Semiquantitative assessment of hirsutism in Dutch women

Clinical Phenotypes of PCOS: a Cross-Sectional Study

This cross-sectional study examines the Doi-Alshoumer PCOS clinical phenotype classification in relation to measured clinical and biochemical characteristics of women with polycystic ovary syndrome (PCOS). Two cohorts of women (Kuwait and Rotterdam) diagnosed with PCOS (FAI > 4.5%) were examined. These phenotypes were created using neuroendocrine dysfunction (IRMA LH/FSH ratio > 1 or LH > 6 IU/L) and menstrual cycle status (oligo/amenorrhea) to create three phenotypes: (A) neuroendocrine dysfunction and oligo/amenorrhea, (B) without neuroendocrine dysfunction but with oligo/amenorrhea, and (C) without neuroendocrine dysfunction and with regular cycles. These phenotypes were compared in terms of hormonal, biochemical, and anthropometric measures. The three suggested phenotypes (A, B, and C) were shown to be sufficiently distinct in terms of hormonal, biochemical, and anthropometric measures. Patients who were classified as phenotype A had neuroendocrine dysfunction, excess LH (and LH/FSH ratio), irregular cycles, excess A4, infertility, excess T, highest FAI and E2, and excess 17αOHPG when compared to the other phenotypes. Patients classified as phenotype B had irregular cycles, no neuroendocrine dysfunction, obesity, acanthosis nigricans, and insulin resistance. Lastly, patients classified as phenotype C had regular cycles, acne, hirsutism, excess P4, and the highest P4 to E2 molar ratio. The differences across phenotypes suggested distinct phenotypic expression of this syndrome, and the biochemical and clinical correlates of each phenotype are likely to be useful in the management of women with PCOS. These phenotypic criteria are distinct from criteria used for diagnosis.

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.

Sonographic markers of ovarian morphology, but not hirsutism indices, predict serum total testosterone in women with regular menstrual cycles

OBJECTIVE

To determine whether sonographic markers of ovarian morphology or male pattern hair growth scores predict androgen levels in women with regular or irregular menstrual cycles.

DESIGN

Cross-sectional observational study.

SETTING

Clinical research unit.

PATIENT(S)

Seventy-six women of reproductive age (18-39 years) were evaluated for male-pattern hair growth (using a modified Ferriman-Gallwey scoring system), ovarian morphology (by transvaginal ultrasonography), and total serum testosterone (T) (by liquid chromatography tandem mass spectrometry).

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Regional and total modified Ferriman-Gallwey scores, number of follicles per follicle size category, follicle number per ovary, ovarian volume, ovarian area, stromal to ovarian area ratio, stromal echogenicity index, total testosterone (total T), and menstrual cycle length.

RESULT(S)

Neither regional nor total modified Ferriman-Gallwey scores correlated with total T concentrations in women with regular or irregular menstrual cycles, as judged by the Least Absolute Shrinkage and Selection Operator technique. By contrast, a sonographic marker (follicle number per ovary 6-9 mm) significantly predicted total T concentrations in women with regular menstrual cycles but not in women with irregular menstrual cycles.

CONCLUSION(S)

Sonographic markers of ovarian morphology, but not hirsutism scores, predicted total T levels. However, the predictive value of ovarian morphology for total T differed by menstrual cycle status. That sonographic markers did not predict androgen levels in a diverse cohort of women with cycle irregularity suggests the potential for distinct variations in ovarian morphology for androgenic and nonandrogenic types of cycle irregularity. Overall, our findings support that an assessment of ovarian morphology may be helpful in reflecting total T levels.

Social support: an important factor for quality of life in women with hirsutism

Background

Women with hirsutism have reported imparied health and health-related quality of life (HRQoL). Social support is a factor that might increase HRQoL in chronic diseases, but little is known about this association among women with hirsutism.

Aim

The aim of the study was to describe social support and explore its association with HRQoL among women with hirsutism. A further aim was to compare HRQoL in women with hirsutism with a Swedish normal population.

