Idiopathic hirsutism

Androgens and Hirsutism in a Large Cohort of Portuguese Women

Background/Objectives: Hirsutism is excessive male-patterned hair in postpubertal women with multifactorial etiology and is an indicator of hyperandrogenism associated with polycystic ovary syndrome (PCOS). Indeed, it can be caused by the enhanced peripheral conversion of androgen precursors to testosterone, as in idiopathic hirsutism (IH). Moreover, hirsutism can be caused by hirsutism-related hyperandrogenic syndromes like non-classic congenital adrenal hyperplasia (NCAH) and idiopathic hyperandrogenism (IHA). Methods: In this study, we characterized a large cohort of Portuguese women referred for hirsutism and estimated the prevalence of PCOS, NCAH, IHA, and IH. The levels of androgens and gonadotropins and body mass index (BMI) were measured and compared with controls. The correlation between each variable was calculated. Results: In the cohort, we found a prevalence of PCOS of 56.2%, IH of 20.2%, IHA of 17.3%, and NCAH of 6.2%. Subjects with PCOS were the only ones showing a significant difference in BMI compared to the controls and had the lowest levels of sex hormone-binding globulin (SHBG). Those with NCAH were younger and more hirsute with higher levels of testosterone, among other androgens. Those with IH had lower luteinizing hormone (LH) and LH/follicle-stimulating hormone (FSH) ratios than those with PCOS. Those with IH had lower SHBG levels compared to the controls and a higher free androgen index (FAI). Those with IHA had higher androgens compared to those with IH, in particular, adrenal-derived androgens. Conclusions: The pathogenesis of hirsutism is complex, and the contributions of the pituitary gland, ovaries, adrenals, adipose tissue, and liver have to be ascertained to understand the clinical manifestations and delineate appropriate treatments. This study sheds new light on the fine hormonal regulation of these diseases.

The Value of Androgen Measures for Diagnosing Polycystic Ovary Syndrome (PCOS) in an Unselected Population

OBJECTIVE

Polycystic Ovary Syndrome (PCOS) is diagnosed by a combination of three features: hyperandrogenism (biochemical and/or clinical), ovulatory dysfunction, and polycystic ovarian morphology, usually detected by ultrasonography. Our study aimed to determine the need for androgen measurements by using hirsutism to establish hyperandrogenism for diagnosing PCOS in a medically unbiased population.

MATERIALS AND METHODS

We utilized a pre-existing cohort of unselected (medically unbiased) females aged 18-45 years. All underwent a history and physical, including a modified Ferriman-Gallwey (mFG) hirsutism score. Subjects were categorized clinically as eumenorrheic non-hirsute (CONTROLS), menstrual dysfunction only (OLIGO-ONLY), hirsutism only (HIRSUTE-ONLY), or menstrual dysfunction and hirsutism (OLIGO + HIRSUTE). All subjects underwent measurements of androgens using high-quality assays. CONTROLS established the upper normal limit for androgen levels. We defined PCOS using the NIH 1990 criteria.

RESULTS

Of 462 individuals with complete evaluations, 311 (67.3%) were CONTROLS, 71 (15.4%) were OLIGO-ONLY, 64 (13.9%) were HIRSUTE-ONLY, and 16 (3.5%) were OLIGO + HIRSUTE. Neither HIRSUTE-ONLY nor OLIGO-HIRSUTE women required androgen measures to demonstrate hyperandrogenism. Among OLIGO-ONLY, 19 (26.8%) demonstrated hyperandrogenemia without hirsutism, with White women significantly more likely than Black women to demonstrate this.

CONCLUSIONS

In our study of medically unbiased reproductive-aged women using the NIH 1990 criteria for PCOS, only 15.4% of women evaluated (those with menstrual dysfunction only) required androgen measurements. In these women only one-quarter demonstrated hyperandrogenemia. These data provide a strategy to minimize the need for androgen assays, including firstly categorizing subjects by clinical presentation and then assessing circulating androgens in the subgroup with menstrual dysfunction only.

Insulin resistance in Iraqi women with idiopathic hirsutism in Najaf City: A case-control study

Background: Hirsutism is a common endocrine problem with high prevalence in Iraqi women. Polycystic ovarian syndrome and idiopathic hirsutism (IH) are the most common etiology of this disorder. There is a clear association between insulin resistance and polycystic ovarian syndrome. However, there is insufficient data on the relationship between insulin resistance and IH. Aim: The aim of this study was to determine whether Iraqi women with IH have insulin resistance. Methods: The study included two groups: 60 Iraqi women with IH and 60 women without hirsutism as a control group. A physical examination, a medical history, and the patient's age and BMI were collected. Blood samples were collected for hormone analysis, including insulin, follicle-stimulating hormone, luteinizing hormone, prolactin, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, and free testosterone. To evaluate insulin resistance in both groups, the homeostasis model assessment-insulin resistance (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI) were used in addition to the Matsuda index. Results: Basal insulin was higher in the IH group (9.5 ± 0.2 mIU/L) than in the control group (4.8 ± 3.7 mIU/L), with a p value of < 0.0001. HOMA-IR was higher in the IH group (2.3 ± 4.1 μU mg), while in the control group, it was (0.8 ± 1.2 μU mg), with a p value of 0.007. There was a significant difference in the QUICKI, which was lower in the IH group (0.31 ± 0.2 μU-1/mg) than in the control group (0.45 ± 0.1 μU-1/mg), with a p value of < 0.0001. The insulin sensitivity index (Matsuda) was significantly lower in the IH group (3.1 ± 0.4) than in the control group (7.8 ± 1.3), with a p value of < 0.0001. Conclusion: According to the results of this study, Iraqi women with IH have insulin resistance and higher basal insulin levels.

An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists

INTRODUCTION

Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists.

AREAS COVERED

We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism.

EXPERT OPINION

Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

Testosterone or dihydrotestosterone: what should be evaluated in hirsutism?

PURPOSE

Dihydrotestosterone is a more potent androgen derived from testosterone and androstenediones, but its measurement has not been routinely recommended in women with hirsutism, and there is limited information in this regard with equivocal findings. This study aimed to evaluate serum dihydrotestosterone level in patients with hirsutism compared to women without hirsutism.

METHODS

In this case-control study (during 2021-2022), serum levels of total testosterone, free testosterone, and dihydrotestosterone were evaluated in 101 women with hirsutism and 101 healthy women. Hormonal levels were measured with chemiluminescent immunoassay method. Age and hormonal levels in each group, body mass index, menstrual status, complaint of decreased scalp hair density, and ovarian ultrasound findings in hirsutism group were collected and analyzed.

RESULTS

There was significant difference in free testosterone and dihydrotestosterone levels (P < 0.001) and no significant difference in total testosterone level between two groups (P = 0.628). Dihydrotestosterone level was significantly higher in women with hirsutism with menses irregularity, complaint of decreased scalp hair density, and presence of polycystic ovary on ultrasound (P < 0.05).

CONCLUSIONS

Measuring dihydrotestosterone level is not considered in routine evaluation of hirsutism, but we think that this significant difference shows that elevated level of dihydrotestosterone hormone in women with hirsutism is an important factor.

Assessment of Health-Related Quality of Life in Patients with Idiopathic Hirsutism Compared to Patients with Polycystic Ovary Syndrome

Objective

Hirsutism affects 5-15% of women of reproductive age. Health-related quality of life (HQOL) is a multidimensional assessment of well-being that considers the physical, social, and emotional aspects associated with a specific disease. The aim of this study is to evaluate HQOL in patients diagnosed with idiopathic hirsutism (IH) and compare it with patients diagnosed with polycystic ovary syndrome (PCOS).

