Clinico-investigative Profile of Patients of Hirsutism in a Tertiary Level Institution

Practise Updates: Diagnosis and Management of Idiopathic Hirsutism

Idiopathic hirsutism (IH) is a common clinical condition with multiple diagnostic and therapeutic uncertainties. There are no clear recommendations for the diagnosis and management of the condition. This practice update was developed to guide the primary care physicians and the specialists in better and more systematic management of IH particularly in the Indian context. Twelve experienced members consisting of eminent endocrinologists, physicians, a dermatologist, a gynaecologist and a psychiatrist were invited by the Integrated Diabetes and Endocrine Academy (IDEA). A literature search was performed using online databases from PubMed, Cochrane Library and Google Scholar. Published articles from peer-reviewed indexed journals, with a preference for meta-analyses and randomized controlled trials, were selected. A meeting took place with all the 12 members individually giving their opinions on predetermined questions of interest. After the initial meeting during IDEACON 2023, two more meetings were held and the practice update was formulated after voting. Practice updates were made on important areas such as the cut-off for modified Ferriman-Gallwey Score for the Indian population, conditions to be excluded before diagnosing IH, when to refer to specialists, investigations in a suspected case of IH and choice of therapies for its management.

Fifteen-minute consultation: Approach to the adolescent presenting with hirsutism

Hirsutism, unwanted terminal hair growth in androgen-dependent areas, is a common presentation to general paediatricians, dermatologists and endocrinologists. Polycystic ovarian syndrome is the most common cause but can be challenging to diagnose in young people due to the significant overlap of features with the healthy adolescent population. There are other rare, but important, causes to consider such as non-classic congenital adrenal hyperplasia and androgen-secreting tumours. Hirsutism carries a significant psychological burden for those living with it. This 15 min consultation piece describes the causes of hirsutism, introduces a novel assessment tool and suggests an approach to investigations and management, including signposting to psychological support.

Modified ferriman-gallwey score and hirsutism among normal healthy female population

Objective

This study aimed to investigate the prevalence of Hirsutism by using the mFG score and to identify the mean mFG score among the normal healthy female population of Peshawar.

Methods

A cross-sectional study was conducted among 448 normal healthy married women aged between 20 to 40 years from 14th April 2022 to 13th October 2022 at Hayatabad Medical Complex in Peshawar. The mFG score was used to evaluate Hirsutism, a score of eight or above was regarded as indicative of Hirsutism.

Results

The mean modified Ferriman-Gallwey (mFG) score was 8.89 ± 4.33. 255 (56.9%) of the individuals had a mFG score of more than 8. These people showed mild hirsutism in 52.0% of cases, moderate hirsutism in 4.5% of cases, and severe hirsutism in 0.4% of cases. It was observed that the lower abdomen and thigh region had the highest prevalence of mild to moderate hirsutism, with a considerable number of individuals scoring two and three. Conversely, the back and buttocks showed predominantly minimal to no hirsutism, with the majority of participants scoring 0 and 1. There was no discernible difference in mean mFG scores between age groups, according to statistical analysis (p=0.195). Intriguingly, rates of hirsutism were found to be higher in urban versus rural populations, at 78.7% versus 36.6%, respectively (p<0.01). In addition, 80.3% of people who had a positive family history of hirsutism had a mFG score of 8 or higher.

Conclusion

The prevalence of Hirsutism among the normal healthy female population based on the mFG score was relatively high.

Interplay between polycystic ovary syndrome and hypothyroidism on serum testosterone, oxidative stress and StAR gene expression in female rats

INTRODUCTION

Endocrine disorders such as polycystic ovary syndrome (PCOS) and hypothyroidism can cause infertility. There are evidence that they happen jointly in some circumstances. It still remains unknown, how these two illnesses interact and influence the body.

