Abstract

PIP: This discussion of the management of hirsutism focuses on clinical assessment, investigations, evaluation of treatment methods, therapeutic regimens, medical therapy, cosmetic therapy, and supportive therapy for hirsute women. Initial clinical evaluation of the hirsute woman should consider the site, type, and extent or area of hair growth as well as age of onset and rate of appearance. In part what is normal is determined by societal attitudes and cultural norms, and it may be that a woman seeking treatment for hirsutism is simply over concerned by a normal growth pattern. A well defined coarse growth of hair on the chin and cheeks of sudden onset at any age suggests an underlying endocrine problem, whereas women with fine downy facial hair, even when this is extensive, are less likely to have an endocrine disturbance than those with a coarse growth. Data about family history, ethnic background, age of onset, and rate of appearance will help identify those cases needing more detailed investigation. Physical examination included pelvic examination to exclude ovarian enlargement and examination of genitals to exclude clitoral hypertrophy together with assessment of the overall severity of hirsutism will further define those patients who require further investigation. Urinary 24 hour 17 ketosteroid excretion and plasma androgens should be estimated as a baseline investigation to identify those patients whose hirsutism is due to androgen secreting tumors or adrenal hyperplasia. Testosterone production rate and testosterone metabolic clearance rate have been shown to be well increased in hirsute women and to correlate well with severity of hirsutism. In certain patients laboratory evidence may suggest either the ovaries or the adrenals as the major source of androgen excess. The ideal response to treatment is reduced growth rate and reversion of coarse, dark, terminal hair to a lighter, more downy growth. There is no uniformly reliable, simple, objective method of assessing response to therapy. The aim of medical therapy for idiopathic hirsutism is suppression or inhibition of androgen effect. Cosmetic therapy aims to minimize or remove the excess hair either temporarily or permanently. There are 2 types of medical therapy--suppressive therapy and antiandrogen therapy. In suppressive therapy, treatment regimens suppress abnormal plasma androgen levels. Antiandrogen therapy counteracts the effect of androgens at the hair follicles. Some form of cosmetic therapy is almost always needed in conjunction with the various forms of medical therapy. Cosmetic treatments include camouflage by bleaching and various mechanical means of removing the hair temporarily or permanently.