Methods

This cross-sectional observational study was performed on 183 female individuals, consisting of 51 patients diagnosed with idiopathic hirsutism, 76 patients diagnosed with PCOS, and 56 healthy volunteers. Participants with a history of neuropsychiatric disorders, under 18 and over 45 years of age, during pregnancy and lactation, with any chronic disease that could interfere with diagnostic laboratory tests, and who had previously been treated for IH or PCOS were excluded from the study. Demographic, anthropometric, laboratory, and clinical data on the cases were recorded. The Short Form-36 (SF-36) questionnaire, the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI) were administered in a face-to-face interview by related authors involved in the study.

Results

The mean age, level of education, lifestyle, and marital status of all three groups were similar. There were no significant differences in body mass index (BMI) or waist circumference between the groups. Mean modified Ferriman-Gallwey (mFG) scores were similar in the IH and PCOS groups. In the IH patients, the general health and mental health domains of the SF-36 questionnaire scores were significantly lower than in the control group (p<0.001 and p=0.026, respectively). When the SF-36 questionnaire scores were compared between the IH and PCOS groups, the general health and role emotional domains were significantly lower in the PCOS group (p=0.013 and p<0.001, respectively), and the other domains were similar. All SF-36 questionnaire domains were significantly and negatively correlated with BMI and waist circumference measurements in IH patients. Both BDI and BAI scores were significantly and positively correlated with BMI (r=0.348, p<0.001, and r=0.162, p=0.012, respectively) and waist circumference (r=0.326, p<0.001, and r=0.344, p<0.001, respectively). Six out of eight domains of the SF-36 QOL scores were significantly and negatively correlated with the mFG scores.

Conclusion

Patients diagnosed with IH have impaired HQOL, similar to patients diagnosed with PCOS. Improving HQOL should be a goal when deciding on a management approach for hirsutism, which is one of the most common reasons for referral to endocrinology and dermatology outpatient clinics.

Idiopathic hirsutism: Is it really idiopathic or is it misnomer?

Hirsutism, which is characterized by excessive growth of terminal hair in a male pattern, may result from various causes including polycystic ovary syndrome (PCOS), non-classic congenital adrenal hyperplasia, adrenal or ovarian tumors or it may be idiopathic. Idiopathic hirsutism is currently defined as hirsutism associated with normal ovulatory function, normal serum androgen levels and normal ovarian morphology, however, the pathogenesis of idiopathic hirsutism is not clear. The androgens are the main hormones to stimulate growth of body hair, therefore, there should be any form of increased androgen effect irrespective of normal serum androgen levels in any patient with hirsutism. In accordance to this scientific truth, we have previously shown that, although within normal limits, patients with idiopathic hirsutism have relatively higher serum androgen levels (relative hyperandrogenemia) in comparison to healthy subjects which let as to think that is idiopathic hirsutism really idiopathic? In addition to relative hyperandrogenemia, we have previously shown that, in comparison to healthy subjects, women with idiopathic hirsutism demonstrated higher expression of steroid sulphatase and 17-beta hydroxysteroid dehydrogenase mRNA both in the subumbilical region and arm skin, which contributes to local androgen metabolism. Those results support the idea that, in some patients, although the adrenals or ovaries do not secrete increased amount of androgens leading to hyperandrogenemia, pilocebaceous unit locally produce increased amount of androgens leading to hirsutism without ovulatory dysfunction. Upon the demonstration of relative hyperandrogenemia and possible increase in local androgen synthesis in patients with idiopathic hirsutism, we think that idiopathic hirsutism is not idiopathic and it may be named as “normoandrogenic hirsutism”. Furthermore, it may not be a different entity but may be an early stage of hyperandrogenic disorders such as PCOS. Clinically, this can be find out by following-up patients with idiopathic hirsutism prospectively.

Effects of Hormones and Endocrine Disorders on Hair Growth

Hormones have a close association with hair growth; thus, they have a big impact on the hair cycle and hair follicle structure. Many hormones control hair growth, cycle, and density. Hair abnormalities are frequent in therapeutic practice, and they can cause severe emotional discomfort depending on societal and ethnic standards. As a result, disorders that impact the endocrine system can induce a variety of physiological hair growth and cycling alterations. Hirsutism and patterned hair loss have a significant impact on human personality. These illnesses necessitate a comprehensive approach to diagnosis and treatment. The hormonal impact on hair growth and the association of different endocrine disorders with hair changes are briefly discussed here.

Hirsutism, Normal Androgens and Diagnosis of PCOS

Hirsutism is defined as the presence of terminal hair with male pattern distribution in women. While in the general population, hirsutism affects around 4-11% of women, it is the main manifestation of hyperandrogenism in women with polycystic ovary syndrome (PCOS), with a prevalence estimated at 65-75%. Hirsutism in PCOS is associated with both androgen excess and individual response of the pilosebaceous unit to androgens. The modified Ferriman-Gallwey (mFG) scoring system has been widely used in clinical practice to visually score excessive terminal hair, thus standardizing hirsutism evaluation and facilitating data comparison. Although a universal mFG score cutoff would be useful for comparisons, ethnic variations, as well as skin type and other factors, should be considered when evaluating hirsutism in distinct populations. In turn, androgen levels, measured by conventional techniques, have been shown to correlate poorly with the severity of hirsutism. Indeed, while most women with PCOS and hirsutism also have higher than reference values for serum androgen levels, some of them may not present with biochemical hyperandrogenism, representing a challenge to the diagnosis of PCOS. In this article, we critically review this not uncommon condition in women with PCOS presenting with hirsutism but normal androgen levels.

Clinical Characteristics of Hyperandrogenism Include Hirsutism, Polycystic Ovary Syndrome, and Acne: Association with Psychiatric Disease in Women -A Nationwide Population-Based Cohort Study in Taiwan

Objective

Previous studies have shown an increased in psychiatric disorders in women with disorders associated with hyperandrogenism, but few nationwide cohorts have studied this phenomenon. Therefore, this study is aimed to examine the association between the clinical manifestations of hyperandrogenism and subsequent psychiatric disorders.

Methods

Based on the National Health Insurance Research Database, 49,770 enrolled participants were matched for age and index date between January 1, 2000, and December 31, 2015. Hirsutism, polycystic ovary syndrome, and acne are characterized by hyperandrogenism. After adjusting for confounding factors, we used Cox proportional analysis to compare the risk of psychiatric disorders during the 16 years of follow-up.

Results

Of all the participants, 1319 (13.25%) had psychiatric disorders in the study group, whereas only 3900(9.80%) had psychiatric disorders in the control group. After adjusting for age, and monthly income, the Cox regression analysis showed that the study patients were more likely to develop psychiatric disorders (hazard ratio [HR]: 2.004, 95% confidence interval [CI] = 1.327–2.724, P < 0.001). The results demonstrated that women aged 20–29 years had a more significant risk.

Conclusion

Women with clinical characteristics of hyperandrogenism have a higher risk of developing psychiatric disorders, especially those aged 20–29 years.

From diagnosis to treatment of androgen-secreting ovarian tumors: a practical approach

About 5% of all ovarian tumors develop some form of hormonal activity. Only 1% of ovarian tumors will secrete androgens causing clinical hyperandrogenism. Most androgen-secreting neoplasms (ASN) derive from sex cord or stroma cells of the ovary and may affect both premenopausal and postmenopausal women. Typically, a patient will present reporting symptoms of rapidly increasing hyperandrogenization such as: hirsutism, acne, frontal/male pattern balding, and in severe cases even virilization. Sertoli-Leydig Cell Tumors are the most frequent ASN and constitute about 0.5% of all ovarian neoplasms. Typically affecting women under 30 years of age, these tumors are usually unilateral and benign. They are also the most common tumor in postmenopausal women suffering with hyperandrogenism. Other tumors originating from the sex-cord stroma are also known to develop in this population, but the incidence of these is much lower. Approaching suspected hyperandrogenemia and its related symptoms in a clinical setting can be a significant diagnostic challenge. When evaluating a patient for hyperandrogenism, it is important to assess the severity of symptoms but most of all it is critical to assess the time of onset and dynamics of symptom progression. Diagnostic tools including laboratory tests and imaging studies should also be engaged. When deriving a differential diagnosis for androgen-secreting ovarian tumors, adrenal gland tumors should be considered as well as typical endocrine pathologies including polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing's disease, and acromegaly. Treatment options for an androgen-secreting ovarian tumors is mainly surgical, but in exceptional cases can involve pharmacotherapy alone.