Methods

A questionnaire including socio-demographic questions, Short-Form Health Survey (SF-36), the Multidimensional Scale of Perceived Social Support (MSPSS), and a self-estimation of hairiness using the Ferriman-Gallway scale (F-G scale) was answered by 127 women with hirsutism.

Results

Multiple regression analyses showed significant associations between social support and all health dimensions in the SF-36, also after the model was adjusted for age, hairiness and body mass index. Compared to the normal Swedish population, women with hirsutism reported significantly lower HRQoL in all dimensions of the SF-36 (p < 0.01).

Conclusions

There is a significant positive association between social support and HRQoL, demonstrating its importance for the ability to adapt to problems associated with hirsutism. As women with hirsutism reported poorer HRQoL compared to the normal population, social support may be a factor to consider in clinical practice.

Evaluation of only the chin or lower abdomen for predicting hirsutism

BACKGROUND

Hirsutism is defined as the growth of terminal hair in a male pattern in women; it affects 5-15% of women.

OBJECTIVE

The aim of this study is evaluation of only the chin or lower abdomen for predicting hirsutism.

MATERIALS AND METHODS

In this cross-sectional diagnostic study, we randomly selected 695 women aged 15-45 years. The examiners scored the subjects on a scale of 0 - 4 for terminal hair growth on nine different body areas according to the Ferriman-Gallwey (FG) scoring system in a form given to the examiners before the examination. An FG score of 8 or more was considered diagnostic of hirsutism. If the sum of the FG scores for the chin or lower abdomen was 2 or more, the test result was assumed to be positive. Statistical analysis was performed using the MacNemar test, and a P value of less than 0.05 was considered to be statistically significant.

RESULTS

The age group with the highest prevalence rate was 21-25 years. From the 695 subjects examined, 81 subjects (11.7%) had an FG score of 8 or more with a resultant prevalence rate of 11.7% for hirsutism. In our study population, 39% of the patients had an FG score of 2 or more for the chin or lower abdomen, and 61% of the patients had an FG score of less than 2 for the chin or lower abdomen.

CONCLUSION

Evaluating terminal hair growth on the chin or lower abdomen for predicting hirsutism seems to be an acceptable screening method.

Epidemiology of hirsutism among women of reproductive age in the community: a simplified scoring system

OBJECTIVE

The purpose of our research was to generate large sample evidence for the clinical diagnostic criteria of hirsutism and to simplify the modified Ferriman-Galwey (mF-G) scoring system for Asian women.

STUDY DESIGN

This study was a large-scale, cross-sectional epidemiologic investigation conducted in 10 provinces of China. A total of 10,120 reproductive-age women in the community were involved in using the mF-G scoring system to evaluate hirsutism.

RESULTS

Of the participants, 95.5% had an mF-G score <5. The strongest contributors to the nine mF-G positions were upper lip, thighs, and lower abdomen. If the cut-off value was set at 2 for these 3 areas, the area under the ROC curve was 0.987 (95% CI 0.983-0.992), which had a sensitivity of 98.7% and a specificity 91.0%. The percentage of hirsutism (mF-G score >4) and the average mF-G score decreased with advancing age.

CONCLUSIONS

An mF-G scoring >4 can be used to diagnose hirsutism in this population. The results also suggest that hair growth involving the upper lip, thighs, and lower abdomen with scores >2 can be used to diagnose hirsutism in women in the community.

Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society

BACKGROUND

Hirsutism, defined by the presence of excessive terminal hair in androgen-sensitive areas of the female body, is one of the most common disorders in women during reproductive age.

METHODS

We conducted a systematic review and critical assessment of the available evidence pertaining to the epidemiology, pathophysiology, diagnosis and management of hirsutism.

RESULTS

The prevalence of hirsutism is ~10% in most populations, with the important exception of Far-East Asian women who present hirsutism less frequently. Although usually caused by relatively benign functional conditions, with the polycystic ovary syndrome leading the list of the most frequent etiologies, hirsutism may be the presenting symptom of a life-threatening tumor requiring immediate intervention.

