Case 31: Excessive hair growth

 

Case 31: Excessive hair growth

CASE 31: EXCESSIVE HAIR GROWTH

History

A 19-year-old woman was referred by her general practitioner (GP) with increased hair growth.

She first noticed the problem when she was about 16 years old and it has progressively worsened such that she now feels very self-conscious and will never wear a bikini or go swimming.

It also affects her forming relationships. The hair growth is noticed mainly on her arms,

thighs and abdomen. Hair has developed on the upper lip more recently. She has tried shaving but this seems to make the problem worse. She feels depilation creams are ineffective.

Waxing is helpful but very expensive and she has bleached her upper-lip hair. Her GP has not

prescribed any medication in the past.

There is no significant previous medical history of note. Her periods started at the age of 13

years and she bleeds every 30–35 days. The periods are not painful or heavy and there is no

intermenstrual bleeding or discharge. She has never been sexually active.

Examination

On examination she has an increased body mass index (BMI) of 29 kg/m2. The blood pressure

is 118/70 mmHg. There is excessive hair growth on the lower arms, legs and thighs and in the

midline of the abdomen below the umbilicus. There is a small amount of growth on the upper

lip too. The abdomen is soft and no masses are palpable. Pelvic examination is not indicated

as she has not been sexually active.

INVESTIGATIONS

Normal range

Follicle-stimulating hormone (FSH) 7 IU/L Day 2–5

1–11 IU/L

Luteinizing hormone (LH) 12 IU/L Day 2–5

0.5–14.5 IU/L

Prolactin 780 mu/L 90–520 mu/L

Testosterone 3.2 nmol/L 0.8–3.1 nmol/L

Thyroid-stimulating hormone 4.9 mu/L 0.5–5.7 mu/L

Free thyroxine 14.7 pmol/L 10–40 pmol/L

Questions

• What is the likely diagnosis?

• How would you further investigate and manage this woman?100 Cases in Obstetrics and Gynaecology

76

ANSWER 31

The likely diagnosis is of polycystic ovarian syndrome (PCOS). This is supported by the clinical features of hirsutism, acne, increased BMI and slight menstrual irregularity. The biochemical results show the typical moderately raised androgen and raised LH:FSH ratio.

If the testosterone level was higher, androgen-secreting tumours should be considered

(androgen-secreting ovarian, pituitary or adrenal tumours).

Other causes of hyperandrogenism include iatrogenic (glucocorticoids, danazol, testosterone), idiopathic or familial.

Further investigation

A transabdominal ultrasound scan should be arranged to confirm the ultrasound features of polycystic ovaries, although this is not in fact an essential feature for the diagnosis of the syndrome.

Treatment

Various treatments are used for hirsutism once serious causes of hyperandrogenism

have been excluded. One of the commonest is to commence the cyproterone acetatecontaining combined oral contraceptive pill (co-cyprindiol). Cyproterone acetate is an

antiandrogen with progestogenic activity. It takes several months for an improvement to

be seen in the hair growth and she would continue to need to use the cosmetic treatments

in the meantime.

If this is ineffective then cyproterone acetate at a higher dose can be used either alone or in

addition to co-cyprindiol.

General advice should include weight loss, as this counteracts the metabolic imbalance associated with PCOS and is favourable in the long term in terms of the known cardiovascular

risks associated with hyperandrogenism.

KEY POINTS

• Most women with hirsutism have PCOS or a familial tendency.

• Androgen-secreting tumours should be excluded in women with testosterone

level above 5 nmol/L.

• Hirsutism has significant psychosocial consequences.