Practical Approach to Hyperandrogenism in Women

The approach to hyperandrogenism in women varies depending on the woman's age and severity of symptoms. Once tumorous hyperandrogenism is excluded, the most common cause is PCOS. Hirsutism is the most common presenting symptom. The woman's concern about her symptoms plays an important role in the management of disease. Although measurement of testosterone is useful in identifying an underlying cause, care must be taken when interpreting the less accurate assays that are available commercially. Surgical resection is curative in tumorous etiologies, whereas medical management is the mainstay for non-tumorous causes.

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.

Is There Any Association Between Hirsutism and Serum Zinc Levels in Adolescents?

Zinc has shown to have an anti-androgenic effect through 5 alpha-reductase enzyme activity inhibition in skin. However, there are contradicting findings concerning the effect of zinc on hirsutism mainly from studies including adult women with polycystic ovary syndrome (PCOS). The aim of our study was to investigate the association between serum zinc levels and hirsutism in adolescents. Between October 2017 and June 2018, 51 female adolescents with hirsutism (mean age: 16.11 ± 1.47 years) and 51 healthy female controls were included in the study (mean age: 15.5 ± 1.40 years). Adolescents with hirsutism were classified under two groups; PCOS (n = 34, 66.7%) and idiopathic causes of hirsutism (idiopathic hirsutism (n = 9, 17.6%) and idiopathic hyperandrogenemia (n = 8, 15.7%)). The serum zinc levels were measured via atomic absorption spectrophotometry. The mean zinc levels of adolescents with hirsutism (102.02 ± 11.64 μg/dl) and the control group (101.72 ± 16.71 μg/dl) were similar (p = 0.915). Additionally, there was no significant difference among the mean zinc levels of the hirsutism sub-groups and the control group (p = 0.979). While some studies demonstrated low zinc levels in women with hirsutism, some studies similar to ours showed no association. Adolescence is a developmental phase where generally isolated mild hirsutism is not associated with hyperandrogenism and more studies are needed to evaluate the effect of zinc on hirsutism in this age group.

Is Idiopathic Hirsutism Truly Idiopathic?

Objective

To determine whether other androgens [androstenedione (A4), 17-hydroxy progesterone (17OHP) and dehydroepiandrosterone (DHEA)] were elevated in women with classically defined idiopathic hirsutism (IH)/patient-important hirsutism (PIH).

Study Design

Retrospective analysis.

Setting

Outpatient endocrine department of a tertiary care hospital.

Patients

In total, 30 consecutive women with IH/PIH were included. IH/PIH was defined as presentation with hirsutism with normal menstrual cycles (25-35 days), normal total (< 45 ng/dL) and free T (fT) (< 0.6 ng/dL) and normal ovaries sonologically (transabdominal ultrasonogram ovarian volume < 10 cm³) without any other signs of virilization. Clinical and biochemical details were collected and analyzed. Androgens were measured by LC-MS/MS. A4 ≥ 2.5 ng/mL, DHEA ≥ 15 (age < 18) or ≥ 11.8 (age ≥ 18) ng/mL, DHEAS ≥ 2847 ng/mL or 17OHP ≥ 2 ng/mL were considered high.

Results

With the mean age of 22 years and mean BMI of 25 kg/m², 12/30 (40%) had IH and remaining PIH. DHEA alone was elevated in 60% and A4 alone in 33%. Overall, 23/30 (73%) had any one elevated androgen with normal total and free testosterone. There was no correlation with modified Ferriman-Gallwey score, and there was no significant difference in androgens between IH and PIH.

Conclusion

A high proportion of women with classically defined IH/PIH have elevated DHEA and/or A4. Though on pharmacotherapy basis, there would be no change in management, the role of hyperandrogenemia detected by sensitive assays on metabolic functions and cardiovascular risk has to be studied.

Impact of Short-Term Isoflavone Intervention in Polycystic Ovary Syndrome (PCOS) Patients on Microbiota Composition and Metagenomics

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 5-20% of women of reproductive age worldwide and is associated with disorders of glucose metabolism. Hormone and metabolic signaling may be influenced by phytoestrogens, such as isoflavones. Their endocrine effects may modify symptom penetrance in PCOS. Equol is one of the most active isoflavone metabolites, produced by intestinal bacteria, and acts as a selective estrogen receptor modulator.

METHOD

In this interventional study of clinical and biochemical characterization, urine isoflavone levels were measured in PCOS and control women before and three days after a defined isoflavone intervention via soy milk. In this interventional study, bacterial equol production was evaluated using the log(equol: daidzein ratio) and microbiome, metabolic, and predicted metagenome analyses were performed.

RESULTS

After isoflavone intervention, predicted stool metagenomic pathways, microbial alpha diversity, and glucose homeostasis in PCOS improved resembling the profile of the control group at baseline. In the whole cohort, larger equol production was associated with lower androgen as well as fertility markers.

CONCLUSION

The dynamics in our metabolic, microbiome, and predicted metagenomic profiles underline the importance of external phytohormones on PCOS characteristics and a potential therapeutic approach or prebiotic in the future.

Investigation of galectin-3, lipocalin 2, retinol binding protein (RBP), small dense low-density lipoprotein (sdLDL) in patients with hirsutism

Introduction

Hirsutism is defined as excessive terminal hair in androgen-dependent areas in women. Adipose tissue is no longer regarded as a storage site for triglycerides or as a source of free fatty acids but is currently emerging as a key constituent of energy metabolism secreting numerous enzymes, cytokines, growth factors, and hormones.

Aim

To evaluate serum levels of galectin-3 (Gal3), lipocalin-2 (LCN2), retinol binding protein (RBP), and small dense low-density lipoprotein (sdLDL) in patients with hirsutism and patients co-presenting with polycystic ovary syndrome (PCOS) and hirsutism.

Material and methods

The study included 90 patients that were divided into three groups: (I) patients with idiopathic hirsutism (IH) (n = 30), (II) PCOS patients with hirsutism (H-PCOS) (n = 30), and (III) the control group (n = 30). Informed consent was obtained from each participant. Idiopathic hirsutism was scored using the modified Ferriman-Gallwey (mFG) scoring system and the diagnosis of PCOS was established based on the modified Rotterdam criteria. Human Gal3, LCN2, RBP, and sdLDL levels were analysed using a commercially available double-antigen sandwich enzyme-linked immunosorbent assay.

Results

No significant difference was found between the three groups with regard to serum Gal3, LCN2, RBP, and sdLDL levels (p > 0.05). Median values were higher in the H-PCOS group than in the other two groups: body weight (median: 76.5 kg) (p < 0.001), waist circumference (median: 82.5 cm) (p = 0.001).

Conclusions

No significant correlation was found between the adipokines that play a role in the aetiology of numerous diseases and some mediators of the lipid metabolism and hirsutism.

Sexual Function and Socio-Sexual Difficulties in Women with Polycystic Ovary Syndrome (PCOS)

Introduction PCOS is the most common endocrine syndrome in women of the reproductive age that has manifold effects on the life of affected women. Little scientific attention has been devoted to these womenʼs sexual lives.

Aim To investigate sexual quality of life in women with PCOS.