CONCLUSIONS

Following evidence-based diagnostic and treatment strategies that address not only the amelioration of hirsutism but also the treatment of the underlying etiology is essential for the proper management of affected women, especially considering that hirsutism is, in most cases, a chronic disorder needing long-term follow-up. Accordingly, we provide evidence-based guidelines for the etiological diagnosis and for the management of this frequent medical complaint.

Visually scoring hirsutism

BACKGROUND

Hirsutism is the presence of excess body or facial terminal (coarse) hair growth in females in a male-like pattern, affects 5-15% of women, and is an important sign of underlying androgen excess. Different methods are available for the assessment of hair growth in women.

METHODS

We conducted a literature search and analyzed the published studies that reported methods for the assessment of hair growth. We review the basic physiology of hair growth, the development of methods for visually quantifying hair growth, the comparison of these methods with objective measurements of hair growth, how hirsutism may be defined using a visual scoring method, the influence of race and ethnicity on hirsutism, and the impact of hirsutism in diagnosing androgen excess and polycystic ovary syndrome.

RESULTS

Objective methods for the assessment of hair growth including photographic evaluations and microscopic measurements are available but these techniques have limitations for clinical use, including a significant degree of complexity and a high cost. Alternatively, methods for visually scoring or quantifying the amount of terminal body and facial hair growth have been in use since the early 1920s; these methods are semi-quantitative at best and subject to significant inter-observer variability. The most common visual method of scoring the extent of body and facial terminal hair growth in use today is based on a modification of the method originally described by Ferriman and Gallwey in 1961 (i.e. the mFG method).

CONCLUSION

Overall, the mFG scoring method is a useful visual instrument for assessing excess terminal hair growth, and the presence of hirsutism, in women.

Interobserver variability of modified Ferriman-Gallwey hirsutism score in a Turkish population

OBJECTIVE

The aim of the study was to evaluate the interobserver variability of modified Ferriman-Gallwey (mFG) hirsutism scores on each body area in a Turkish population.

DESIGN

A cross-sectional study of simultaneous mFG scoring design was used. Observers did not make any interview with the subjects and were masked to the previous score results. Analyses included percentage of agreement, kappa coefficients, the Bland and Altman plot, confidence intervals, minimum and maximum kappa coefficients.

SETTING

The study was performed at a teaching and research hospital.

PATIENTS

Hundred and twenty-one Turkish women without any complaints of excessive body hair were studied.

INTERVENTIONS

Interventions included two special trained physicians, simultaneous and independent mFG scoring.

MAIN OUTCOME MEASURES

The main outcome measures were mFG scores in each body area.

RESULTS

Agreement analysis demonstrated that the scores of the two physicians were quite concordant. The mean kappa value for nine body area was 0.744 and the highest kappa values from the upper back and the lowest kappa values from the upper lip revealed kappa=0.847, kappa=0.585, respectively. The highest (upper lip) and the lowest (arm) mean range scores for the two researchers among the 9 areas were 1.46-1.55 and 0.17-0.12, respectively. Only 68.6 and 67.8% of the mFG scores observed by each of the two observers were equal or below 8.

CONCLUSION

The mFG scoring system was found to be clinically useful. The upper lip was observed to have the highest score of androgen sensitive area of the body as well as the highest interobserver variability. The cut-off value to establish the diagnosis of hirsutism should be population-specific.

Hirsutism in Saudi females of reproductive age: a hospital-based study

BACKGROUND

Hirsutism among women of fertile age is commonly seen in clinical practice, but the pattern of the disease in Saudi Arabs has not been studied. The aim of the study was to determine the clinical, biochemical and etiologic features of hirsutism in Saudi females.

METHODS

101 Saudi Arab women presenting with hirsutism at King Khalid University Hospital, Riyadh, Saudi Arabia, from 1 January 2000 to 31 December 2005 were prospectively assessed using the recently approved diagnostic guidelines for hyperandrogenic women with hirsutism.