METHODS

Accordingly, a five-group was designed, first is the control group, followed by the PCOS group. Estradiol valerate (EV) induced PCOS, the second group had only PCOS and the third, fourth and fifth groups were given varied dosages of propylthiouracil (PTU) to cause hypothyroidism after induction of PCOS. Steroidogenic acute regulatory protein (StAR) expression was measured in the ovaries, and serum was obtained to determine testosterone levels, as well as superoxide dismutase (SOD) as an antioxidant and malondialdehyde (MDA) as an oxidant.

RESULTS

Based on radioimmunoassay data, testosterone levels were significantly higher in the PCOS group than the control group, and significantly lower (p ˂ .05) in PTU groups comparing with the PCOS group. According to the quantitative real-time polymerase chain reaction (qRT-PCR) data, the same results were obtained for the StAR gene as well. The data also indicated a positive correlation between these two. Although both oxidant and antioxidant level increased in PCOS group compared than control group, after hypothyroidism, oxidant level increased significantly (p ˂ .05), meanwhile antioxidant level decreased significantly (p ˂ .05).

CONCLUSIONS

The results of this study illustrate that the presence of both PCOS and hypothyroidism alters the situation more than just PCOS. They also indicate that this situation is associated with imbalanced oxidative/antioxidative status.

Clinico-investigative attributes of 122 patients with hirsutism: A 5-year retrospective study from India

BACKGROUND

Hirsutism is common across ethnicities and a significant cause of negative self-esteem from presumptive loss of femininity. It remains understudied in Indian patients.

OBJECTIVE

We studied the clinical and investigative attributes of patients with hirsutism.

METHODS

The medical records of 233 patients with hirsutism diagnosed between 2014 and 2019 were analyzed retrospectively.

RESULTS

The complete records of 122 patients age 14 to 45 years were available. Approximately 32% were adolescents, and 50% patients were age 21 to 30 years. The mean ± standard deviation modified Ferriman-Gallway (mF-G) score was 17.95 ± 10.58, and hirsutism was graded zero/mild in 57.4% patients. Polycystic ovaries were present in 29.5% of patients. Serum-free testosterone levels were elevated in 16.4% of patients. Associated signs of clinical hyperandrogenism, such as acne, obesity, acanthosis nigricans, and menstrual irregularities, were present in 12 patients (9.8%). Familial hirsutism occurred in 13% of patients and was idiopathic in 10.7% of patients. Significantly more patients (47.7% vs. 27.9%) with severe hirsutism did not complete investigations compared with those with mild hirsutism (45.9% vs. 21.6%), which may be due to the high cost of investigative work-up (as often stated by many patients) compared with periodic depilation.

LIMITATIONS

The mF-G score is a visual and subjective scale, and its validity remains limited by interobserver variations. The score's cut-off values may vary among races/ethnicities. A small number of patients and the retrospective study design are other limitations.

CONCLUSION

Hirsutism of polycystic ovary syndrome or idiopathic origin is not uncommon in Indian women. Hirsutism of adrenal or thyroid origin remains uncommon. Self-referral and high cosmetic concerns for facial hair were common in adolescents and young unmarried patients, and the majority had an mF-G score of < 8 to 16. Cut-off values for the mF-G score specific to our population assigning higher than current mF-G value to facial hair are highly desirable.

The Contribution of New Areas to the Total Hirsutism Scores in Basrah Hirsute Women

BACKGROUND

Hirsutism is the presence of excessive growth of terminal hair in a female in the male-like pattern. It is the most common indicator of hyperandrogenism. The primary objective of this study was to evaluate the clinical impact of new androgens sensitive skin area to total body hirsutism score.

METHODS

This was cross-sectional study. Most of the patients in this study group (n = 300) were women of reproductive age group (20-39 years) with a mean age of 26.6 ± 7.1 years. They were recruited in Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC) during the period from August 2016 to the end of August 2017. All complained from hirsutism and were assessed by using modified Ferriman-Gallwey (m-FG) score system by a single examiner. Each patient underwent detailed clinical assessment in addition to transabdominal or transvaginal ultrasonography of the pelvis with endocrinological investigations.