Methods The sample size was n = 44. Measures employed were: An extended list of sexual dysfunctions and perceived distress based on DSM-IV-TR, Female Sexual Function Index (FSFI), German Questionnaire on Feelings of Inadequacy in Social and Sexual Situations (FUSS), Rosenberg Self-Esteem Scale (RSE), Brief Symptom Inventory (BSI) subscale depression. The relationships of these components were examined including further variables (body mass index, degree of hirsutism using the Ferriman-Gallwey Score, wish for a child). An open question about what participants see as the source of their sexual problems was presented.

Results Only moderate impairment in sexual function was detected, but feelings of inadequacy in social and sexual situations were markedly elevated and positively correlated with the degree of hirsutism. Depression showed to be a major problem.

Conclusion Patients with PCOS should be screened for socio-sexual difficulties and emotional problems. Specialized psychological and sexological counselling can complement patient care.

Reproductive Assessment: Findings from 20 Years of the Tehran Lipid and Glucose Study

CONTEXT

Reproductive domains of the Tehran lipid and glucose study (TLGS) are unique in that they provide reliable information on reproduction of an urban population of West Asia. The aim of this review is to present the most important reproductive findings of TLGS.

EVIDENCE ACQUISITION

This review is summarizing all articles published in the context of reproductive aspects of TLGS results over the 20-year follow-up. A comprehensive databases search was conducted in PubMed (including Medline), Web of Science and Scopus for retrieving articles on the reproductive histories in context of the TLGS.

RESULTS

The mean (SD) age at menarche and menopause was 13 (1.2) and 49.6 (4.5) years respectively. While pills were the most commonly used modern methods at the initiation of TLGS, the prevalence of condoms rose sharply and significantly over the follow up duration. Among women with history of gestational diabetes, the risk of diabetes and dyslipidemia progression were 2.44 and 1.2 fold higher than others. Prevalences of PCOS and idiopathic hirsutism among reproductive age participants of TLGS were 8.5% (95% CI: 6.8% - 10.2%) and 13.0% (95% CI: 10.9% - 15.1%), respectively. Trend of cardio-metabolic risk factors among women with PCOS showed that there were no statistically significant differences between mean changes of each cardio metabolic variables between PCOS and healthy women; PCOS status also significantly associated with increased hazard of diabetes and prediabetes among women aged younger than 40 years (HR: 4.9; 95% CI: 2.5 - 9.3, P value < 0.001)) and (HR: 1.7; 95% CI: 1.1 - 2.6), P value < 0.005), respectively.

CONCLUSIONS

The population based nature of TLGS provides a unique opportunity for valid assessment of reproductive issues, the results of which could provide new information for modification of existing guidelines.

Evaluation of Topical Capislow Extract and Long Pulsed Nd-YAG Laser in the Treatment of Idiopathic Hirsutism

Introduction: Hirsutism is a condition that affects 10% of women worldwide. In many cultures, hirsutism is regarded as loss of femininity and can be psychologically traumatizing to the suffering females. The aim of the present study was to evaluate how topical capislow would affect or enhance the efficacy of laser hair removal. Methods: A randomized, monoblinded, placebo controlled split face study of combined topical capislow and long pulsed Nd-YAG laser on one side of the face versus long pulsed Nd-YAG laser alone on the opposite side of the face. Laser sessions were done at 4 weeks interval for maximum seven sessions. Topical capislow and placebo were applied once daily from the day of the first laser session to the day of the last laser session. Patients were evaluated both subjectively and objectively in each laser session and for six months after the last laser session. Results: Both treatment modalities were well tolerated and accepted with significantly better results in combined capislow and laser group versus laser alone. Conclusion: Topical capislow can represent a safe and effective synergistic method for laser with faster results but this is a temporary effect retained only to the time of its application.

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.

Ovarian surgery for symptom relief in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine condition, affecting approximately one in 10 women. PCOS is defined by two of three features: oligo- or anovulation, clinical or biochemical hyperandrogenism or both, or polycystic ovaries.Women with PCOS can have a wide range of health problems, including infrequent and irregular periods, unwanted hair growth and acne, and subnormal fertility. Long-term health concerns include an increased risk of heart disease, diabetes and the development of precancerous disease of the womb.

OBJECTIVES

To assess the effectiveness and harms of ovarian surgery as a treatment for symptomatic relief of hirsutism, acne and menstrual irregularity in PCOS.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group specialized register, CENTRAL, MEDLINE, Embase and PsycINFO (from inception to 17 October 2016). We handsearched citation lists, registers of ongoing trials and conference proceedings.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of women undergoing ovarian drilling in comparison to no treatment, medical treatment, or other forms of surgical treatment for the symptoms of PCOS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary outcome measures were improvement in menstrual regularity and androgenic symptoms of PCOS (hirsutism, acne); the secondary outcome measures included harms, change of body mass index (BMI), waist circumference, androgen levels, metabolic measures and quality of life. We assessed the quality of the evidence using GRADE methods.

MAIN RESULTS

We included 22 RCTs (2278 women analyzed) of participants with PCOS and symptoms of acne, hirsutism or irregular menstrual cycles, all of which included laparoscopic ovarian drilling (LOD) as an intervention.Two studies reported their funding source (Farquhar 2002 - supported in part by the Auckland Medical Research Foundation; Sarouri 2015 - the authors thank the Vice Chancellor for Research of Guilan University of Medical Sciences for funding this project).The quality of the evidence ranged from very low to moderate quality. The main limitations were imprecision associated with the low number of studies, inconsistency and risk of bias associated with the inability to blind participants. There were too few studies to assess risk of publication bias. Menstrual RegularityTwo studies compared LOD versus metformin (n=226) but no conclusions could be drawn with regard to menstrual regularity, as their findings were inconsistent and they were unsuitable for pooling. There appeared to be little or no difference in the rate of women reporting improvement in menstrual regularity when LOD was compared with medical treatment including metformin + clomiphene (OR 1.02, 95% CI 0.64 to 1.64, 2 studies, 332 women, I² = 13%, low-quality evidence), letrozole (OR 1.08, 95% CI 0.64 to 1.84, 1 study, 260 women, low-quality evidence), or metformin + letrozole (OR 0.95, 95% CI 0.49 to 1.81, 1 study, 146 women, low-quality evidence). However, one study reported that LOD was superior to gonadotrophin (OR 19.2, 95% CI 3.17 to 116.45, 1 study, 35 women, very low-quality evidence).There appeared to be little or no difference in the rate of women reporting improvement in menstrual regularity when bilateral unipolar LOD was compared to unilateral LOD (OR 1.51, 95% CI 0.62 to 3.71, 2 studies, 104 women, I² = 0%, moderate-quality evidence), transvaginal ultrasound-guided LOD (OR 1.23, 95% CI 0.64 to 2.37, 1 study, 147 women, low-quality evidence), LOD using adjusted thermal dose in accordance with the ovarian volume (OR 0.42, 95% CI 0.16 to 1.14, 1 study, 115 women, low-quality evidence) or bipolar LOD (OR 1.00, 95% CI 0.05 to 18.57, 1 study, 18 women, low-quality evidence).Four to five punctures per ovary may improve the rate of women reporting menstrual regularity compared with two or fewer (OR 16.04, 95% CI 4.19 to 61.34, 2 studies, 73 women, I² = 0%, low-quality evidence). Androgenic SymptomsThere was probably little or no difference in improvement in androgenic symptoms when LOD was compared to metformin (OR 1.00, 95% CI 0.42 to 2.37, 1 study, 126 women, moderate-quality evidence) or gonadotrophins; acne (OR 3.20, 95% CI 0.33 to 30.94, 1 study, 25 women, low-quality evidence), hirsutism (OR 2.31, 95% CI 0.22 to 23.89, 1 study, 25 women, low-quality evidence).There appeared to be little or no difference in improvement of androgenic symptoms when LOD was compared to transvaginal ultrasound-guided LOD, with respect to hirsutism (OR 1.09, 95% CI 0.30 to 3.91, 1 study, 39 women, low-quality evidence) or acne (OR 0.84, 95% CI 0.20 to 3.50, 1 study, 31 women, low-quality evidence). HarmsLOD was associated with fewer gastrointestinal side effects than metformin plus clomiphene (OR 0.05, 95% CI 0.01 to 0.36, 2 studies, 332 women, I² = 0%, moderate-quality evidence). One study suggested little or no difference in rates of ovarian hyperstimulation syndrome between LOD and gonadotrophins (OR 0.08, 95% CI 0.00 to 1.61, 1 study, 33 women, low-quality evidence).There were fewer adhesions with transvaginal hydrolaparoscopy compared to LOD (OR 0.10, 95% CI 0.05 to 0.18, 1 study, 246 women, moderate-quality evidence). There appeared to be little or no difference in adhesions when variable energy LOD was compared with standard LOD (OR 0.96, 95% CI 0.32 to 2.88, 1 study, 64 women, low-quality evidence). Another study (44 women) reported that none of the women who returned for surgery following either traditional or unilateral LOD were found to have adhesions.

