Year : 2008 | Volume
: 53 | Issue : 3 | Page : 111--114
Hirsutism: Clinico-investigative profile of 50 Indian patients
Nand Lal Sharma, Vikram K Mahajan, Rashmi Jindal, Mudita Gupta, Anju Lath
Department of Dermatology, Venereology and Leprosy, Indira Gandhi Medical College, Shimla, India
Nand Lal Sharma
Department of Dermatology, Venereology and Leprosy, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh
Background: Despite worldwide prevalence of hirsutism studies on hirsutism in Indian patients are not many. Aims: This retrospective study was carried out to assess the clinico-investigative profile of patients presenting with hirsutism. Materials and Methods: Medical records of 82 hirsutism patients diagnosed consecutively during July 2005 to October 2007 were analyzed. Results: The complete data of 50 patients aged between 13 and 47 years were available. Fifty percent patients were aged 20 to 30 years. The average F-G score was 10.3 ± 2.46. Associated signs of hyperandrogenism were acne (64%), oligomenorrhea or menstrual irregularities (36%), androgenetic alopecia (16%), acanthosis nigricans (6%) and seborrhea (4%). Polycystic ovaries were detected in 30% patients and 22% patients had elevated serum free testosterone levels. Family history of hirsutism was present in 18% patients. Conclusion: Hirsutism in Indian patients is not uncommon. Adolescent patients appear to be more concerned about hirsutism as compared to those in the older age group who were more often worried of late onset acne. All patients, however, were more concerned for facial hair than those on other body areas signifying that facial hair need to be given higher than current value in F-G score.
|How to cite this article:|
Sharma NL, Mahajan VK, Jindal R, Gupta M, Lath A. Hirsutism: Clinico-investigative profile of 50 Indian patients.Indian J Dermatol 2008;53:111-114
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Sharma NL, Mahajan VK, Jindal R, Gupta M, Lath A. Hirsutism: Clinico-investigative profile of 50 Indian patients. Indian J Dermatol [serial online] 2008 [cited 2020 Jul 2 ];53:111-114
Available from: http://www.e-ijd.org/text.asp?2008/53/3/111/42387
Hirsutism is defined as male-pattern growth of terminal body hair in women in androgen-stimulated locations such as face, chest, and areolae. Hirsutism can be classified broadly into 2 groups viz. androgen induced and non-androgen induced. Androgen induced can either be due to excessive endogenous androgen production (ovarian/adrenal) or exogenous due to drugs. Central over production of androgens, increased peripheral conversion of androgens, decreased metabolism and enhanced receptor binding are potential causes of hirsutism. Non-androgen induced hirsutism can be idiopathic, familial or drug induced.
Other accompanying signs and symptoms of hyperandrogenism include acanthosis nigricans, obesity, pelvic mass, signs or symptoms of virilization, features of Cushing's syndrome, acne, increased sebaceous activity and alopecia. The modified Ferriman-Gallwey (F-G) score  is used to determine the severity of hirsutism by assessing the extent of hair growth in nine key anatomical sites. Simple laboratory measurement of total and free testosterone, dehydroepiandrosterone sulfate, and androstenedione identifies about half of the patients with hyperandrogenism.
Hirsutism is a frequent reason of cosmetic embarrassment, poor self esteem, and psychological distress for women world over. However, hirsutism has rarely been studied in Indian patients. In this communication, we report clinico-investigative profile of 50 patients of hirsutism diagnosed in the Dermatology Outpatient Department during July 2005 to October 2007.
Materials and Methods
Medical records of 82 patients of hirsutism maintained in the department were analyzed retrospectively for age, family history of hirsutism, medications and systemic diseases, menstrual and obstetric history, and associated signs of hyperandrogenism. Quantification of hirsutism was done using modified F-G score [Table 1]. Investigations included were estimation of thyroid hormones, free testosterone, luteinizing hormone (LH), follicular stimulating hormone (FSH) and serum prolactin levels and ultrasonography (USG) for adrenals and ovaries. Polycystic ovarian syndrome (PCOS) was diagnosed by Rotterdam criteria: presence of two of the three elements viz. clinical or biological hyperandrogenism, polycystic ovaries and chronic anovulation.  Polycystic ovaries (PCO) were diagnosed on pelvic USG by presence of ≥12 follicles measuring 2-9 mm in diameter and/or ≥10 ml ovarian volume.  Clinical hyperandrogenism was defined by presence of hirsutism, acne or androgenetic alopecia.  Oligomenorrhea was defined as fewer than nine menses per year. 
Data of only 50 patients was complete and could be analyzed [Table 2]. Age of these patients was between 13-47 (Mean 25.84 ± 8.30) years, 25 (50%) of them were in age group of 20-30 years. The maximum hirsutism F-G score was 17 with an average of 10.3 ± 2.46. Acne was found to be associated in 32 (64%) patients aged between 15-41 years. Other signs of hyperandrogenism were acanthosis nigricans in 3 (6%) and seborrhea in 2 (4%) patients respectively. Oligomenorrhea or irregular menstrual cycles was reported by 18 (36%) patients; 10 of them had PCO as well. Androgenetic alopecia was observed in 8 (16%) patients. Nine (18%) patients had history of hirsutism in first degree relatives; 2 of them showed no investigative abnormality. Eleven (22%) patients had no investigative/menstrual abnormality except for a family history of hirsutism in first degree relatives of 2 of these patients. None of the patients was obese, hypertensive, diabetic or had clinical/laboratory evidence of adrenal, thyroid or Cushing's disease. No patient had history of any drug intake.