RESULTS

Comparison of the mean score at different body areas revealed that new androgens sensitive skin areas (sideburn, lower jaw/neck, buttocks/perineum) were comparable to others area of original m-FG score system or higher than at least three area used in the score. The sideburn area was observed to have the highest score among the new androgens sensitive skin areas.

CONCLUSION

Evaluating the terminal hair growth in the new three androgen-sensitive skin areas (sideburn, lower jaw/neck, and buttocks/perineum) were clinically useful in assessing hirsutism score with high impact on total score.

Modified Ferriman-Gallwey Score in Hirsutism and its Association with Metabolic Syndrome

BACKGROUND

Hirsutism is the presence of terminal hair in females in males pattern. It occurs in 5%-15% of women. Modified Ferriman-Gallwey (mFG) score of ≥ 8 is considered hirsutism, but there are populations with a low mFG score. In clinical practice, hirsutism is subjective. Although hirsutism is considered as a purely esthetic problem, it is associated with many underlying disorders, especially androgen excess disorders. Polycystic ovarian syndrome (PCOS) disease is the most common cause of androgen excess in females, and there are reports of its association with metabolic syndrome. Metabolic syndrome occurs alone in hirsutism.

AIMS

To assess mFG score in patients who consider themselves as hirsute. To study the association between metabolic syndrome and hirsutism.

METHODS

Hospital-based cross-sectional study design was adopted. A structured questionnaire was used to collect sociodemographic and clinical data. The severity of hirsutism was assessed using mFG score and metabolic syndrome was diagnosed by the American Heart Association criteria. mFG score was expressed as mean and Student's t-test and Chi-square statistic were used as the tests of significance. Logistic regression analysis was performed.

RESULTS

The mean mFG score was 5.5. Metabolic syndrome was present in 44%. About 65.2% of patients with score ≥8 had metabolic syndrome, whereas only 37.7% of patients with score <8 had metabolic syndrome (P = 0.019). Metabolic syndrome (P = 0.018) and PCOS (P = 0.003) were the significant variables in logistic regression analysis. Triglyceride levels ≥150 mg/dl and waist circumference ≥88 cm were the components of metabolic syndrome that were significantly associated with hirsutism (P = 0.006 in both).

CONCLUSIONS

To find the ideal cutoff of mFG score to define hirsutism in our population, a population study among females in the reproductive age group has to be conducted. As there is a definite association of hirsutism and metabolic syndrome, and metabolic syndrome can result in cardiovascular complications, any women presenting with terminal hair in a male pattern should be evaluated for metabolic syndrome irrespective of the mFG score.

Women self-perception of excess hair growth, as a predictor of clinical hirsutism: a population-based study

PURPOSE

Hirsutism is the most common indicator of hyperandrogenism. Both, the sensitivity of the patients to the serum androgen levels and the responsiveness of women to the perceived excess hair growth vary among different populations. This report elaborates the relationship between the woman's discerned abnormal hair growths with the clinical diagnosis of hirsutism.

METHODS

The survey was conducted among 1160 women aged 18-45 and randomly selected from Tehran Lipid and Glucose Study for further detailed assessment of Hirsutism; using the m-FG scoring method. Data gathering was performed by interviews and physical examinations. The receiver operating characteristic curve was drawn and the new cutoff value, sensitivity, specificity and concordance percentage were calculated.

RESULTS

The results demonstrated that among 12 androgen-dependent body areas, the chin skin had the highest area under curve of 0.81 (CI; 0.78-0.84). According to the patient's evaluation, a threshold point of 4 had the optimum concordance percentage of 0.77 with the modified Ferriman-Gallwey scoring system.

CONCLUSIONS

Patient's self-identification of excess terminal hair based on the chin area has great sensitivity and reliability in predicting the clinical hirsutism.