AUTHORS' CONCLUSIONS

There was no clear evidence that LOD improves menstrual regularity or the androgenic symptoms of PCOS, compared to most of the medical treatments used in the included studies. LOD was associated with fewer gastrointestinal side effects compared to metformin and clomiphene.There was also no clear evidence of different effectiveness between types of LOD, except that LOD with four to five punctures per ovary may be more effective than two or fewer punctures. There was little evidence comparing LOD with different types of surgery, although one study concluded that transvaginal hydrolaparoscopy had a lower risk of adhesions than LOD.There was evidence from one small study of benefit from LOD compared to gonadotrophins for menstrual regulation. However, gonadotrophins are seldom used for this indication.

Dihydrotestosterone: Biochemistry, Physiology, and Clinical Implications of Elevated Blood Levels

Benefits associated with lowered serum DHT levels after 5α-reductase inhibitor (5AR-I) therapy in men have contributed to a misconception that circulating DHT levels are an important stimulus for androgenic action in target tissues (e.g., prostate). Yet evidence from clinical studies indicates that intracellular concentrations of androgens (particularly in androgen-sensitive tissues) are essentially independent of circulating levels. To assess the clinical significance of modest elevations in serum DHT and the DHT/testosterone (T) ratio observed in response to common T replacement therapy, a comprehensive review of the published literature was performed to identify relevant data. Although the primary focus of this review is about DHT in men, we also provide a brief overview of DHT in women. The available published data are limited by the lack of large, well-controlled studies of long duration that are sufficiently powered to expose subtle safety signals. Nonetheless, the preponderance of available clinical data indicates that modest elevations in circulating levels of DHT in response to androgen therapy should not be of concern in clinical practice. Elevated DHT has not been associated with increased risk of prostate disease (e.g., cancer or benign hyperplasia) nor does it appear to have any systemic effects on cardiovascular disease safety parameters (including increased risk of polycythemia) beyond those commonly observed with available T preparations. Well-controlled, long-term studies of transdermal DHT preparations have failed to identify safety signals unique to markedly elevated circulating DHT concentrations or signals materially different from T.

Endocrine evaluation of hirsutism

Hirsutism is defined as excessive terminal hair growth in a male pattern in females. It typically affects 5 to 10% of reproductive-age women. Excessive hair growth can often cause significant psychological and emotional distress. As a result, hirsutism is a common presenting complaint to healthcare professionals, including dermatologists, as women search for cosmetic and medical solutions to their problem. Hirsutism results from excess production of androgens, often from ovarian or adrenal sources. It is typically associated with a metabolic syndrome like polycystic ovarian syndrome (PCOS), but can be idiopathic or medication-induced. This article provides an endocrine perspective for the evaluation and management of hirsutism.

Autistic Trait, Empathy, and Attention-Deficit/Hyperactivity Symptoms in Women with Idiopathic Hirsutism

Aim:

Many psychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD), disruptive behavioral disorders, autism spectrum disorders, and some psychiatric characteristics, such as poor empathizing, are regarded to be related to elevated levels of androgens or androgen sensitivity. Thus, numerous studies have investigated the potential association between androgen-related physical diseases and these psychiatric conditions. Idiopathic hirsutism (IH) is a disease characterized by an increased sensitivity of the pilosebaceous unit to circulating androgens in women. The purpose of this study was to examine whether IH has a relationship with androgen-related psychiatric conditions.

Materials and Methods:

Totally 37 females with IH and 33 healthy female controls were included in this study. Childhood and present ADHD symptoms of the participants were assessed using the Wender Utah Rating Scale (WURS) and the Adult ADHD Self-Report Scale, respectively. The Autism-spectrum quotient and the interpersonal reactivity index were used to assess autistic traits and different aspects of empathy. Hirsutism severity was measured using the Ferriman–Gallwey scoring system.

Results:

No significant difference was found between the patients and controls on psychiatric questionnaire scores, except for a trend for subjects with IH to show higher levels of the school-associated problems than controls according to WURS. The severity of hirsutism was strongly correlated with the WURS irritability and behavioral problems/impulsivity subscores and WURS total score, and moderately correlated with the WURS attentional deficit subscore.

Conclusions:

This study provides preliminary evidence that common etiological factors may be involved in both the severity of IH, ADHD, and coexisting disruptive behavioral problems.

Complementary Therapies for Idiopathic Hirsutism: Topical Licorice as Promising Option

Hirsutism is one of the most prevalent health problems in women. The aim of the study was to compare the effect of 755 nm alexandrite hair removal laser with that of alexandrite laser plus topical licorice on the improvement of idiopathic hirsutism. A double-blind, randomized placebo-controlled study was performed on 90 female subjects. The patients were divided into two groups: alexandrite laser plus 15% licorice gel (group A) and placebo (group B). Each subject received one of both products over one side of the face, twice daily for 24 weeks on the hirsute locations. Each group underwent five sessions of alexandrite laser at 6-week intervals. To minimize the effects of confounding variables, the test was performed on two separate zones of patients' skin. The mean ± SD numbers of terminal hairs in group A were 7.05 ± 4.55 for zone 1 and 6.06 ± 3.70 for zone 2. In group B, they were 3.18 ± 1.75 for zone 1 and 2.49 ± 1.63 for zone 2. The difference in the mean number of terminal hairs was statistically significant between the two groups (p < 0.001), and there were no serious adverse reactions. The treatment of idiopathic hirsutism with 755 nm alexandrite laser plus topical licorice is more effective than alexandrite laser only.

Endocrine evaluation of hirsutism

Hirsutism is defined as excessive terminal hair growth in a male pattern in females. It typically affects 5 to 10% of reproductive-age women. Excessive hair growth can often cause significant psychological and emotional distress. As a result, hirsutism is a common presenting complaint to healthcare professionals, including dermatologists, as women search for cosmetic and medical solutions to their problem. Hirsutism results from excess production of androgens, often from ovarian or adrenal sources. It is typically associated with a metabolic syndrome like polycystic ovarian syndrome (PCOS), but can be idiopathic or medication-induced. This article provides an endocrine perspective for the evaluation and management of hirsutism.

Insulin resistance and skin diseases

In medical practice, almost every clinician may encounter patients with skin disease. However, it is not always easy for physicians of all specialties to face the daily task of determining the nature and clinical implication of dermatologic manifestations. Are they confined to the skin, representing a pure dermatologic event? Or are they also markers of internal conditions relating to the patient's overall health? In this review, we will discuss the principal cutaneous conditions which have been linked to metabolic alterations. Particularly, since insulin has an important role in homeostasis and physiology of the skin, we will focus on the relationships between insulin resistance (IR) and skin diseases, analyzing strongly IR-associated conditions such as acanthosis nigricans, acne, and psoriasis, without neglecting emerging and potential scenarios as the ones represented by hidradenitis suppurativa, androgenetic alopecia, and hirsutism.

