommendations: Suggest testing for elevated androgens in all women with an abnormal hirsutism score. If serum total testosterone levels are normal, and hair growth is moderate/severe or mild with hyperandrogenic clinical signs, measure early morning total and free testosterone.
NCCAH Screening: Suggest screening for NCCAH (21-hydroxylase deficiency) in women with hirsutism, particularly if they have a family history, or belong to a high-risk ethnic group, regardless of normal testosterone levels. Measure early morning 17-hydroxyprogesterone levels during the follicular phase for amenorrheic women, or any random day.
Normal Local Hair Growth: Do not test eumenorrheic women with unwanted local hair growth (no abnormal hirsutism score).

Treatment of Hirsutism in Premenopausal Women

Pharmacological Therapies: Oral combined estrogen-progestin contraceptives are the initial treatment for patient-important hirsutism in women not seeking fertility.
Antiandrogen Monotherapy: Suggest against antiandrogen monotherapy as initial therapy, except for women not sexually active, permanently sterilized, or using long-acting reversible contraception. Their choice is dependent on personal preferences.
Oral Contraceptives: Do not suggest one oral contraceptive over another as initial therapy given similar efficacy and low side effects.
VTE Risk: Suggest lowest effective dose of ethinyl estradiol (usually 20mcg) and low-risk progestin if women are at higher VTE risk (obesity, over 39 years old).
Adding Antiandrogens: If hirsutism persists after 6 months of monotherapy with an oral contraceptive, suggest adding an antiandrogen.
Flutamide: Do not use flutamide due to hepatotoxicity.
Combination Therapy: Combination therapy (estrogen-progestin and antiandrogen) is an option for severe hirsutism causing distress, but is not a standard first-line approach.

Other Drug Therapies

Insulin-Lowering Drugs: Do not use insulin-lowering drugs for solely treating hirsutism.
GnRH Agonists: Do not use GnRH agonists except for women with severe hyperandrogenemia (e.g., ovarian hyperthecosis) who do not respond well to OCs and antiandrogens.

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Description

This quiz covers the latest guidelines for evaluating and treating hirsutism in premenopausal women, based on updated consensus by medical experts. It emphasizes testing for androgen levels and outlines treatment options for patients with significant hirsutism. Stay informed about the best practices in managing this common condition.