RESULTS

Polycystic ovary syndrome (PCOS) was the cause of hirsutism in 83 patients (82%) followed by idiopathic hirsutism (IH) in 11 patients (11%). Others causes of hirsutism included late onset congenital adrenal hyperplasia in 4 patients (4%), microprolactinoma in 2 (2%) and Cushingâs syndrome in 1 (1%) patient. Age at presentation of PCOS was 24.5+/-6.6 years (mean+/-SD) and 51% of the subjects were obese. Furthermore, 74 (89%) of patients with PCOS had an oligo/anovulatory cycle while the remaining 9 patients (11%) maintained normal regular menstrual cycle. Luteinizing hormone and total testosterone were significantly higher in patients with PCOS than in those with IH (P<.05).

CONCLUSIONS

The present data show PCOS to be the commonest cause of hirsutism in our clinical practice and PCOS is prominent amongst young obese females. However, further studies on a larger scale are needed to verify our findings.

Steroidogenic alterations and adrenal androgen excess in PCOS

BACKGROUND

This cross-sectional study was undertaken to improve our understanding of the steroidogenic alterations leading to adrenal hyperandrogenism in polycystic ovarian syndrome (PCOS).

METHODS

Two-hundred and thirty-four women with clinical and biochemical features suggestive of PCOS underwent metabolic and hormonal evaluation. We used the androstenedione/DHEAS ratio as a surrogate for the level of ovarian 3betaHSD activity. We then selected the 90th percentile for the ratio in those with elevated DHEAS (>9 micromol/l) as the cut-off level beyond which excess DHEAS production will be minimized by excess ovarian 3betaHSD activity. This cut-off level was at a ratio of 1.5 and all PCOS women were then divided into two groups, the higher (>1.5) being the group with excess ovarian 3betaHSD activity. We hypothesized that women with a high ratio would be unlikely to have DHEAS excess due to the rapid conversion of DHEA to androstenedione. Those with a low ratio (concordant ovarian and adrenal steroidogenesis) could then either have high DHEAS or normal DHEAS, depending on whether CYP17 activity was higher or lower respectively.

RESULTS

Insulin resistance was found to be associated with decreased CYP17 activity while irregular cycles and neuroendocrine dysfunction were determined to be associated with higher ovarian 3betaHSD activity.

CONCLUSION

Adrenal androgen excess in PCOS seems to be related to insulin sensitivity as well as decreased activity of 3betaHSD, the latter being preferentially present in those women with regular cycles or without neuroendocrine dysfunction.

Irregular cycles and steroid hormones in polycystic ovary syndrome

BACKGROUND

This cross-sectional study was undertaken to evaluate the factors that relate to menstrual status (oligo-amenorrhoea versus eumenorrhoea) in polycystic ovary syndrome (PCOS).

METHODS

A total of 234 women with clinical and biochemical features suggestive of PCOS underwent metabolic and hormonal evaluation. A forward stepwise logistic regression model was created based on the results to determine variables related to ovulatory status.

RESULTS

Only follicular phase progesterone and estradiol (E(2)) were retained in the final model. This model correctly classified 80% of PCOS women by ovulatory status. Univariate analysis revealed no difference in progesterone between ovulatory groups but E(2) was higher in anovulatory groups. This suggested interaction between progesterone and E(2) and the single interaction variable (progesterone/E(2)) also classified 80% of women by ovulatory status correctly.

CONCLUSION

The results suggest that a low ratio of progesterone to E(2) is associated with menstrual irregularity and ovulatory status in PCOS.

The prevalence of upper lip hair in black and white girls during puberty: a new standard

In order to develop standards for upper lip hair in adolescent girls, 4693 observations in 856 black and white subjects were made over 9 years. Up to 2 years after menarche, 90% of girls had no upper lip hair. More than 2 years after menarche, 48.8% of black girls and 9.0% of white girls had small amounts of upper lip hair. This may be more significant in adolescent girls than in older women.