A population-based study of the relationship between idiopathic hirsutism and metabolic disturbances

PURPOSE

To evaluate the association of idiopathic hirsutism, insulin resistance and metabolic disorders.

METHODS

Participants of this study included 137 women with idiopathic hirsutism and 698 women as controls selected from two large population-based cross-sectional studies including 1,772 reproductive-aged women. Anthropometric and biochemical characteristics of the participants were measured and compared; for instance, insulin resistance was estimated through the homeostatic model assessment and the metabolic syndrome was detected using the Joint Interim Statement.

RESULTS

Mean age, body mass index and other anthropometric measures including waist and hip circumferences were statistically higher in women with idiopathic hirsutism. No differences were observed in blood pressure, glucose and lipid profiles, homeostatic model assessment or the prevalence of insulin resistance, obesity and metabolic syndrome in women with idiopathic hirsutism and controls after adjustment of age and body mass index. In the subgroup of women with metabolic syndrome, fasting glucose levels of those with idiopathic hirsutism were significantly higher than controls, after adjustment of age and body mass index as 114 ± 25.85 vs. 103.52 ± 41.90 mg/dL, P = 0.003. Furthermore, the age and body mass index-adjusted prevalence of impaired fasting glucose in women with idiopathic hirsutism were higher than controls as 16.8 vs. 4.6%, OR = 2.26, 95% CI 1.59-5.38. A threshold of 74.5 cm for waist circumference had the optimal combined sensitivity and specificity for prediction of insulin resistance in women with idiopathic hirsutism, though this value was 90.5 cm for controls.

CONCLUSIONS

Our data suggest that although the overall metabolic characteristics were similar in women with idiopathic hirsutism and controls, glycemic disturbances were more often seen in those suffered from metabolic syndrome and idiopathic hirsutism simultaneously.

Total testosterone levels are often more than three times elevated in patients with androgen-secreting tumours

Hirsutism is present in up to 25% reproductive aged women and is most often caused by polycystic ovary syndrome. Less than 5% of patients with hirsutism are diagnosed with rare endocrine diseases including ovarian or adrenal androgen-producing tumours, but these tumours may be malignant and need surgery. Terminal hair growth on lip and chin gradually increases after menopause, which complicates distinction from normal physiological variation. Precise testosterone assays have just recently become available in the daily clinic. We present three women diagnosed with testosterone-producing tumours. Gold standard techniques were used to measure testosterone levels. All tumours originated from the ovaries. Based on the present cases and the existing literature, we suggest that androgen-producing tumours should be suspected in patients with rapid progression of hyperandrogen symptoms, particularly when total testosterone levels are above three times the upper reference limit.

Acne in hirsute women

Introduction

Acne and hirsutism are common manifestations of hyperandrogenism.

Aim

To investigate whether or not acne is present in women with hirsutism, associated with different clinical, endocrine and ultrasonographic features.

Material and methods

The prospective study included 135 women with hirsutism, aged 14–46 years. We measured the levels of hormones with radioimmunoassay/immunoradiometric assay methods.

Results

Acne were present in 63 (47.6%) women with hirsutism. Sixty women had mild forms of acne, including: whiteheads, blackheads, papules and pustules. Only 3 women had moderate to severe acne, including nodules. In a group of women with hirsutism and acne, 6 (9.5%) were obese. In our study we found a high prevalence of androgen excess among hirsute women with acne: total testosterone was increased in 79%, free testosterone in 20.6%, androstenedione in 69.8%, dehydroepiandrosterone sulfate (DHEAS) in 30.1%, 17-OH-progesterone 68.2% and sex hormone-binding globulin (SHBG) was decreased in 33.3% of women. Women with hirsutism and acne have received oral contraceptives for a year, without or in a combination with other medication. Thirty-four (53.9%) women have shown improvement in hirsutism and acne.

Conclusions

In this study we found a high prevalence of acne in hirsute women. The prevalence of acne was higher in polycystic ovarian syndrome. Since these women have associated endocrine changes it is important to correct them with hormonal therapy.

Preparation and clinical evaluation of Finastride gel in the treatment of idiopathic Hirsutism

OBJECTIVE

Hirsutism is the presence of excess terminal hairs in females in a male-like pattern. The most accepted hypothesis for the development of hirsutism is increased 5α-reductase activity in hair follicles of hirsute women. Finasteride partially blocks the conversion of testosterone to dihydrotestosterone through inhibition of 5α-reductase in hair follicles. This study was designed to determine the efficacy of finasteride gel 0.25% in management of idiopathic hirsutism and treatment of hirsutism with topical finasteride to lessen the side-effects.

METHODS

Women after puberty that have idiopathic hirsutism criteria are divided randomly in two groups; treatment and control. The number of patients in each group is 15 and received finasteride and placebo gel once a day on their skins. The patients were visited every month by a dermatologist and the amount of response to the treatment and the patient satisfaction was recorded. Ferriman-Gallwey score of the treated area was determined.

RESULTS

After 6-months, mean thickness hairs in treating group were decreased from 102.00 ± 9.58 µm to 86.4 ± 11.4 µm (p < 0.05), this difference was statistically significant. Gel application did not indicate any type of side-effects.

LIMITATIONS

Inclusion and exclusion criteria.

CONCLUSION

Finasteride partially blocks 5α-reductase. Because of the good absorption through the skin and good solubility of this medicine, the prepared gel formulation applied on the hirsutism area showed a significant decrease in hair growth locally, so finasteride gel is an efficient and harmless therapy in patients with idiopathic hirsutism.

Endocrine check-up in adolescents and indications for referral: A guide for health care providers

The American Academy of Pediatrics recommends that young people between the ages of 11 and 21 years should be seen annually by their pediatricians, since annual checkups can be an important opportunity for health evaluation and anticipatory guidance. Parents of infants and young children are accustomed to regularly visiting a pediatrician for their child's checkups. Unfortunately, when children reach the teen years, these annual checkups may decrease in frequency. In routine check-ups and medical office visits, particular attention should be paid to the possibility of a developmental or endocrine disorder. Early diagnosis and treatment may prevent medical complications in adulthood and foster age-appropriate development. Our purpose is to acquaint readers with the concept, based on current scientific understanding, that some endocrine disorders may be associated with a wide range of deleterious health consequences including an increased risk of hypertension and hyperlipidemia, increased risk of coronary artery disease, type 2 diabetes, significant anxiety and lack of self-esteem. Understanding the milestones and developmental stages of adolescence is essential for pediatricians and all other health providers who care for adolescents. Treating adolescents involves knowledge of a variety of medical, social and legal information; in addition, close working relationships must be established within the adolescent's network to create an effective care system. In summary, we underline the importance of a periodic endocrine checkup in adolescents in order to identify endocrine problems early and develop an approach to treatment for those patients who need help during this time. Indications for endocrine referral for professional and other healthcare providers are also included. These lists are clearly not intended to be comprehensive, but will hopefully serve as a guide for specific clinical circumstances.