Serum free testosterone levels were elevated in 11 (22%) patients and 10 (20%) patients had elevated serum prolactin levels. LH/FSH ratio was increased in 17 (34%) patients, 9 of them had normal serum free testosterone levels and menstrual cycles. Fifteen (30%) patients revealed polycystic ovaries on pelvic USG. In total 17 (34%) patients fulfilled Rotterdam criteria  for hyperandrogenism of polycystic ovarian syndrome origin and 9 of them also had anovulatory menstrual cycles.
Hirsutism affects 5-10% of women of reproductive age.  It can be classified as androgenic and non-androgenic hirsutism. Hirsutism can be caused by abnormally high androgen levels or by hair follicles which are more sensitive than usual to normal androgen levels. Biologically active free testosterone is responsible for hair growth and is regulated by sex hormone-binding globulin. The causes of androgenic hirsutism can be exogenous due to drugs (testosterone, dehydroepiandrosterone sulfate, danazol, corticotropin, high-dose corticosteroids, metyrapone, phenothiazine derivatives, anabolic steroids, androgenic progestin, and acetazolamide) or excess endogenous androgen of adrenal or ovarian origin. Various causes of ovarian hyperandrogenism are PCOS and virilizing ovarian neoplasia (Luteoma of pregnancy, arrhenoblastomas, leydig cell tumors, hilar cell tumors, thecal cell tumors, etc.). However, PCOS alone accounts for 75-80% cases of hyperandrogenism. , Clinically the most common sign of hyperandrogenism in PCOS is hirsutism. The prevalence of hirsutism in PCOS varies between 17% and 83%.  Polycystic ovaries were detected in our 30% patients. However by using Rotterdam criteria for diagnosing PCOS,  17 (64%) of our patients had clinical hyperandrogenism. Acne appears another consistent feature and was found in 64% patients across all age groups followed by oligomenorrhea in 18% and androgenetic alopecia in 16% patients respectively. Acanthosis nigricans (6%) and seborrhea (4%) appear other but less common signs of hyperandrogenism in our patients. Since gonadotrophins are released in a pulsatile manner their concentration varies over the menstrual cycle and a single measurement of LH and/or FSH may not be a sensitive method for diagnosis.  This is also evident in our 17 patients having abnormal LH to FSH ratio but elevated serum free testosterone levels and abnormal menstrual cycles, features of hyperandrogenism, were observed in 11 and 9 patients only.
Adrenal hyperandrogenism is uncommon and seen in congenital adrenal hyperplasia, late-onset adrenal hyperplasia, Cushing's syndrome, pituitary adenomas that produce excess corticotropin or prolactin and acromegaly. None of our patients had adrenal abnormality. Hirsutism in 8 of 10 patients having raised serum prolactin levels appears to be more of PCOS associated hyperandrogenism in view of additional features such as elevated free serum testosterone, LH-FSH ratio, oligomenorrhea and/or polycystic ovaries.
The non-androgenic causes of hirsutism may be familial, idiopathic or due to drugs like cyclosporine, phenytoin, diazoxide, triamterene-hydrochlorothiazide, minoxidil, hexachlorobenzene, penicillamine and psoralens. Other less common causes include anorexia nervosa, hypothyroidism and porphyria. Idiopathic hirsutism, also called simple or peripheral hirsutism, is diagnosable in women who have normal ovulatory function and normal androgen profile. Only 5-15% of hirsute women qualify for this diagnosis by these criteria. ,, Except for our two patients who had hirsutism in first degree relatives other 4 patients with normal investigative profile can be considered to be of idiopathic origin.
Despite limitations of small number of patients and lack of long-term follow-up in most patients, the study indicates that hirsutism in Indian women is not uncommon. Although its clinical presentation does not differ from its description in the literature, hirsutism of adrenal or thyroid origin does not appear to be common in our patients. Interestingly, while patients in the adolescent group showed more concern for their facial hair than acne, the patients in the older age group had worries more often for late onset acne signifying a varied perception of the same problem. However, all patients were more concerned for facial hair than those on other body areas. We feel that facial hair be given higher than current value in F-G scoring system in view of the psychological/cosmetic embarrassment it causes.
|1||Hatch R, Rosenfield RL, Kim MH, Tredway D. Hirsutism: implications, etiology and management. Am J Obstet Gynecol 1981;140:815-30.|
|2||Rotterdam ESHRE/ASRM sponsored PCOS consensus workshop group 2004 revised 2003 consensus on diagnostic criteria and long term health risk related to polycystic ovary syndrome. Hum Reprod 2004;19:41-7.|
|3||Balen AH, Laven JS, Tan SL, Dewally D. Ultrasound assessment of the polycystic ovary: International consensus definition. Hum Reprod Update 2003;9:505-14.|
|4||Carmina E, Rosato F, Janni A, Risso M, Longo RA. Relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab 2006;91:2-6.|
|5||Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005;32:773-7.|
|6||Azziz R, Sanchez LA, Knochenhauer ES, Moran C, Lazenby J, Stephens KC, et al . Androgen excess in women: Experience with over 1000 consecutive patients. J Clin Endocrinol Metab 2004;89:453-62.|
|7||Carmina E. Prevalence of idiopathic hirsutism. Eur J Endocrinol 1998;139:421-3.|
|8||Azziz R, Carmina E, Sawaya ME. Idiopathic hirsutism. Endocr Rev 2000;21:347-62.|