Hirsutism overview

# Overview
Hirsutism (from Latin hirsutus = shaggy, hairy) is defined as excessive and increased hair growth in women in locations where the occurrence of terminal hair normally is minimal or absent. It refers to a male pattern of body hair (androgenic hair) and it is therefore primarily of cosmetic and psychological concern. Hirsutism is a symptom rather than a disease and may be a sign of a more serious medical indication, especially if it develops well after puberty.It affects 5-15% of women . In most of the cases there is an underlying hormonal imbalance . Excessive amount of androgen plays a major role, as 70% of patients with excessive androgen will develop hirsutism. However in 5 to 15% of patients suffering from hirsutism , there is no increase in androgen level and are considered as idiopathic hirsutism. About 50% of hirsutism cases have high androgen level. Free testosterone is the main circulating androgen and is often elevated in hirsute women and the level of androgens and hair follicle sensitivity to androgens play the major role . Ovulatory dysfunction (PCOs), diabetes, thyroid hormone abnormalities and CAH are some of the underlying causes for hirsutism.There is a scoring system which is called  FerrimanGallwey scale, which quantitates the extent of hair growth in the most androgen-sensitive sites and patients with a score of 8 or more ,would be considered a hirstue .Hirsutism must be distinguished from hypertrichosis which is a result of either heredity or the use of medications such as glucocorticoids, phenytoin, minoxidil, or cyclosporine. Hypertrichosis is not caused by excess androgen.Pubertal onset hirsutism specially when it is mild ,points toward PCOS or idiopathic hirsutism but sever late onset hirsutim with other virlization signs can be due to ovarian or adrenal tumors.  Hirsutism can lead to significant psychological distress for women and even depression if left untreated and based on the underlying cause other medical complications can occur (e.g. in cases of hirsutism due to PCOS , if the treatment doesn't address PCOS , it can lead to infertility.) Prognosis depend on underlying etiology .Treatment options include: Cosmetic and hormonal therapy .Cosmetic therapy includes shaving, waxing , laser hair removal therapy , etc. Hormonal therapy includes : oral contraceptives, finestride , spironolactone ,etc.

# Historical Perspective
Throughout the history hirsutism has been regarded as a syndrome of hair growth in women in a male pattern , obesity and menstural irregularity (Apert, 1910) . Other authors considered hirsutism as masculine hair growth only(Howard and Whitehill, 1937; Glass and Bergman, 1938). Hirsutism has been the most outstanding symptom in virilism and masculinization and also the major feature of adreno-genital syndrome which was introduced in 1905 by Bulloch and Sequiera.

# Classification
Hirsutism is classified using 11 body areas to assess hair growth using the FerrimanGallwey score, a method of evaluating and quantifying hirsutism in women.

# Pathophysiology
Androgens are essential for sexual hair and sebaceous gland development. Pilosebaceous unit (PSU) growth and differentiation require the interaction of androgen with numerous other biological factors. In the embryo the pattern of PSU responsiveness to androgen is determined. Hair follicle growth involves close reciprocal epithelial-stromal interactions that recapitulate ontogeny; these interactions are necessary for optimal hair growth in culture. Androgens are responsible for hair follicle size, hair fiber diameter, and the proportion of time terminal hairs spend in the anagen phase. Almost all hirsute women have an increased production rate of androgens specially testosterone. In some women, an increased conversion of testosterone to dihydrotestosterone (DHT) by the enzyme 5-alpha-reductase, is responsible for hirsutism.

# Causes
The cause of hirsutism can be either an increased level of androgens (male hormones) or an oversensitivity of hair follicles to androgens. Male hormones such as testosterone stimulate hair growth, increase size and intensify the pigmentation of hair. Other symptoms associated with a high level of male hormones include acne and deepening of the voice and increased muscle mass. Growing evidence implicates high circulating levels of insulin in women to the development of hirsutism. This theory is consistent with the observation that obese (and thus presumably insulin resistant hyperinsulinemic) women are at high risk of becoming hirsute. Further, treatments that lower insulin levels will lead to a reduction in hirsutism.

# Differentiating Hirsutism from Other Diseases
The diagnosis of hirsutism requires the exclusion of related disorders with peripheral androgen activity. Hirsutism starts shortly after puberty with a slow course and progression.

# Epidemiology and Demographics
Hirsutism only affects women, since the rising of androgens causes a male pattern of body hair, particularly in locations where women normally do not develop terminal hair within their puberty (chest, abdomen, back and face). The medical term for excessive hair growth that affect both men and women is hypertrichosis.

# Risk Factors
Several factors increase the risk of developing hirsutism and an accurate history would aid in accurately identifying the risk.

# Screening
Screening in all hirsute women should be done in order to detect possible malignant and concerning underlying causes .

# Natural History, Complications, and Prognosis
Pubertal onset hirsutism specially when it is mild ,points toward PCOS or idiopathic hirsutism but sever late onset hirsutim with other virlization signs can be due to ovarian or adrenal tumors.  Hirsutism can lead to significant psychological distress for women and even depression if left untreated and based on the underlying cause other medical complications can occur (e.g. in cases of hirsutism due to PCOS , if the treatment doesn't address PCOS , it can lead to infertility.) Prognosis depend on underlying etiology .

# Diagnosis

## Diagnostic Criteria
There are no specific diagnostic criteria for hirsutism. Most women seek medical help for the inconvenience of the presence of hirsutism and clinical assessment is to determine the underlying cause.

## History and Symptoms
The hallmark of hirsutism is excessive facial hair growth. A positive history of virilizing symptoms is suggestive of an underlying hormonal imbalance.

## Physical Examination
Patients with hirsutism usually appear normal and in no acute distress. The degree of hirsutism can be estimated using the Ferriman-Gallwey score.

## Laboratory Findings
Laboratory tests that should be done in hirsutism include testosterone level, DHEAS, and 24-hour cortisol level.

## CT scan
CT scan is helpful in the diagnosis of underlying adrenal or ovarian tumors.

## MRI
Magnetic resonance imaging can be helpful in finding the underlying etiology of hirsutism.

# Treatment

## Medical Therapy

### Pharmacological treatments
Pharmacologic medical therapies for hirsituism include oral contraceptives, androgen receptor blockers, 5-alpha reductase inhibitors, gonadotrophin-releasing hormone (GnRH agonist), adrenal suppressive glucocorticoids, insulin-sensitising agents, and biological modifiers of hair follicular growth. Treatment options are systemic therapy and topical therapy.

### Non-pharmacologic treatments
Non-pharmacologic medical therapies for hirsituism include lifestyle modification and some cosmetic measures. Lifestyle modifications are majorly for polycystic ovary syndrome (PCOS) patients, include decreasing weight, exercise, diet, and smoking cessation. Cosmetic measures are classified as permanent methods, such as electrolysis or laser therapy, and transient home methods, such as pluking, shaving, waxing, chemical depilators, and bleaching.

## Surgery
The mainstay of treatment for hirsutism is medical therapy. Surgery is usually reserved for patients with either ovarian tumor, adrenal tumor, perimenopausal or postmenopausal women with severe hyperandrogenism who are candidated for oophorectomy, or bariatric surgery for severe obesity.

## Primary Prevention
Primary prevention in hirsutism is focused on controlling the conditions that can lead to hyperandrogenism in women.

## Secondary Prevention
Effective measures for the secondary prevention of hirsutism include lifestyle modification and pharmacological prevention. The goal of secondary prevention is to prevent cardiovascular and metabolic diseases (diabetes mellitus).