Hyperinsulinaemic androgen excess in adolescent girls

Hyperinsulinaemic androgen excess is the most common cause of hirsutism, acne and menstrual irregularity in adolescent girls. Here, we propose that the disorder frequently originates from an absolute or relative excess of lipids in adipose tissue, and from associated changes in insulin sensitivity, gonadotropin secretion and ovarian androgen release. Girls from populations with genotypes attuned to nutritionally harsh conditions seem to be particularly vulnerable to the development of hyperinsulinaemic androgen excess in today's obesogenic environment. We propose that hirsutism, hyperandrogenaemia and menstrual irregularity (≥2 years after menarche) is used as a diagnostic triad for the disorder. No pharmacological therapy has been approved for girls with androgen excess; however, lifestyle intervention is essential to reduce adiposity. In girls without obesity who are not sexually active, insulin sensitization has more broadly normalizing effects than estradiol-progestogen combinations. The early recognition of girls at risk of developing hyperinsulinaemic androgen excess might enable prevention in childhood.

Prevalence of nonclassic congenital adrenal hyperplasia in Turkish children presenting with premature pubarche, hirsutism, or oligomenorrhoea

Background. Nonclassic congenital adrenal hyperplasia (NCAH), caused by mutations in the gene encoding 21-hydroxylase, is a common autosomal recessive disorder. In the present work, our aim was to determine the prevalence of NCAH presenting as premature pubarche (PP), hirsutism, or polycystic ovarian syndrome (PCOS) and to evaluate the molecular spectrum of CYP21A2 mutations in NCAH patients. Methods. A total of 126 patients (122 females, 4 males) with PP, hirsutism, or PCOS were included in the present study. All patients underwent an ACTH stimulation test. NCAH was considered to be present when the stimulated 17-hydroxyprogesterone plasma level was >10 ng/mL. Results. Seventy-one of the 126 patients (56%) presented with PP, 29 (23%) with PCOS, and 26 (21%) with hirsutism. Six patients (4,7%) were diagnosed with NCAH based on mutational analysis. Four different mutations (Q318X, P30L, V281L, and P453S) were found in six NCAH patients. One patient with NCAH was a compound heterozygote for this mutation, and five were heterozygous. Conclusion. NCAH should be considered as a differential diagnosis in patients presenting with PP, hirsutism, and PCOS, especially in countries in which consanguineous marriages are prevalent.

Therapeutic strategy for hair regeneration: hair cycle activation, niche environment modulation, wound-induced follicle neogenesis, and stem cell engineering

INTRODUCTION

There are major new advancements in the fields of stem cell biology, developmental biology, regenerative hair cycling, and tissue engineering. The time is ripe to integrate, translate, and apply these findings to tissue engineering and regenerative medicine. Readers will learn about new progress in cellular and molecular aspects of hair follicle development, regeneration, and potential therapeutic opportunities these advances may offer.

AREAS COVERED

Here, we use hair follicle formation to illustrate this progress and to identify targets for potential strategies in therapeutics. Hair regeneration is discussed in four different categories: i) Intra-follicle regeneration (or renewal) is the basic production of hair fibers from hair stem cells and dermal papillae in existing follicles. ii) Chimeric follicles via epithelial-mesenchymal recombination to identify stem cells and signaling centers. iii) Extra-follicular factors including local dermal and systemic factors can modulate the regenerative behavior of hair follicles, and may be relatively easy therapeutic targets. iv) Follicular neogenesis means the de novo formation of new follicles. In addition, scientists are working to engineer hair follicles, which require hair-forming competent epidermal cells and hair-inducing dermal cells.

EXPERT OPINION

Ideally self-organizing processes similar to those occurring during embryonic development should be elicited with some help from biomaterials.

Possible efficacy of Lavender and Tea tree oils in the treatment of young women affected by mild idiopathic hirsutism

BACKGROUND

Hirsutism is defined as the presence of excessive terminal hair in androgen-dependent areas of a woman's body. Regarding this it has been suggested that Lavender and Tea tree oils may have antiandrogenic activities.

AIM

To evaluate therapy based on Lavender and Tea tree oils in women suffering from mild idiopathic hirsutism (IH).

SUBJECTS AND METHODS

A prospective, open-label, placebo- controlled, randomized study was performed: women affected by mild IH were randomly assigned to receive oil spray containing Lavender and Tea tree oils (group T) (no. = 12) or placebo (group P) (no. = 12) twice a day for 3 months in areas affected by hirsutism. Evaluation of hirsutism was carried out at baseline and after 3 months by Ferriman-Gallwey score and by measuring hair diameter taken from some body areas. A hematological and hormonal evaluation was carried out at baseline and after 3 months.

RESULTS

No significant variations were found in any of the hormones studied in groups T and P between baseline and after 3 months. A statistically significant decrease of hirsutism total score and of hair diameter was found in group T, while no statistically significant difference in these two parameters was observed in group P; in group T percentual reduction of hair diameter was significantly greater than in group P.

CONCLUSIONS

Lavender and Tea tree oils applied locally on skin could be effective in reducing mild IH; this treatment could represent a safe, economic and practical instrument in the cure of this disease.

Insulin resistance in women with hirsutism

INTRODUCTION

There are still not enough data showing whether patients with idiopathic hirsutism (IH) also have insulin resistance. The association between polycystic ovary syndrome (PCOS) and insulin resistance is well documented in the literature, but the Rotterdam Consensus has concluded that principally obese women with PCOS should be screened for the metabolic syndrome. We intended to investigate the presence/absence of insulin resistance in non-obese women with hirsutism.

MATERIAL AND METHODS

Twenty-eight women with PCOS (14 non-obese and 14 obese), 12 non-obese with IH, and 16 non-obese healthy women were included in the study. The presence of insulin resistance was investigated by using basal insulin levels and the homeostasis model assessment (HOMA) score in the study group.

RESULTS

Patients with obese and nonobese PCOS had significantly (p < 0.05) higher basal insulin levels and HOMA scores than IH and control subjects. Insulin levels and HOMA scores did not differ between obese and non-obese PCOS patients. Patients with IH did not show any difference from the control group.

CONCLUSIONS

Insulin resistance exists in non-obese women with PCOS as well as obese women with PCOS. The PCOS is associated with insulin resistance independent of obesity. Insulin resistance should be assessed in all hirsute women with PCOS regardless of their body mass index. More studies in larger numbers of patients should be performed to investigate the role of insulin resistance in women with IH.

The prevalence of idiopathic hirsutism and polycystic ovary syndrome in the Tehran Lipid and Glucose Study

BACKGROUND

There is no clear and contemporaneous method for screening of idiopathic hirsutism (IH) and polycystic ovary syndrome (PCOS) at the community level and current estimates regarding their prevalence are limited. We aimed to ascertain the prevalence of IH and PCOS in a randomly selected sample of reproductive aged female participants of the Tehran Lipid and Glucose Study (TLGS).

METHODS

One thousand and two women, aged 18-45 years, were randomly selected from among reproductive aged women who participated in the TLGS. Those women with either hirsutism or menstrual dysfunction were assessed for biochemical hyperandrogenemia; whereas those participants with hirsutism per se were further assessed for subclinical menstrual dysfunction. PCOS were diagnosed using the National Institute of Health (NIH) criteria. IH was defined as hirsutism without clinical or sub clinical menstrual dysfunction or biochemical hyperandrogenemia (BH).

RESULTS

The mean±SD of age of study population was 29.2±8.7 years. Estimated prevalences of idiopathic hirsutism and pure menstrual dysfunction were 13.0% (95% CI: 10.9%-15.1%) and 1.5%(95% CI: 1.1%-1.9%), respectively. The prevalence of PCOS was 8.5% (95% CI: 6.8%-10.2%); more than one third of these cases would possibly have remained undiagnosed or misdiagnosed, had we not assessed them for subclinical menstrual dysfunction or biochemical hyperandrogenemia.

CONCLUSIONS

These data from a large representative and non selected population of women confirm the concept that IH and PCOS are the two most common gynecological endocrinopathies among reproductive aged women. The estimated prevalence of these conditions is highly influenced by their screening methods at the community level.

Ethinylestradiol/Chlormadinone acetate for use in dermatological disorders

The diagnosis and management of four cases of dermatological disorders, most of which are related to the endocrine disorder of androgen excess, are presented. Combined oral contraceptives (COCs) may be useful when well-tolerated hormonal therapy and/or when contraception is required. A female patient with androgenetic alopecia or female pattern balding, without underlying hyperandrogenism, was treated with ethinylestradiol/chlormadinone acetate (EE/CMA) 0.03 mg/2 mg for 6 months and experienced stabilization of hair loss (case report 1). A patient who had previously received a COC for an irregular menstrual pattern but again experienced irregular menses and also acne after stopping treatment was diagnosed with acne associated with polycystic ovary syndrome (PCOS) [case report 2]. After 6 month's treatment with EE/CMA 0.03 mg/2 mg, this patient had fewer acne lesions and became eumenorrheic. A third patient who had excess hair since childhood was diagnosed with idiopathic hirsutism (no underlying gynecological or endocrinological disorder was found) and was treated with EE/CMA 0.03 mg/2 mg (case report 3). Less hair growth was reported after 6 months' treatment. Case report 4 describes a patient who presented with oligomenorrhea and acne. She was diagnosed with PCOS with acne, seborrhea and mild hirsutism. Treatment with EE/CMA 0.03 mg/2 mg for 6 months resulted in improvements in her facial acne, seborrhea and hirsutism; she also became eumenorrheic. These four cases illustrate that EE/CMA may be a useful and well tolerated treatment option in the management of patients with dermatological disorders with or without hyperandrogenization.

Hirsutism: evaluation and treatment

Hirsutism is a common clinical condition seen in female patients of all ages. It affects around 5-10% of the women and is a common presenting complaint in the dermatological out patient department for cosmetic reasons. The cause is mainly hyperandrogeneism, which may be ovarian or adrenal. It may be part of a rare metabolic syndrome, drug induced, or just idiopathic. Hirsutism has a huge psychosocial impact, especially in the young females. This article reviews the current evaluation guidelines and management of hirsutism.

Proteomic profiles in hyperandrogenic syndromes

BACKGROUND

Polycystic ovary syndrome (PCOS) and congenital adrenal hyperplasia (CAH) represent the most common causes of hyperandrogenism. Although the etiopathogeneses of these syndromes are different, they share many clinical and biochemical signs, such as hirsutism, acne, and chronic anovulation. Experimental data have shown that peripheral T-lymphocytes function as molecular sensors, being able to record molecular signals either at staminal and mature cell levels, or hormones at systemic levels.

METHODS

Twenty PCOS women and 10 CAH with 21-hydroxylase deficiency, aged between 18-35 yr, were studied. T-cells purified from all patients and 20 healthy donors have been analyzed by 2-dimensional gel electrophoresis. Silver-stained proteomic map of each patient was compared with a control map obtained by pooling protein samples of the 20 healthy subjects.

RESULTS

Spots of interest were identified by peptide mass fingerprint. Computer analysis evidenced several peptidic spots significantly modulated in all patients examined. Some proteins were modulated in both syndromes, others only in PCOS or in CAH. These proteins are involved in many physiological processes as the functional state of immune system, the regulation of the cytoskeleton structure, the oxidative stress, the coagulation process, and the insulin resistance.

CONCLUSION

Identification of the physiological function of these proteins could help to understand ethiopathogenetic mechanisms of hyperandrogenic syndromes and its complications.

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.

HMG-CoA reductase inhibitors: do they have potential in the treatment of polycystic ovary syndrome?

Many women of reproductive age are affected by polycystic ovary syndrome (PCOS), a heterogeneous endocrinopathy characterized by androgen excess, chronic oligo-anovulation and/or polycystic ovarian morphology. In addition, PCOS is often associated with insulin resistance, systemic inflammation and oxidative stress, which, on one hand, lead to endothelial dysfunction and dyslipidaemia with subsequent cardiovascular sequelae and, on the other hand, to hyperplasia of the ovarian theca compartment with resultant hyperandrogenism and anovulation. Traditionally, HMG-CoA reductase inhibitors (statins) have been used to treat dyslipidaemia by blocking HMG-CoA reductase (the rate-limiting step in cholesterol biosynthesis); however, they also possess pleiotropic actions, resulting in antioxidant, anti-inflammatory and anti-proliferative effects. Statins offer a novel therapeutic approach to PCOS in that they address the dyslipidaemia associated with the syndrome, as well as hyperandrogenism or hyperandrogenaemia. These actions may be due to an inhibition of the effects of systemic inflammation and insulin resistance/hyperinsulinaemia. Evidence to date, both in vitro and in vivo, suggests that statins have potential in the treatment of PCOS; however, further clinical trials are needed before they can be considered a standard of care in the medical management of this common endocrinopathy.

A comparison between finasteride, flutamide, and finasteride plus flutamide combination in the treatment of hirsutism

To investigate the clinical efficacy and safety of the finasteride (5 mg/day) plus flutamide (125 mg/day) combination therapy in unselected women with hirsutism, 44 women were involved in the study. The effects of such combination treatment have not been reported previously. The patients were assigned to 3 treatment groups: 14 patients (group 1) were treated with finasteride (5 mg per day), 16 patients (group 2) were treated with flutamide (125 mg per day), and 14 patients (group 3) were treated with finasteride (5 mg per day) plus flutamide (125 mg per day) for 12 months. Serum FSH, LH, estradiol, total testosterone, free testosterone, androstenedione, DHEAS, and SHBG were obtained. Hirsutism score was measured before and after treatment. Blood chemistry and side effects were evaluated during the study. The reductions in hirsutism score (% of the baseline) at 6 months were as follows: 24% for group 1, 35% for group 2, and 33% for group 3. Combination therapy resulted in (49%) similar improvement to flutamide alone (45%), but significantly (p<0.05) more efficacious improvement in hirsutism when compared to finasteride (32%) after 12 months of treatment. In conclusion, flutamide is more effective than finasteride and the combination of these two drugs is not better than flutamide alone, but better than finasteride in hirsute women.

Statins in the treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-aged women. The hyperandrogenemia associated with the syndrome is a result of excessive growth and steroidogenic activity of theca-interstitial tissues in response to various factors, including elevated gonadotropins, hyperinsulinemia, and oxidative stress. PCOS frequently coexists with other cardiovascular risk factors, such as dyslipidemia and systemic inflammation. Statins inhibit the synthesis of mevalonate, the key precursor to cholesterol biosynthesis, and reduce cardiovascular morbidity and mortality. Blockade of mevalonate production may also lead to decreased maturation of insulin receptors, inhibition of steroidogenesis (e.g., via limiting the amount of substrate: cholesterol), and alteration of signal transduction pathways that mediate cellular proliferation. The latter depend upon posttranslational modification of proteins (prenylation), a process mediated by mevalonate derivatives. Statins also have intrinsic antioxidant properties. Given the pleiotropic actions of statins, they are likely not only to improve the dyslipidemia associated with PCOS but may also exert other beneficial metabolic and endocrine effects.

Hirsutism: clinico-investigative profile of 50 Indian patients

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.

Polycystic ovary syndrome in adolescence

Polycystic ovary syndrome (PCOS) is a syndrome of variable combinations of menstrual irregularity, hirsutism or acne, and obesity. It can be diagnosed in adolescence and has early childhood antecedents. PCOS is the single most common endocrine cause of an ovulatory infertility and a major risk factor for the metabolic syndrome and, in turn, development of type 2 diabetes mellitus in women. Thus, it appears that PCOS increases a woman's risk of developing cardiovascular disease. Therefore, identifying girls at risk for PCOS and implementing treatment early in the development of PCOS may be an effective means of preventing some of the long-term complications associated with this syndrome. This article reviews the definition, clinical features, diagnosis, and treatment of PCOS.